Every finding on record at Magnolia Post Acute Care

Based on interview and record review, the facility failed to ensure three out of three residents (Resident 1, 2, and 3) were free from sexual abuse when:1. Resident 1 stated certified nursing assistant (CNA) 4 fondled her clitoris and inserted his fingers in her vagina during care.2. Resident 2 stated CNA 4 massaged her vagina during a brief change. 3. Resident 3 stated CNA 4 inserted his fingers into her vagina during a brief change.4. The facility hired CNA 4 with reference checks that reflected negative past employment performance. As a result of this deficient practice, Resident 1, 2, and 3 experienced psychosocial harm (damage to a person's mental, emotional, and social well-being that was caused by their environment or experiences), stating the incidents with CNA 4 made them feel angry, humiliated, embarrassed, ashamed, and worried. Findings: On 11/26/25 at 10:19 A.M., an onsite investigation was conducted to investigate three Facility Reported Incidents (FRIs) alleging CNA 4 inappropriately touched Residents 1, 2, and 3. 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included constipation, difficulty walking, and need for assistance with personal care. A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 11/28/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues).A review of Resident 1's History and Physical dated 11/10/25 indicated the resident had capacity to understand and make decisions. A review of Resident 1's facility investigative summary dated 11/16/25, indicated, .According to [Resident 1], during the NOC [night] shift on 11/11/25. [Resident 1] had a large soft stool that needed to be cleaned. The CNA came in, introduced himself as [CNA 4] . and explained that he would change the brief.felt as if something brushed against her vaginal area. On 12/9/25 at 11:13 A.M., an interview was conducted with Resident 1. Resident 1 was asked about the allegation which the resident reported to the facility on [DATE]. The resident stated she told a nurse about her abdominal pain caused by her constipation in the early morning of 11/12/25. Resident 1 stated CNA 4 came into her room and told her he could help with her constipation around 3 A.M. The resident stated CNA 4 then removed the front part of her brief and she felt his fingers rubbing against her clitoris. The resident then stated she felt CNA 4's fingers going into her vagina. Resident 1 stated when CNA 4 rubbed her clitoris and inserted his fingers into her vagina, it felt sexual in nature and was uncomfortable. Resident 1 stated she felt humiliated and ashamed, and she was glad CNA 4 no longer worked at the facility. The resident stated she reported this incident to her husband and the facility later that day. Resident 1 stated she reported the incident because it felt wrong that CNA 4 was taking advantage of people like her sexually. The resident remembered and verbalized CNA 4's name and stated she was worried if there were other residents who had been abused by CNA 4. A review of Resident 1's Care Plan initiated on 11/12/25, indicated, the resident requested to have only female CNA or a female CNA to be present if a male CNA was to give her care. 2. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's MDS assessment dated [DATE], indicated the resident's BIMS was 15 out of 15.A review of Resident 2's History and Physical dated 9/30/25, indicated the resident had capacity to understand and make decisions. A review of Resident 2's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 2100pm [9 P.M.], a report was received . [Resident 2] alleged that a male staff touched her inappropriately while.changing her brief. [Resident 2] heard the alleged situation of inappropriate behavior with another resident in the building. On 12/9/25 at 12 P.M., an interview was conducted with Resident 2. Resident 2 was asked about the incident with CNA 4 that she had reported to a CNA on 11/13/25. Resident 2 stated CNA 4 had changed her soiled brief. The resident stated CNA 4 told her that he was going to give her a massage which would make her feel better and help her go to sleep. Resident 2 stated CