Every finding on record at Laramie Health and Rehabilitation

Based on staff interviews, medical record review, and facility investigation and policy review, the facility failed to protect the residents' right to be free from physical abuse by other residents for 1 of 5 sample residents (#3) reviewed for allegations of abuse and neglect, which resulted in actual harm to resident #3. The findings were:The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 4/9/26.1. Review of the quarterly MDS assessment dated [DATE] showed the BIMS assessment for resident #3 wasn't able to be completed which indicated severe cognitive impairment, and included diagnoses of chronic obstructive pulmonary disease, Parkinson's disease, and dementia. Review of the quarterly MDS assessment dated [DATE] showed resident #11 had a staff assessment of mental status which indicated severe cognitive impairment for daily decision making, and included diagnoses of Alzheimer's disease, dementia with severe agitation, and anxiety. Review of the care plan dated 2/11/26 showed resident #11 had a history of behaviors which included agitation, grabbing, hitting, kicking and being physically aggressive towards others, and interventions of redirection, one to one staff monitoring, reassurance and ensuring resident safety. The following concerns were identified:a. Review of the facility investigation dated 3/29/26 showed resident #11 had attempted to push resident #3's wheelchair. When resident #3 told him/her to stop, resident #11 hit resident #3 in the face multiple times with a closed fist. Resident #3 put his/her arms up in defense and resident #11 then grabbed the resident's oxygen tubing and attempted to put it around resident #3's neck. Facility staff intervened before injury with the oxygen tubing occurred. The residents were separated and assessed for injury, which showed resident #11 had red knuckles with a break in the skin and resident #3 had redness to the cheek area. Resident #11 was placed on 1 to 1 observation until the interdisciplinary team could assess the resident's needs. Following the incident, the staff on duty had been provided with re-education on behavioral interventions to use if resident #3's demonstrated behaviors.b. Interview with hospitality aid #1 on 6/3/26 at 10:23 AM confirmed when she arrived on shift resident #11 had been drinking out of a flower vase and became agitated after it was taken away. S/he then walked with him/her down the hallway and when they walked by resident #3, resident #11 punched resident #3, grabbed the oxygen tube and attempted to wrap it around resident #3's neck. Hospitality aide #1 put her hands in between the tubing and resident #3's neck. The residents were separated and resident #3 had a red cheek from being punched.c. Interview with the DON on 6/03/26 at 10:48 AM revealed she had assessed both residents after the incident and found resident #3 had redness to his/her face, and resident #11 had redness and broken skin to his/her knuckles. She confirmed resident #11 had not had any additional resident to resident aggressions since this incident.d. Review of the facility policy titled Freedom from abuse, neglect, corporal punishment, involuntary seclusion, mistreatment, misappropriation of resident property, and exploitation showed Each resident has the right to be free from abuse.The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members, and others who may have unsupervised access to residents.2. The facility implemented the following corrective action by 4/9/26:a. A 1:1 was placed on resident #11;b. Resident safety interviews were conducted;c. Education to all staff on abuse was completed on 4/1/26;d. The facility implemented audits; ande. The incident was discussed in quality assurance on 4/9/26 and the results of audits are monitored through quality assurance.

Based on observation, review of the resident council notes, resident interview, staff interview, review of the Facility assessment dated [DATE], PBJ staffing data report review, review of worked staff schedule 10/1/25 through 12/21/25, and review of the Declaration of Nursing Staffing sheets, the facility failed to ensure adequate staff were provided to meet the needs of the residents. The findings were: Review of the facility assessment with a completion date of 12/11/2025 showed for short stay, the average number of residents admitted within past 6 months was 48. The average number discharged within the past 6 months was 45. The long-stay average number of residents admitted within the past 6 months was 29. The average number of residents discharged within the past 6 months was 37. Further review showed the Hours Per a Resident Days (HPRD) Day - RN 32, LPN 54, CNA/STNA 75, Nights - RN 32, LPN 54, CNA/STNA 75. Interview with the DON on 6/3/26 at 3:31 PM revealed when she staffs the schedule it was 2 day shift nurses, 2 night shift nurses, and a minimum of 2 CNAs per station during the day and night shifts, then 1 CNA per station during the overnight 10 PM through 6 AM shift (the facility only had 2 stations). She stated she was unaware of the hours needed for staffing from the Facility Assessment. The following concerns were identified: 1. Observation on 5/31/26 upon entry to the facility showed only 1 CNA was seen in the front hall. 2. Review of PBJ Staffing Data Report for FY Quarter 1 2026 (October 1, 2025 - December 31,2025) showed Excessively Low Weekend Staffing triggered. 3. Review of the October – December 2025 staff worked schedules showed the following concerns. a. Review of October 2025 worked schedule showed the shortage of CNAs on the following dates. - On Saturday, 10/11/25 from 2PM - 6PM the facility only had 2 CNAs on duty. - On Sunday, 10/12/25 from 6AM – 10AM the facility only had 2.5 CNAs on duty. - On Friday, 10/31/25 from 6PM – 10PM the facility only had 2.5 CNAs on duty. b. Review of the November 2025 worked schedule showed the shortage of CNAs on the following dates. - On Friday, 11/7/25, from 6AM-10AM the facility only had 3 CNAs on duty and then from 2PM – 10 PM the facility had only 2 to 2.5 CNAs on duty. - On Sunday, 11/9/25 from 6AM – 10AM the facility only had 2.9 CNAs on duty. - On Friday, 11/14/25 from 2PM – 10PM the facility only had 2 to 2.5 CNAs on duty - On Saturday, 11/15/25 from 2PM – 6PM the facility only had 3 CNAs on duty - On Friday, 11/21/25 from 6AM – 10AM and 6PM – 10PM the facility only had 3 on duty. - On Saturday, 11/22/25 from 10AM – 6PM 3 CNAs and 6PM – 10PM 2.5 CNAs were on duty. - On Sunday, 11/23/25 from 6AM – 10AM and 6PM – 10 PM the facility only had 3 CNAs on duty. - On Friday, 11/28/25 from 10PM – 6AM the facility only had 1 CNA on duty. - On Saturday, 11/29/25 from 2PM – 10PM the facility only had 3 CNAs on duty. - On Sunday, 11/30/25 from 6AM – 10AM and 6PM – 10PM the facility only had 3 CNAs on duty. c. Review of the December 2025 worked schedule showed the shortage of CNAs on the following dates. - On Saturday, 12/6/25 from 6AM – 2PM the facility only had 2 CNAs on duty, and from 10PM – 6AM the facility only had 1 CNA on duty. - On Sunday, 12/7/25 from 6AM – 2PM the facility only had 2 CNAs on duty and from 2 PM – 6 PM only 3 CNAs were on duty. - On Friday, 12/12/25 from 6AM – 6PM the facility only had 3 CNAs on duty, and from 6PM – 10PM on 2 CNAs were on duty. - On Saturday, 12/13/25 from 6PM – 10PM the facility only had 2 CNAs on duty, and from 10PM – 6AM only 1 CNA was on duty. - On Sunday, 12/14/25 from 6PM – 10PM the facility only had 2 CNA on duty. - On Friday, 12/19/25 from 6PM – 10PM the facility only had 2 on duty. - On Saturday, 12/20/25 from 10PM – 6AM the facility only had 1 CNA on duty. - On Sunday, 12/21/25 from 6AM – 6 PM the facility only had 3 CNAs on duty, and from 6PM – 10PM only 2 CNAs on duty. - On Friday, 12/26/25 from 2PM – 6PM only 2 CNAs on duty, from 6PM – 10PM only 3 CNAs on duty. Then from 10PM – 6AM only 1 CNA was on duty. - On Saturday, 12/27/25 from 2PM – 6PM only 3 CNAs were on duty, and then from 6PM – 10PM only 2 CNAs were on duty. 4. Review of the 5/25/26 through 5/31/25 Declaration of Nursing Staffing showed the following concerns: - On 5/25/26 from 6AM - 6PM only 3 CNAs were on duty. - On 5/26/26 from 6PM – 10 PM only 3 CNAs were on duty. - On 5/27/26 from 6PM – 10PM only 3 CNAs were on duty. - On 5/28/26 from 2PM – 10PM only 3 CNAs were on duty. - On 5/29/26 from 6PM – 10PM only 3 CNAs were on duty. - On 5/30/26 from 6AM – 6PM only 1 CNA was on duty, and then from 6PM – 10PM only 2 CNAs were on duty. - On 5/31/26 from 6AM – 10AM only 2 CNAs were on duty, then from 10AM – 6PM only 1 CNA was on duty, and then from 6PM – 10 PM only 3 CNAs were on duty. 5. Interview with the resident council on 6/1/26 at 1:28 PM revealed they felt the long call light times and delayed or missing food delivery was due to low staffing. 6. Interview with resident #40 on 6/1/26 at 11:19 AM revealed s/he felt there was not enough staff. S/he stated when they only had 1 person covering any length of time, it was not enough staff. 7. Interview with resident #5 on 6/2/26 at 11:44 AM revealed s/he felt the facility was short on CNAs. S/he stated that it takes a long time for them to answer call lights. S/he stated they are so busy that s/he does not get his/her clothing changed for 2 to 3 days. 8. Interview with CNA #2 on 6/3/26 at 9:29 AM revealed she felt low staffing is an issue and felt like scheduled staff called out frequently. She reported feeling overwhelmed. 9. Interview with the DON on 6/3/26 at 3:31 PM revealed she did the staff schedule for the nursing staff. She stated the PBJ was connected with the facility system. So, it would automatically fill in the required field, and Corporate oversees the PBJ system.

Based on observation, staff interview, and medical record review, the facility failed to ensure bathing was performed per the plan of care for 2 of 3 residents (#31, #59) reviewed for bathing. The findings were:1. Review of the admission MDS assessment dated [DATE] showed resident #31 admitted to the facility on [DATE]. Review of the care plan last revised on 4/13/26 showed the resident required maximum assistance from staff for bathing. Review of the care plan last revised on 5/26/26 showed Bathing Schedule/Frequency: prior to hospitalization [s/he] showered every other day. The following concerns were identified:a. Observation on 5/31/26 at 4:24 PM showed the resident wore a hospital gown and wrap around brief, was in bed, and hair appeared greasy and uncombed.b. Review of the bathing log provided by the DON showed the resident preferred bathing on Tuesday and Friday afternoons, and had been provided with a bed bath on 5/6, 5/18, and 5/26. The resident refused on 5/12, and activity did not occur on 5/15 and 5/19.2. Review of the medical record showed resident #59 admitted to the facility on [DATE]. S/he discharged to the hospital on 4/13/26, returned on 4/21/26, and discharged to the hospital again on 5/14/26, and returned on 5/27/26. Review of the care plan last revised on 5/6/26 showed the resident was at risk for ADL self-care performance deficit related to amputation, impaired balance and pain, and may at time refuse cares and showers. S/he required maximum assistance of 1 person for bathing, and staff was to encourage the resident to bathe on scheduled shower days. The following concerns were identified:a. Observation on 5/31/26 at 2:45 PM showed resident #59 wore a hospital gown and had long hair that appeared greasy and uncombed. Continued observation on 6/1/26 at 11:31 AM showed the resident's hair continued to appear greasy and uncombed.b. Review of the bathing log provided by the DON showed the resident preferred showers on Tuesday and Friday afternoons, and had been provided with a shower on 4/29/26, 5/8/26 and 5/9/26. The resident refused a shower on 5/12/26.3. Interview with CNA #3 on 6/2/26 at 4:34 PM revealed there were no scheduled shower aides, and the CNAs were expected to bathe the residents. Further interview revealed it had been tricky to get any showers done because it had been a crazy day, and when the residents did not receive baths, it was not usually due to their refusals.4. Interview with the DON on 6/3/26 at 4:43 PM revealed if residents refused a shower, she expected staff to reapproach with a different staff member or nurse. She stated every refusal should be charted, and she had implemented a plan to improve documentation in general, which included a current PIP for bathing. She reported she had started to keep bathing charts at the unit desks in February 2026. She confirmed the facility did not use bath aides, and the expectation was that CNAs and nurses provided bathing for the residents.

Based on observation, resident, staff, and representative interviews, medical record review, and activity calendar review, the facility failed to ensure individual activities of preference were provided to 4 or 4 sample residents (#4, #8, #23, #30) , and weekend activities were provided to 5 of 5 sample residents (#4, #8, #23, #30, #40) reviewed for activities. This was verified at the confidential resident council meeting. The findings were: Regarding activities of preference 1. Review of the care plan last revised 10/6/25 showed resident #4 had interventions for psychosocial well-being and one-to-one. The following concerns were identified: a. Interview with the resident on 6/1/26 at 10:28 AM revealed the activities were for young kids and not old adults, therefore s/he did not participate. S/he did participate in resident council when s/he was told about it. b. Interview with the Social Worker on 6/2/26 at 3:09 PM revealed the resident had not participated in activities since s/he was admitted to the facility. She stated the resident would occasionally come out of his/her room and talk with staff. c. Review of the activity participation logs showed the resident participated in independent activities 58 out of 94 opportunities, and one-to-one activities 1 out of 94 opportunities. There was no documented activity participation on weekends. 2. Review of the care plan for resident #8, initiated on 11/13/25 showed activity staff would escort him/her to and from activities and provide one-to-one visits twice weekly. The following concerns were identified: a. Review of the activity participation log showed resident #8 had participated in one-to-one 2 out of 94 opportunities. The resident was documented as participating in independent activity 51 out of 94 opportunities and group activity 2 out of 94 opportunities. There was no documented activity participation on weekends. 3. Review of the care plan last revised 1/15/26 showed resident #23 would be out of his/her room daily to avoid self-isolation. a. Interview with resident #23 on 6/1/26 at 12:01 PM revealed there's nothing to do here. b. Observations throughout the survey showed the resident did not leave his/her room. c. Review of the activity participation logs showed the resident participated in independent activities 55 out of 94 opportunities, group activities 1 out of 94 opportunities and one-to-one activities 4 out of 94 opportunities. There was no documented activity participation on weekends. d. Interview with the activity director on 6/3/26 at 4:05 PM revealed the resident went to group music activities 2 to 3 times per month, and other than that, s/he liked to use his phone, watch movies, have conversation or do his/her shaving and hair. 4. Review of the care plan last revised on 10/6/25 showed resident #30 identified keeping my hands busy as important. Interventions initiated on 3/3/26 showed to include one-to-one visits 3 times per week. The following concerns were identified: a. Observations throughout the survey showed the resident was in bed, sitting in a wheelchair by the nurses' station, and sitting in the dining room. The resident was not observed in activities. b. Review of the activity participation log showed the resident had participated in one-to-one 3 out of 94 opportunities. The resident was documented as participating in independent activity 49 out of 94 opportunities and group activity 10 out of 94 opportunities. There was no documented activity participation on weekends. c. Interview with the resident representative on 6/3/26 at 11:11 AM revealed the resident did not participate in many activities, and s/he liked to do things with his/her hands. d. Interview with the activity director on 6/3/26 at 4:09 PM revealed the resident participated in trivia, bingo, people watching and snacks. She reported s/he liked to walk around with a one-to-one, and she put the resident in an activity to watch a movie and have coffee. She stated she documented one-to-one as independent in her documentation. 5. Interview with the activity director on 6/2/26 at 4:01 PM revealed she did one-to-one visits if residents did not participate in the group activities, and she chatted and did their nails and usually provided a snack. She charted through POC in Point Click Care (PCC) and she did rounds in the morning to assesses what activities residents wanted to do for the day. Further interview revealed she had been the activity assistant and she worked as a director under the activity director of another facility while she waited to take the course to be a director. Regarding weekend activities 1. Observation on 5/31/26 at 2:30 PM showed 2 residents independently played a trivia game on the TV in the activity room. No staff was present in the room. 2. Review of the activity participation logs showed no weekend activity participation for residents. 3. Review of the Weekly Activity Agenda showed no activities scheduled for the weekend. 4. Interview with resident #40 on 6/1/26 at 10:50 AM revealed there was not an activity assistant to help with the activity program, and there was no one to assist on the weekend. S/he had to wait for people who walked by to change stations on the TV and push the buttons for the games on the TV. 5. Interview with the supervising activity director on 6/3/26 at 8:53 AM revealed the expectation was for one-to-one activities to be resident directed, and if they had no interest she expected the activity personnel to visit and talk to the residents. She stated goals should be resident specific and added to the care plan on admission, and the need for independent activity should be communicated in the care plan. Further interview revealed they needed to provide activities 7-days a week, and they should have weekend staff for activities. She revealed the activity director needed assistance, and it was hard for her to update the MDS assessments and care plans because she always had to catch up with documentation. She confirmed weekend activities were self-directed and the manager on duty should help engage residents with activities on the weekend. 6. Interview with the DON on 6/3/26 at 4:43 PM revealed a support nurse was supposed to help with activities on the weekend, but she did not know how much they were able to help or if they documented any activities. 7. Review of the policy titled Activity Program updated July 2015 showed .1. The activity program: a. Is multifaceted to reflect the entire resident population's needs and interests. b. Is varied to provide stimulation or solace. c. Promotes physical, cognitive, and/or emotional well-being. d. Enhances to the extent practical each resident's physical, mental, and psychological status. e. Encourages self-respect through activities that support self-expression and choice. f. Meets applicable state and federal guidelines. g. Reflects individual resident evaluations as well as MDS assessments.6. Activities are offered at a variety of times to reflect resident's scheduling needs and preferences.

Based on observation, resident interview, staff interview and review of meeting notes and grievance documentation, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration resident preferences. The census was 58. The findings were: 1. Observation on 5/31/26 at 2 PM showed resident lunch meal trays were being delivered. 2. Interview with resident #4 on 6/1/26 10:28 AM revealed that the food that was delivered was not always what was listed on the menu, at times s/he could not tell what the food had been, the temperature could be extreme hot and cold, and most times portions were small. 3. Interview with resident #41 on 6/1/26 at 10:07 AM revealed that the food is a 3/10, and included a lot of canned veggies and potato or rice. In addition, the food tasted bland and boring, and the same food was repeated frequently. The resident also reported s/he was not always able to identify the food by looking at it or tasting it. 4. Interview with resident #40 on 6/1/26 at 10:50 AM revealed he food was pretty bland and the room trays were not hot. 5. Interview with resident #23 on 6/1/26 at 12:07 PM revealed the facility ran out of food frequently, the food they are served is lousy, and s/he wanted different choices on beverages. 6. Interview with resident #47 on 6/1/26 at 1:28 PM revealed s/he had late meal trays, and s/he had not turned in any grievances because when s/he did they just told her/him it didn't happen. S/he reported s/he had to go looking for her/his meal tray that day at 1 PM because it had not been delivered yet and the meal had been found in a unmanned cart in the dining room. 7. Interview with the resident council on 6/1/26 at 1:28 PM revealed the residents had often complained of food quality, resident preferences not being followed and late timing of trays. These topics had also been discussed at the food committee meetings. They also revealed the residents had often decided to not fill out grievance forms regarding food because they felt they were not being looked into appropriately and they did not hear back on the resolution every time. a. Review of the resident council minutes for March, April and May of 2026 showed new incidents of complaints of food timing and palatability were discussed at every meeting. 8. Review of the March, April and May of 2026 grievance log showed there were 15 grievances related to food, which included 11 for late and missing trays, and 4 for food quality. Five grievances were filled out by the resident's family members that had to go find the food trays for the residents to get their meals. Grievance resolutions showed staff checked meal pass time documentation and reviewed that they had been passed out within the allotted time frame and considered those grievances unfounded. There was no evidence of pattern tracking or meal time observation. Food preferences were reviewed with residents on grievances with quality of meal and there was no evidence of food quality review. 9. Review of resident food committee meeting notes for March, April, and May of 2026 showed food quality, palatability, temperature, late meal trays, snack options, and food preferences not always being followed were being discussed with no evidence of dietary staff's changes or interventions to improve resident experiences. 10. Interview with the dietary manager on 6/3/26 at 2:12 PM confirmed she had been aware of the concern for meal tray timing and food quality and reported interventions had been adjusted but had no documentation of it. She had been running the food committee meetings and could not provide any documentation of new interventions or system changes that she had implemented to improve delays and quality.

Based on medical record review, staff interview, and policy review, the facility failed to provide a notice of transfer/discharge prior to a facility-initiated hospital transfer for 4 of 5 sample residents (#6, #23, #30, #31). The findings were: 1. Review of the medical record showed resident #6 was transferred to the hospital on 3/19/26. Further review showed no evidence the facility had issued a written transfer/discharge notice to the resident and/or the resident representative2. Review of the medical record showed resident #23 was transferred to the hospital on 2/10/26. Further review showed no evidence the facility had issued a written transfer/discharge notice to the resident and/or the resident representative.3. Review of the medical record showed resident #30 was transferred to the hospital on 2/27/26. Further review showed no evidence the facility had issued a written transfer/discharge notice to the resident and/or the resident representative.4. Review of the medical record showed resident #31 was transferred to the hospital on 5/21/26 and 5/24/26. Further review showed no evidence the facility had issued written transfer/discharge notices to the resident and/or the resident representative.5. Interview with the DON on 6/03/26 at 12:05 PM revealed the Interact form was sent with the residents when they were transferred to the hospital, and the resident or their representatives were provided with the bed hold information. Further interview confirmed residents or their representatives were not provided with a written transfer/discharge notice.6. Review of the policy titled Transfer and Discharge and updated May 2025 showed .5. When the transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge which includes the includes the [sic] following items: a. Date notice is given, b. Effective date of the transfer/discharge. c. Reason for the transfer/discharge. d. Where the resident is to be moved. e. Contact information for the State Long-Term Care Ombudsman .

Based on observation, and staff interview, the facility failed to ensure recertification and complaint survey reports, and any plans of correction, during the 3 preceding years, were available for any individual to review upon request. The findings were: 1. Observation on 5/31/26 at 3:20 PM showed the State Survey binder had a document stating State Surveys Public Record 1 year. The other documentation dated on 2/24/26 was the iQIES (Internet Quality Improvement and Evaluation System) ePOC (Electronic Plan of Correction), and a complaint survey 2567 dated on 2/12/26. Inside of front binder was a piece of tape showing updated 2/26/26. There was no notice of prior surveys. Further observation showed above the binder holder on the wall was a framed notice showing State Surveys & Plan of Corrections, Three years of Results. 2. Interview with the administrator on 6/1/26 at 9:00 AM revealed she was unaware that the last standard survey needed to be posted in the binder as well.

Based on resident interview, staff interview, and record review, the facility failed to properly obtain grievances and maintain evidence demonstrating the appropriate action and issuance of the grievance decision for 4 of 8 residents (#4,#40,#47,#15) reviewed for grievances. The findings were: 1. Interview with resident #4 on 6/1/26 at 10:28 AM revealed the resident had asked staff multiple times to replace a cloth recliner that had stuffing falling out of the armrest. S/he also had been told by the maintenance director that his/her personal large-screen TV had been hit by lightning, and it was replaced with a tiny TV. The large TV had also been removed from his/her room by maintenance and s/he does not know what happened to it. Further interview revealed s/he had reported clothing and a blanket were missing, but s/he did not fill out a grievance because nothing was done when s/he filled them out.a. Observation on 6/1/26 at 10:28 AM showed a recliner in the resident's room had a torn right arm and exposed stuffing. Further observation showed one small TV, and no evidence of a large TV.b. Interview with the infection control nurse on 6/3/26 at 11:56 AM revealed she had been aware aware of resident #4's chair falling apart and considered it to be an infection control risk. She had offered alternative chairs to the resident, but did not fill out a grievance and did not have documentation of her attempts to resolve the issue.c. Interview with the maintenance director on 6/03/26 at 12 PM revealed he was aware of resident #4's broken chair and had offered other chairs and they were not to the resident's liking and refused to have the broken one removed. Further interview showed he had been aware of the large TV in the resident's room being broken and had set up a smaller, working TV for the resident. He reported he expected the large TV to have been left in the resident's room, and did not know it had been removed. Further interview revealed he had no documentation of either situation and did not fill any grievances out himself. He confirmed past records for maintenance had been lost in October 2025 after change of ownership.d. Interview with the DON on 6/03/26 at 12:31 PM revealed she had been unable to find a grievance or any documentation on the resident's recliner or missing TV. She expected grievances to be filled out by resident or staff if the resident declined to fill one out for themselves. She confirmed there were missing maintenance records after the previous maintenance supervisor left the position with changed ownership.2. Interview with the resident council on 6/1/26 at 1:28 PM revealed the residents had often decided to not fill out grievance forms because they felt they were not being looked into appropriately and they did not hear back on the resolution every time. They reported the facility addressed some of the grievances individually but did not address the root cause of frequent. similar complaints.a. Review of the resident council minutes for March, April and May 2026 showed new incidents of missing clothing/items and complaints of food timing and palatability were addressed at every meeting. b. Review of the March, April and May of 2026 grievance log showed there were 15 grievances related to food, which included 11 for late and missing trays, and 4 for food quality. 5 grievances were filled out by the resident's family members that had to go find the food trays for the residents to get their meals. Grievance resolutions showed staff checked meal pass time documentation and reviewed that they had been passed out within the allotted time frame and considered those grievances unfounded. No evidence of pattern tracking or meal time observation. Food preferences were reviewed with residents on grievances with quality of meal and no evidence of food quality review.c. Review of grievances from March, April and May of 2026 showed 2 grievances on missing clothing, one had been resolved with replacement of the clothes and one unresolved but closed as completed. 3.Interview with resident #40 on 6/1/26 at 11:44 AM revealed s/he had missing clothing items, and s/he did not turn in a grievance form because the clothes were not replaced so it didn't make a difference. 4.Interview with resident #47 on 6/1/26 at 1:28 PM revealed s/he had late meal trays, and s/he did not turn in any grievances because when s/he does they just tell her/him it didn't happen. S/he had walked to the dining room at 1PM because it had not been delivered and found it in a unmanned cart in the dining room. 5.Interview with resident #15 on 6/1/26 at 1:44 PM revealed s/he had missing clothing items, and s/he did not turn in a grievance form because the clothes were not replaced and s/he felt it didn't make a difference and it just kept happening. S/he reported when s/he had been offered new clothing to replace missing clothing, s/he had not been given a choice of clothing s/he liked.6. Interview with the administrator on 6/2/26 at 3:28 PM revealed the expectation for grievance reporting had been for residents to fill them out at the time of incident. Staff should offer to fill it out with them, if the resident declined, the staff should fill one out on the resident's behalf. 7. Review of the facility policy titled Grievance Procedure Policy showed .6.grievances are resolved immediately, when possible, by the individual receiving the grievance. The individual receiving the grievance fills out the Grievance Form. 7. When immediate resolution is not possible, the grievance is routed to the Grievance Official promptly.10. The person with the grievance has a right to a written decision regarding his/her grievance.The administrator analyzes grievances monthly for tracking and trending.

Based on resident interview, staff interview, and review of investigation documentation, the facility failed to ensure a thorough investigation of an allegation of physical abuse for 1 of 5 sample residents (#47). The findings were: 1. Review of the facility's investigation documentation showed an allegation of physical abuse involving residents #47 and #30 was reported on 5/14/26. The facility did investigate and placed a 1:1 on the perpetrator right away. The perpetrator room was changed to a different hall. The facility did interview others, and staff. The facility did do abuse education with staff. However, the facility failed to assess the victim right away and waited 2 days later to assess for injuries. 2. Review of the MDS quarterly assessment dated [DATE] for resident #47 (victim) showed a BIMS score of 12 out of 15 (moderate cognitively impaired). The resident did have verbal behavioral symptoms directed towards others. S/he had diagnosis including medically complex conditions, type 2 diabetes mellitus, polyneuropathy chronic pain, and tension-type headache. 3. Review of the MDS significant change assessment dated [DATE] showed resident #30 (perpetrator) had memory problem short and long term and did not have behaviors present. The diagnosis included non-traumatic brain dysfunction, dementia without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety, non-Alzheimer's dementia, and age-related cognitive decline. 4. Interview with the victim on 6/2/26 at 3:30 PM revealed the perpetrator was resident #30. S/he stated the perpetrator had motioned for him/her to come over. S/he stated that s/he bent over so s/he could tell him/her something. S/he stated the perpetrator used his/her right hand and grabbed their left buttock. S/he stated it was not welcomed or did not want the touch. S/he stated s/he did report the incident to the social services. 5. Interview with CMA #1 on 6/2/26 at 5:05 PM revealed resident #47 (victim) reported resident #30 (perpetrator) made an inappropriate comment to him/her. He stated he walked resident #47 down to social services. 6. Interview with Social Services #1 on 6/2/26 at 5:13 PM revealed the victim reported to her that the perpetrator wanted him/her to sit on his/her lap (S/he was demonstrating by slapping his/her lap). She stated they put a 1:1 on the perpetrator and did a room change. 7. Interview with the administrator on 6/2/26 at 5:13 PM revealed they made sure the victim was safe. She stated the staff were educated on abuse. She stated the victim had changed his/her story 3 times. She revealed the facility did not do a skin assessment on the victim right away, and the assessment was done 2 days later.

Based on observation, medical record review, and staff and resident interview, the facility failed to ensure the MDS assessment was accurate in reflecting the resident's status for 1 of 22 sample residents (#10). The findings were:1. Review of the 5/4/26 quarterly MDS assessment showed resident #10 had a BIMS score of 14 out of 15 (cognitively intact), an indwelling catheter and an ostomy. 2. Observation on 5/31/26 at 3:39 PM showed resident #10 sitting in the resident's room a urinary foley catheter tubing and catheter collection bag was noted. Interview with the resident at that time revealed the staff took care of the catheter and collection bag. S/he revealed s/he only had the urinary catheter. 3. Review of the medical record for resident #10 showed the medical history included neurogenic bladder, and obstructive a reflux uropathy. Further review showed the resident's care plan showed the care for an indwelling urinary catheter. Review of the physicians' orders showed Suprapubic catheter sized 16 F (French) balloon: 10cc (cubic centimeter), as needed damage, occlusion, or obtaining UA (Urinalysis) dated 2/2/26. Further review showed no mention of an ostomy. 4. Interview with the MDS Coordinator on 6/2/26 at 3PM revealed PCC (Point Click Care) automatically pulls the ostomy information into the system. She stated she did not catch it. She stated the system did not pull from the RAI, it pulled from any evaluations within the system. She confirmed it was an MDS error. and she would do a modification on it right away. She stated there was no policy that she was aware of. She stated it was their policy is to follow the RAI manual.

Based on observation, and staff interview the facility failed to ensure the daily staff posting data was posted in a prominent place readily accessible to residents, staff, and visitors for 1 of 4 days (Sunday). The findings were: Observation on 5/31/26 at 3:18 PM showed there was no daily staff data sheet posted. Interview with the DON on 5/31/26 at 4:45 PM revealed the facility failed to post the daily staff posting data sheet for the day.

Based on observation, staff interview and policy and professional standards review, the facility failed to ensure standard precaution implementation and semi-critical items were cleaned prior to use for 1 of 8 sample residents (#8) reviewed for infection control. The findings were:1. Observation on 6/2/26 at 10:40 AM showed RN #2 and the wound care nurse had entered resident #8's room to clean the resident of incontinence and complete wound care. The following concerns were identified: a. RN #2 donned gloves and a gown and cleaned the resident of stool. She then moved to the other side of the bed to hold the resident on his/her side for the wound nurse to provide care without doffing her dirty gloves. b. The wound care nurse donned gloves and a gown and held the resident on his/her side while incontinence care was performed then moved to the other side of the bed to perform wound care on an open sacral pressure ulcer. He opened a calcium alginate dressing and had a coworker get his scissors out of his pocket, used them to cut the dressing to wound size and then placed them back in his pocket. 2.Interview with the wound care nurse on 6/3/26 at 3:48 PM confirmed he kept his scissors in his pocket and demonstrated they had been inside a plastic bag inside his pocket. He stated he cleaned the scissors before he put them into the bag, and confirmed he did not clean them after removing them from his pocket prior to use on the wound dressing.3. Interview with the DON on 6/3/26 at 4:03 PM revealed the expectation for wound care was that all tools would be cleaned before using. 4. Review of the CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings showed Use an alcohol-based hand rub or wash with soap and water for the following clinical indications. e. Before moving from work on a soiled body site to a clean body site on the same patient f. Immediately after glove removal.Clean and reprocess (disinfect or sterilize) reusable medical equipment.prior to use on another patient and when soiled. a. Consult and adhere to manufacturers' instructions for reprocessing.Reusable equipment should also be transported and stored in a manner to prevent contamination when moved between treatment areas. For example, bandage scissors should not be carried in pockets 5. Review of the facility policy titled Cleaning and Disinfecting Resident Care Items and Equipment showed 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care:.b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin.2. Critical and semi-critical items are sterilized/disinfected in a central processing location and stored appropriately until use.

Based on medical record review, facility incident investigation review, facility performance improvement plan review, and staff interview, the facility failed to protect the resident's right to be free from verbal abuse by a resident for 1 of 3 incidents of resident-to-resident allegations of abuse reviewed. This failure affected resident #13. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 6/12/25. The findings were:1. Review of the 9/27/25 MDS quarterly assessment for resident #13 showed the resident was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15 (cognitively intact), had a mood score of 1 out of 10; and did not exhibit any behaviors or refusal of care during the look-back period. The resident had a diagnoses which included chronic respiratory failure with hypoxia, anxiety disorder, and depression. Further review of the resident's medical record showed s/he was discharged to an assisted living facility on 12/1/25. Review of the 5/6/25 annual MDS assessment for resident #7 showed the resident was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15, a mood score of 4 out of 10, and did not exhibit any behaviors or refusal of care during the look-back period. The resident had a diagnosis of bipolar disorder. Review of a 5/7/25 nurse progress note showed while the resident was participating in a shopping trip when s/he asked to be taken to the hospital. Resident #7 as admitted to the hospital with aspiration pneumonia and was readmitted to the facility on [DATE]. Review of a nurse progress notes from 5/19/25 through 5/24/25 showed resident #7 had an increase in aggressive and inappropriate sexual behaviors toward staff, refusal of care, and was delusional at times. Review of the facility's incident investigation report showed resident #13 was involved in an altercation with resident #7 on 5/28/25. Resident #13 had asked resident #7 to stop teasing an unidentified resident and resident #7 responded with calling resident #13 a fat bitch, told him/her to shut the fuck up, and threatened to knock [resident #13] fucking teeth out. Resident #13 became visibly upset with resident #7 and responded with go ahead and hit me then. As more staff arrived in the dining area resident #7 left the area and returned to his/her room. The following actions were taken by the facility:a. Law enforcement was notified following the incident with no citations issued.b. Resident #7 was placed on 15-minutes checks and staffing was increased to ensure resident safety.c. A surveillance monitor was placed outside of resident #7's room to alert staff when s/he exited the room.d. Resident #7's primary healthcare provider was notified and the resident was assessed the day following the incident. A medication regimen review was also requested.e. The facility offered to relocate resident #13 to another room; however, s/he declined and stated s/he was fine. f. The social services director met with resident #13 three times per week for 1 month to ensure the resident did not suffer any additional trauma related to the incident.g. Education was provided to all staff and managers on 5/29/25 on abuse and neglect.h. Resident safety interviews were conducted with residents throughout the facility. 2. Interview with the DON on 2/12/25 at 11:18 AM revealed resident #7 showed an increase in behaviors after being treated for pneumonia in May. Following the incident resident #7 was diagnosed with an infection, was placed on antibiotics, and the resident's antipsychotic medication was increased. The DON stated resident #7 had not been involved in any further resident-to-resident incidents. 3. Review of a 6/12/25 Social Services Quality Assurance Committee Report showed abuse Allegations Reported in May: There was one allegation of verbal abuse reported to the State in May: It was resident-to-resident incident. There was a verbal exchange between a male and female resident in the dining room. There was no physical exchange. A camera has been placed in the [gender] resident's hallway to help monitor [his/her] where abouts. Interviews were completed with the [gender] resident involved and with other residents per protocol. No further incidents between these two residents have been noted at this time.

Based on staff interview, the facility failed to ensure the dietary manager met the required qualifications. The facility census was 48. The findings were: Interview with the dietary manager on 10/9/24 at 11:24 AM revealed the manager had one more month to complete the certified dietary manager coursework. Further interview with the dietary manager revealed the facility had two part time dietitians who were not on site. Interview with the administrator on 10/10/24 at 10:57 AM confirmed the facility did not have a qualified dietary manager or a full-time dietitian.

Based on staff interview and policy and procedure review, the facility failed to ensure a qualified individual was designated as the facility infection preventionist. The facility Census was 48. The findings were: Interview with the DON on 10/10/24 at 9:41 AM revealed she had been covering the infection control program since May and she had not completed any specialized training in infection prevention. Review of the facility policy titled Infection Preventionist last revised September 2022 showed .Specialized Training .1. The infection preventionist has obtained specialized IPC beyond initial professional training or education prior to assuming the role .2. Evidence of training is provided through a certificate(s) of completion or equivalent documentation .

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure medications were labeled with an open date or not expired in 2 of 5 medication storage areas (100 hall medication cart, 200 hall medication cart). The findings were: 1. Observation of the 100 hall medication cart on [DATE] at 8:52 AM showed an Insulin Glargine 100 units/milliliter pen for resident #5 was not labeled with an open date and did not indicate when the medication should be discarded. The following concerns were identified: a. Interview with LPN #1 on [DATE] at 8:57 AM revealed the person who opened the insulin should label it with the date it was opened and with a 28-day expiration date. She confirmed she did not know if the insulin, which she administered to the resident, was within the useable timeframe or was expired. b. Interview with the DON on [DATE] at 10:39 AM confirmed insulin pens should be labeled with the open date. She revealed nurses should not administer the medication and should discard the pen if it was not labeled. 2. Observation of the 200 hall medication cart on [DATE] at 8:29 AM showed a multidose bottle of Aspirin 81 milligram (mg) tablets with a manufacturer's expiration date of ,d+[DATE]. Interview with RN #2 at that time revealed multidose medication bottles should not be used after the manufacturer's expiration date on the bottle. 3. Interview with the DON on [DATE] at 4:10 PM stated her expectation is that the nurse who dispensed the medication should check the expiration date prior to administration. 4. Review of the policy titled Administering Medications, provided by the DON on [DATE], showed .The expiration/beyond use date on the medication label is checked prior to administering . 50665

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure infection control procedures were implemented for 4 of 4 sample residents (#2, #14, #23, #41) who required enhanced barrier precautions. The findings were: 1. Observation on 10/9/24 at 9:56 AM showed CNA #1 and CNA #2 assisted resident #41 to transfer from the bed to the wheelchair. Prior to the transfer, CNA #1 applied gloves, disconnected the resident's wound vacuum, and placed the tubing over the bed. Following the transfer, the end of the tubing for the wound vacuum dropped on floor and CNA #1 picked it and reconnected the tubing, without disinfecting the open end of the tubing which was on the floor. Further observation showed neither CNA used enhanced barrier precautions during the care. Interview with the DON and regional nurse on 10/9/24 at 11:35 AM revealed open tubing dropped on the floor should not have been reconnected without disinfection of the tubing. 2. Observation on 10/9/24 at 3:51 PM showed CNA #3 and CNA #4 entered resident #2's room with a sit to stand lift, applied gloves, and positioned the lift sling behind the resident. The CNAs assisted the resident to stand and removed his/her pants. The resident had a dressing present on his/her coccyx which was not attached on bottom right side. CNA #4 performed perineal care and without removing her soiled gloves, touched a bottle of silicone cream, the outside of the resident's clean brief, and the resident's pants when she pulled them up. The CNA also touched the lift, the lift sling, a wipe container, and a bedside table without removing the gloves. Further observation showed no enhanced barrier precautions were used. Interview with the DON on 10/10/24 at 9:41 AM revealed gloves should be changed prior to touching clean surfaces. 3. Observation of catheter care performed on resident #14 on 10/9/24 at 9:44 AM showed the CNA #3 performed the catheter care while wearing only gloves. Observation of resident #14's room at that time showed no enhanced barrier precaution signage posted in the room or additional personal protective equipment (PPE), other than gloves, was available. Interview with the CNA on 10/9/24 at 9:52 AM revealed she was not aware of the need for enhanced barrier precautions when performing catheter care. 4. Observation of resident #23 on 10/7/24 at 2:08 PM, 10/8/24 at 9:43 AM, and 10/9/24 at 8:31 AM, showed the resident was in his/her wheelchair, his/her bilateral lower legs were wrapped with a dressing, and the resident's bare feet were on the floor. Observation of the resident's room on 10/8/24 at 8:31 AM showed no PPE, other than gloves, was available. Interview with LPN #1 on 10/9/24 at 10:40 AM revealed she was not aware of any interventions in place to prevent reinfection of the resident's legs, or keep his/her bare feet off of the floor. The LPN revealed there were no residents on enhanced barrier precautions on South or North Birch Halls, which was where the resident's room was located. Interview with the DON on 10/9/24 at 10:55 revealed she was unaware the resident did not have foot pedals on his/her wheelchair or that his/her bare feet were on the floor. 5. Interview with CNA #1 on 10/9/24 at 9:52 AM revealed she was not aware of enhanced barrier precautions until 10/9/24 when education was provided by the DON. 6. Interview with CNA #2 on 10/9/24 at 9:52 AM revealed she was not aware of enhanced barrier precautions until 10/9/24 when education was provided by the DON. 7. Review of policy titled Enhanced Barrier Precautions, provided by the DON on 10/9/24, showed .Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multidrug resistant organisms (MDRO) to residents. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. EBP's are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization . 8. Review of the policy titled Briefs/Underpads dated 2001 showed .12. Perform perineal care the resident's back side .14. Remove gloves, sanitize hands and replace with clean gloves .

Based on observation and staff interview, the facility failed to ensure ventilation was working in 7 of 10 resident rooms observed. The census was 48. The findings were: 1. Observation of room [ROOM NUMBER] on 10/10/24 at 8:16 AM showed the ventilation in the room was not working. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 8:58 AM confirmed the ventilation in the room was not working. 2. Observation of room [ROOM NUMBER] on 10/10/24 at 8:20 AM showed the ventilation in the room was not working. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 8:54 AM confirmed the ventilation in the room was not working. 3. Observation of room [ROOM NUMBER] on 10/10/24 at 8:24 AM showed the ventilation in the room was not working. 4. Observation of room [ROOM NUMBER] on 10/10/24 at 8:26 AM showed the ventilation in the room was not working. 5. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 8:32 AM showed the ventilation in the room was not working. 6. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 8:38 AM showed the ventilation in the room was not working. 7. Observation of room [ROOM NUMBER] with the maintenance director on 10/10/24 at 9 AM showed the ventilation in the room was not working, the floor was sticky, and the room smelled of urine. Interview with the maintenance director at that time confirmed the ventilation system was not working in some of the resident rooms.

Based on observation and resident and staff interview, the facility failed to ensure a clean environment for 1 of 3 sample residents (#5) reviewed for bowel and bladder incontinence and activities of daily living. The findings were: 1. Observation of resident #5's room on 10/7/24 at 2:28 PM showed the resident was in his/her room with a visitor and there was a strong urine odor present, which could be smelled in the hallway. 2. Observation of resident #5's room on 10/8/24 at 8:22 AM showed the room had a very strong urine odor and the floor was sticky. 3. Observation of resident #5's room on 10/9/24 at 10:24 AM showed a housekeeper #1 was cleaning the resident's room. Upon completion at 10:32 AM, the housekeeper #1 exited the room; however, the urine odor and sticky floors remained. Interview with the resident at that time revealed s/he could not smell the odors; however, s/he asked housekeeper #1 to mop again due to the floors remaining sticky. 4. Observation of resident #5's room on 10/10/24 at 9 AM showed the room smelled of urine, the bathroom ventilation was not working, and the resident's floor was sticky. 5. Interview with the housekeeping manager on 10/10/24 at 9:13 AM revealed the facility was aware of increased urination on the floor in resident #5's room and revealed they did not perform a heavy mop on the floor while the resident was in the room due to potential fall risk. She revealed nursing staff had a mop bucket available to clean if housekeeping was not available.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified and monitoring of target symptoms was completed for 1 of 5 sample residents (#2) reviewed for unnecessary psychotropic medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had diagnoses which included non-Alzheimer's dementia, anxiety disorder, and depression. Review of the physician orders showed the resident received Sertraline (antidepressant) 100 milligrams (mg) by mouth daily for anxiety with depression. The following concerns were identified: a. Review of the physician orders showed behaviors related to the use of Sertraline were to be monitored every shift; however, there were no medication or resident specific target symptoms identified; b. Review of the care plan, last revised on 10/7/24, showed no medication or resident specific target symptoms were identified related to the use of the Sertraline. c. Review of the medication administration record for October 2024 showed no evidence of medication or resident specific target symptoms were identified related to the use of the Sertraline. d. Review of the Anti-Depressant Informed consent for medication dated 8/23/24 showed the consent was for Sertraline; however, there was no medication or resident specific target symptoms were identified related to the medication use. e. Interview with the DON and regional nurse on 10/9/24 at 3:09 PM revealed target symptoms should be on the care plan, medication administration record, or medication consent. f. Interview with the DON and regional nurse on 10/10/24 at 10:16 AM confirmed the resident did not have resident or medication specific target symptoms identified. 2. Review of the policy titled Psychotropic Medication Use dated July 2022 showed .Resident Evaluations .3. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether: b. signs and symptoms are clinically significant to warrant medication therapy .

Based on medical record review, staff interview, and review of incident and quality improvement documentation, the facility failed to ensure residents were free from physical abuse by other residents for 2 of 10 sample residents (#2, #5), resulting in harm to resident #5 who suffered a fracture. The findings were: 1. Review of the 2/25/24 admission Minimum Data Set (MDS) assessment showed resident #2 (victim) had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 (significant cognitive impairment). The diagnoses included dementia, COPD, gout, pain and skin cancer. 2. Review of the 4/3/24 comprehensive MDS assessment showed resident #5 (victim) had a BIMS score of 9 out of 15 (moderate cognitive impairment) and diagnoses including diabetes, hypertension and respiratory failure. 3. Review of the 3/26/24 admission MDS assessment showed resident #1 (perpetrator) had a BIMS score of 4 out of 15 (significant cognitive impairment). The diagnoses included dementia, stroke with right sided weakness, and diabetes. 4. Review of an incident report dated 4/26/24 showed a resident-to-resident altercation between resident #1 and resident #5 which resulted in injury to resident #5. Resident #5 stated resident #1 came into his/her room and was agitated. Resident #1 pushed resident #5 backwards and s/he hit their head and sustained a skin tear to the arm. The resident also complained of back pain. Resident #5 was sent to the emergency room where it was determined s/he had a closed fracture of the spinous process of the thoracic vertebra. The report showed resident #1 was redirected and placed on increased supervision. 5. Interview with the director of nursing (DON) on 5/22/24 at 11:50 AM revealed the facility implemented a quality assessment process improvement (QAPI) program addressing the resident-to-resident abuse that occurred between residents #1 and #5 for failure to protect facility residents from abuse. Resident #1 was placed on increased observation while awake. Review of the QAPI program initiated after the resident-to-resident altercation between residents #1 and #5 showed all residents residing in the community were potentially at risk and the facility provided staff training including behavior management and working with residents with behaviors to decrease the risk of aggression towards other residents and a date of compliance of 5/8/24. 6. Review of an incident report dated 5/9/24 showed staff found resident #1 in the room of resident #2. Resident #2 stated resident #1 hit him/her on the shoulder and resident #1 stated, I'm going to hit [him/her] again. There was slight redness on the shoulder of resident #2. Resident #1 was placed on 1:1 observation while awake and plans were made to transfer resident #1 to another facility as soon as a room became available. 7. During an interview on 5/22/24 at 4:18 PM the DON stated resident #1 was on 1:1 observation and the altercation between resident #1 and #2 occurred at shift change when the resident was unsupervised. 8. Review of the facility investigation from the resident-to-resident altercation between residents #1 and #5 on 4/26/24 showed the facility substantiated the allegation. Further review showed the facility investigation of the altercation between resident #1 and #2 on 5/9/24 was also substantiated.

Based on resident representative and staff interview, medical record review, facility incident investigation review, facility performance improvement plan review, and policy and procedure review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 3 sample residents (#43). This failure resulted in harm to resident #43 who experienced sexual abuse a reasonable person would have found humiliating, intimidating, demeaning, and degrading. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 7/19/23. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #43 had short-term and long-term memory problems and diagnoses which included Alzheimer's disease, cerebrovascular accident, transient ischemic attack or stroke, and non-Alzheimer's dementia. Further review showed the resident required extensive physical assistance of 1 person for bed mobility, transfers, dressing, toilet use, locomotion on and off the unit, and personal hygiene. Review of the care plan showed a new focus was initiated on 7/17/23 titled Resident experienced traumatic event. The following concerns were identified: a. Review of a progress note for resident #43 dated 7/17/23 and timed 9:49 AM showed the nurse found resident #44 standing at resident #43's bedside, undressed, with his/her hand in resident #43's brief. Resident #44 believed resident #43 was his/her spouse. The nurse removed resident #44 from the room and assessed resident #43's genitals. The nurse did not identify any injuries or abnormalities and the resident did not report any pain at that time; however, the resident showed symptoms of pain following the incident which resulted in transfer to the hospital. b. Review of an Alleged Abuse Report for resident #43 dated 7/17/23 and timed 6:10 AM showed the nurse found resident #44 undressed at the bedside of resident #43. Resident #44 had his/her right hand under resident #43's brief and believed resident #43 was his/her spouse. Resident #44 was removed from the room and resident #43 was assessed for injuries. Further review showed resident #43 was assessed as having a pain score of 4 due to signs and symptoms of pain based on negative vocalization, facial expression, body language and consolability. The resident was sent to the hospital for evaluation. c. Review of a hospital record for resident #43 dated 7/17/23 and timed 8:54 AM showed Found this AM by nursing staff at [facility name] with undressed [female/male] who had hand down into [his/her] brief. No witnessed [genital to genital] contact. Pt states that [s/he] is unsure of what occurred this AM or why [s/he] is being seen in ER now. Denies pain or injury during external genitalia exam. Redness noted in abdominal fold-photograph taken. Pt confused at baseline. d. Interview with RN #1 on 7/26/23 at 2:02 PM revealed resident #44 had dementia with short-term memory loss and a new diagnosis of urinary tract infection (UTI) which elevated his/her confusion at the time of the incident. The RN revealed prior to the incident, resident #44 had shown aggression towards staff, which included making threats, cursing, and physical behaviors; however, the resident had never directed any behaviors toward other residents. The RN revealed the day of the incident was the first time he had observed resident #44 wander into other rooms and when he found the resident in the room of resident #43, resident #44 was completely undressed standing next to the bed of resident #43. The RN revealed resident #43's brief was not attached on the right side and resident #44 had his/her hand in the brief; however, the RN could not see what resident #44 was doing with his/her hand. The RN revealed resident #43 remained asleep during the encounter and resident #44 became aggressive when the staff member attempted to remove him/her from the room. The RN revealed resident #44 was provided a 1 to 1 staff member and resident #43 was assessed for injuries. Further interview revealed he did not identify any injuries to resident #43. e. Interview with the social services director on 7/26/23 at 11:27 AM revealed the resident representative for resident #43 had visited the facility that day and did not want to be interviewed related to the incident. Further interview revealed the representative was happy with the resident's care and did not feel the resident was unsafe at the facility. f. Review of a discharge summary note for resident #44 dated 7/17/23 and timed 12:51 PM showed the resident discharged from the facility to home with his/her spouse. g. Interview with the resident representative for resident #44 on 7/26/23 at 5:29 PM confirmed the resident discharged from the facility on 7/17/23 after the incident. h. Interview with the administrator, DON, ADON/infection preventionist, SSD, and regional resource nurse on 7/27/23 at 9:37 AM confirmed resident #43 was asleep in bed at the time of the incident with resident #44. The interview revealed resident #44 had behaviors which included using foul language, yelling, and wandering and interventions were different with each behavioral display. Further interview confirmed a reasonable person who was cognitively intact may have been fearful of resident #44 in a similar situation. 2. Review of the policy titled Abuse and Neglect Prohibition last revised July 2018, showed .Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms .Sexual abuse is non-consensual (the resident does not consent) sexual contact of any type with a resident. It may include, but is not limited to, sexual harassment, sexual coercion, and sexual assault . 3. Review of the facility's performance improvement plan of correction dated 7/17/23 showed corrective action included immediate separation of the residents, assessment, first aid, and hospital transfer for evaluation and treatment for resident #43, implementation of 1 to 1 staffing for resident #44 until the resident's risk for unprovoked sexual behavior was addressed or the resident was discharged from the facility. The facility contacted the physician, resident representative, ombudsman, and law enforcement, updated the care plans for both residents, and initiated social services 1 to 1 visits at least 3 times weekly for 1 month for resident #43. The facility reported the incident to the state survey agency and initiated an abuse investigation which included staff and resident interviews. The facility's plan showed all residents were potentially at risk and interviewed all residents, to identify additional incidents or allegations. Further the facility reviewed all skin assessments of incidents/accidents for the prior 30 days. The facility's plan showed system changes included reeducation of all staff on abuse, behavior management, and working with residents with behaviors to decrease risk of aggression and sexually acting out toward other residents. The facility's plan showed monitoring was initiated by reviewing the incident reporting system, reviewing the grievance management system, conducting resident and family interviews, and ombudsman feedback. The facility initiated a review of incident/accident documentation on residents residing at the facility 3 times weekly, decreasing to weekly for 1 month, and then as needed. The facility's plan showed on the spot education will be performed for all staff members present during an incident and counseling will be provided as indicated. The facility's plan showed any issues identified will be trended and reviewed in the facility's QAPI meeting to ensure the plan was implemented, sustained, and evaluated. The facility was determined to be in substantial compliance as of 7/19/23.

Based on medical record review, staff interview, hospital record review, hospital staff interview, and policy and procedure review, the facility failed to ensure residents received care and services necessary to prevent pressure ulcers from developing for 1 of 6 sample residents (#1) reviewed for pressure ulcer risk. This failure resulted in harm to resident #1, who was discovered to have multiple pressure injuries upon transfer to the ED. The findings were: Review of the 12/6/22 admission MDS assessment showed the resident was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus II, osteoporosis, and non-Alzheimer's dementia. The review showed the resident was rarely or never understood. Further review showed the resident required the extensive assistance of 1 staff member for bed mobility and personal hygiene. Review of the resident's 12/13/22 Braden Scale For Predicting Pressure Sore Risk assessment showed a score of 8, which indicated the resident was at very high risk of developing pressure ulcers. Review of all progress notes from admission through 1/1/23 showed no evidence the resident had pressure ulcers. Review of the 12/27/22 Skin and Wound-Total Body Skin Assessment showed the resident had no new pressure ulcers or wounds. Review of the 12/29/22 SBAR (Situation, Background, Assessment, Recommendation) Communication Form showed there were no changes to the resident's skin. Review of the 12/29/22 note timed at 4:12 PM showed the resident was unresponsive after several days of decline, and the family requested the resident be sent to the local ED. The assessment at that time showed no changes to the resident's skin. Review of the 12/29/22 progress note timed 10:43 PM showed the resident returned to the facility from the local ED with orders to start procedures for comfort care per family request. Review of the 1/1/23 progress note timed 12:21 PM showed the family requested the resident again be transferred to the local hospital, and the resident was sent to the ED by non-emergent transfer at 11:40 AM. Review of the related 1/1/23 SBAR Summary for Providers note timed 3:34 PM showed the assessment area for skin was left blank. Interview with the director of nursing on 3/9/23 at 12:05 PM revealed her primary concern on 1/1/23 was starting intravenous fluids and transferring the resident to the local ED per family request. The DON further stated she did not observe any pressure ulcers or skin issues on the resident at that time, but she confirmed she did not perform a head to toe skin assessment. Review of the resident's care plan showed the facility failed to ensure a plan to address the resident's very high risk of developing pressure ulcers. Review of the activities of daily living plan showed the resident required extensive assistance from staff for bed mobility, locomotion, and transfers. Further review of the care plan showed it failed to address the need for repositioning and off-loading. The following concerns were identified: 1. Review of the hospital record showed the resident was admitted to the local ED on 1/1/23 at 12:07 PM and was admitted to the hospital on 1/1/23 at 4:04 PM with a diagnosis of sepsis and a consult for the wound team to examine the resident on 1/2/23. Review of a 1/1/23 nursing note timed 12:15 PM by hospital RN #1 showed the following, On arrival, the patient has new wounds that were not present during [resident #1's] previous stay in the ED, days before. There is a skin tear to [resident #1's] medial knee area and what appear to be blisters from pressure to [his/her] sacral area with boggy centers. [Resident #1] has dry mucous membranes with severe halitosis, dirty teeth, and dry lips. [Resident #1's] perineal area is malodorous and [s/he] has crusting in [his/her] groin and [genitalia]. There is dried crusted bowel movement between [his/her] buttocks. Review of an ED note on 1/1/23 at 12:51 PM written by hospital physician's assistant #1 showed, Spoke with [resident's long-term care physician], states patient has been obtunded [having diminished arousal and awareness] since 12/31 . 2. Review of the hospital record showed the following notes written on 1/1/23 by RN #2 at 4 PM, .Wound #2 Pressure Injury Buttocks Placed Present on Hospital Admission: Yes. Primary Wound #2 Primary Wound Type: Pressure Injury. Wound Assessment: Purple; Fluid Blister; Nonblanchable erythema, Drainage: Scant, Drainage Description: Serosanguinous, Peri-wound Assessment: Non-blanchable erythema; Draining; Blister (Blister open) Wound Covering: Open to air. 3. Review of a General Admission H&P (history and physical) dated 1/1/23 and timed 3:44 PM by hospital DO #1 included the following, .Pressure ulcer Chronic, present on admission. Present over sacral area. Per review of records and discussion with emergency room staff, not present on 12/29/22 when seen that day . 4. Review of a hospital record Daily Progress Note dated 1/2/23 at 11:10 AM written by FNP #1 included the following, .Pressure ulcer Assessment: Chronic, present on admission. Present over sacral area, left heel, left knee, right foot, and right elbow. Per review of records and discussion with emergency room staff, not present on 12/29/2022 when seen that day. Small skin tear on medial left leg as well. Plan: Wound care to evaluate. End of life/Comfort Care. 5. Review of hospital In-Patient Physical Therapy Wound Care Evaluation notes and pictures documented on 1/2/23 by DPT #1 with a time in of 9:52 AM and an out time of 10:39 AM showed the following assessment information for each wound: a. On 1/2/23 at 10:17 AM, Wound 01/01/23 #2 Pressure Injury Buttock (Active), Wound Assessment: Boggy; Draining; Blister; Purple, Peri-wound Assessment; Non-blanchable erythema; Intact, Peri-Wound Skin Temp: WNL, Dressing Status: Dressing applied, Drainage: Small, Drainage Description: Serosanguinous, Periwound Treatment: Barrier-skin barrier wipe, Wound Treatment: Cleansed, Wound Covering: Foam Dressing, Pressure Injury Stage: DTPI, Wound length (cm): 9 cm, Wound Width (cm): 10 cm, Wound Surface Area (cm^2): 90 cm^2, Pressure Injury Stage: Deep Tissue. b. On 1/2/23 at 10:12 AM, Wound 01/01/23 Pressure Injury Elbow Right (Active), Wound Assessment: Nonblanchable erythema, Peri-wound Assessment: Intact, Peri-Wound Skin Temp: WNL, Dressing Status: Dressing discontinued, Drainage: None, Wound Covering: Open to air, Pressure Injury Stage: 1, Wound Length (cm): 1.1 cm, Wound Width: 1.5 cm, Wound Surface Area (cm^2): 1.65 cm^2, Pressure Injury Stage: Stage I. c. On 1/2/23 at 9:59 AM: Wound 01/01/23 #4 Pressure Injury Foot Right; Lateral (Active), Wound Assessment: Purple; Nonblanchable erythema, Peri-wound Assessment: Non-blanchable erythema, Peri-Wound Skin Temp: Cool, Drainage: None, Wound Treatment: Other (Comment), Wound Covering: Open to air, Pressure Injury Stage: DTPI, Wound Length (cm): 1.1 cm, Wound Width (cm): 1.2 cm, Wound Surface Area (cm^2): 1.32 cm^2, Pressure Injury Stage: Deep Tissue. d. On 1/2/23 at 10:01 AM: Wound 01/02/23 Pressure Injury Foot Right; Lateral; Plantar (Active), Wound Assessment: Purple, Peri-wound Assessment: Non-blanchable erythema, Peri-wound Skin Temp: Cool, Drainage: None, Wound Treatment: Other (Comment), Pressure Injury Stage: DTPI, Wound Length (cm): 2 cm, Wound Width (cm): 1.7 cm, Wound Surface Area (cm^2): 3.4 cm^2, Pressure Injury Stage: Deep Tissue. e. On 1/2/23 at 10:03 AM: Wound 01/02/23 Pressure Injury Heel* Left (Active), Wound Assessment: Boggy; Purple, Peri-wound Assessment: Non-blanchable erythema, Callus, Peri-Wound Skin Temp: Cool, Drainage: None, Wound Treatment: Other (comment), Pressure Injury Stage: DTPI, Wound length (cm): 6.8 cm, Wound Width (cm): 5.5 cm, Wound Surface Area (cm^2): 37.4 cm^2, Pressure Injury Stage: Deep Tissue. f. Review of the 1/2/23 In-Patient Physical Therapy Wound Care Evaluation showed: Assessment: Wounds evaluated, photographed, and treated with focus on comfort. Purple foot wounds are consistent with deep tissue injury from prolonged pressure over bony prominence . Applied foam sacral dressing to wound #2 as this will decrease painful shearing on the bedding. Dressing on [left] knee as well due to drainage. Otherwise wounds were left open to air and offloaded using pillows 6. Interview with CNA #1 on 3/13/23 at 4:05 PM revealed the aide had cared for the resident during the last few days at the facility and tried to reposition the resident every 2 hours, but there were times it may have been longer than every two hours between repositioning, and the aide could not recall observing any skin issues on the resident. 7. Interview on 3/9/23 at 12:20 PM with the long-term care family nurse practitioner (FNP) #1 for the resident at the facility confirmed the facility staff had not made her aware of the resident's wounds. She was unaware of the wounds until the 1/1/23 hospital admission when hospital staff at the facility notified her. She confirmed some of the resident's wounds were pressure wounds. She stated the hospital wound team were the ones who assessed the wounds, and she stated there was documentation in the hospital record. She would not provide an opinion on the severity of the wounds or the timeframe for when they occurred. 8. Interview with hospital DO #1 on 3/13/23 at 11:27 AM confirmed he assessed the resident in the local ED on 1/1/23 after concerns about the resident's wounds were brought to his attention by hospital RN #1. He stated that he was not present in the ED on 12/29/22 and did not observe the resident at that time. He stated the ED staff who were present on 12/29/22 were unaware of any wounds on the resident during that ED visit. He further stated he put in a consult for the wound team to assess the resident's wounds for 1/2/23. He was aware of the resident's sacral wound, and confirmed it was a pressure wound. He was unsure as to the timeframe of the sacral wound and was unaware of the left heel wound until the wound team assessed the resident on 1/2/23. He was non-committal when asked if the pressure ulcers were preventable, but he stated it was best practice to ensure a repositioning schedule for the resident to lessen the likelihood of pressure ulcer development. 9. Interview with hospital RN #1 on 3/14/23 at 9:50 AM showed she cared for the resident at the local ED on 12/29/22 and 1/1/23. She stated no wounds were identified on the resident on 12/29/22, but further confirmed the wound on the left heel could have been overlooked. She stated that the resident's multiple skin issues, which included a pressure wound to the sacral area, were concerning enough that she brought them to the attention of hospital DO #1. She confirmed she did not observe the pressure ulcer on the resident's left heel. She further stated it was her professional opinion the resident was not repositioned adequately between 12/29/22 and 1/1/23 at the facility to prevent pressure ulcers. 10. Interview with the assistant director of nursing on 3/13/23 at 4:20 PM confirmed the facility failed to develop a care plan to address the resident's very high risk of developing pressure ulcers. 11. According to the policy titled, Prevention of Pressure Injuries last revised April 2020, Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Skin Assessment: .3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs .e. Reposition resident as indicated on the care plan .Mobility/Repositioning: 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. 3. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions .Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.

Based on medical record review, hospital record review, facility policy and procedure review, and family and staff interview, the facility failed to accurately assess a type of wound, and obtain treatment in a timely manner for 1 of 5 sample residents (#75) at risk for impaired skin integrity, which resulted in health decline and hospitalization for the resident. The findings were: Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission data collection tool dated 6/18/13 revealed the resident had no wounds, although "bruises were noted on body." Review of Medicare daily skilled nursing notes dated 7/11/13 revealed the resident developed a "hard raised area" on (his/her) L (left) upper buttocks next to coccyx. Area blanches. Notified MD via nurse (nurse's name)...Notified family of area. N.O. (nursing order) to monitor area q.d. (every day) et (and) notify MD if area increases in size." The size of the raised area was not noted in the nursing notes. Review of Physician's Telephone Orders revealed an order dated 7/11/13 revealed "Stage II to L buttock resolved. DC [MEDICATION NAME]. Hard 2 cm X 2 cm raised area noted on L (left) buttock, next to coccyx. Monitor q (every) day et (and) notify MD if area increases in size." The order was not signed by the physician. Review of a Physician's Telephone Order dated 7/14/13 (three days later) revealed "Notification: Hard, red, swollen area on L (left) inner buttock. Please advise." Review of the facility's "Skin and Wound Management Program Overview," last revised on 6/1/07, revealed "When a break in skin integrity is identified, the licensed nurse will document a detailed assessment in the medical record including type (pressure ulcer arterial ulcer, [MEDICAL CONDITION] ulcer/wound etc.) size, stage, location, drainage, odor of area. Documentation will also contain treatment orders obtained, a detailed personalized care plan and notification to the Interdisciplinary Skin/Wound Management Committee (ISWMC)." Interview with the facility's wound care nurse on 8/8/13 at 4:10 PM revealed the facility utilized a form entitled "Initial Wound Evaluation" to record detailed initial assessments of breaks in skin integrity, and "Daily Wound Assessment" and "Weekly Wound Progress Note" forms for ongoing assessments of wounds. review of the resident's medical record revealed [REDACTED]. No initial wound evaluation that would have recorded the type of wound, the size, location, drainage or odor was found in the medical record. Additionally, no daily wound assessments were found in the medical record. Interview with the regional health director on 8/8/13 at 3:15 PM confirmed these documents were not filled out, and further confirmed an initial wound evaluation form should have been filled out for the wound on 7/11/13 when it was discovered. Interview with the resident's family member on 8/9/13 at 11 AM revealed the family member had been shown the wound when it was first discovered. S/he stated it looked like "a little boil." S/he further stated that s/he had gone to visit her parent the morning of 7/16/13, at which time s/he noted a "terrible odor" after which s/he had her parent lean forward. S/he checked the back of his/her parent's incontinence brief and saw a foul-smelling, runny substance that s/he thought must be diarrhea. S/he left to allow her parent to be "cleaned up" and later received a call from the facility informing him/her that the "boil" had ruptured and the contents were "oozing out." Further review of Medicare Daily Skilled Nursing Notes revealed no assessment of this wound on 7/12/13, 7/13/13, 7/14/13, or 7/15/13. A Medicare Skilled Nursing Note dated 7/16/13 revealed "[MEDICATION NAME] to coccyx. open area has foul odor. Blood from area noted, drainage noted from open areas." No evidence of physician notification that the area was open and draining could be located in the medical record. Review of a Social Progress Note dated 7/17/13 revealed the resident "has had a significant change in condition since his last assessment. (The resident's) change is related to weight loss and a new pressure ulcer on his coccyx" and the resident "doesn't seem as alert as he was on his first assessment." Medicare Daily Skilled Nursing Notes dated 7/17/13 revealed "Dressing on L (left) buttock changed; foul-smelling discharge; tender and red surrounding area. Dr. (physician name) office notified and got an appt. (appointment) to see the MD tomorrow AM." Medicare Daily Skilled Nursing Notes dated 7/18/13 revealed "Went to see Dr. (physician name) at 0815 (8:15 AM). Resident went directly to ER from MD's office." Review of physician office visit notes dated 7/18/13 revealed the resident was at the physician's office with a family member who had been told "(his/her) decubitus is worse" and noted "our office was informed yesterday (7/17/13) therefore an appt was set up." Examination of the resident's "skin/buttock region" at that time showed "evidence of a large [DIAGNOSES REDACTED]tous area encompassing both buttock region/lumbosacral region with central area of stage II/III decubitus with foul smelling odor and greenish exudates expressed. no active bleeding." The resident was diagnosed with [REDACTED]." Review of a History and Physical from the hospital dated 7/18/13 revealed the resident to have a "Decubitus ulcer, infected - wound culture pending. This wound is large and I suspect it goes all the way to his sacrum. Will need wound care with PT (physical therapy) and may also need surgical intervention if the patient survives his acute episode [MEDICAL CONDITION]." Review of a General Surgery Documentation Report dated 7/19/13 revealed the resident to have a "Sacral wound with purulent drainage. Needs I/D (incision and drainage) and surgical debridement." Review of the results of a CT (computed tomography) scan of the abdomen/pelvis with contrast performed on 7/25/13 revealed "There appears to be an open wound in the soft tissues just interior to the rectum which appear to connect into the pelvic cavity with air tracking along the perineum and to the left side of the rectum internally. There are hypodense collections seen projecting to the right of the rectum within the pelvic cavity and to the left of the bladder inferiorly and prostate gland which contains small air bubbles and is worrisome for an abscess." Review of documentation from the hospital's social worker revealed that hospital social services met with the resident's family on "approximately 7/31/13" to discuss "possible end of life care after being told that (his/her) (parent) was not a surgical candidate due to (his/her) [DIAGNOSES REDACTED] and how involved the sacral ulcer was." Interview with the facility's regional health director on 8/8/13 at 10:45 AM confirmed there were problems with the wound assessment process, acknowledged the facility could have obtained treatment for [REDACTED]." At 3:15 PM that same day, she further revealed "for all intents and purposes we didn't follow our own policy."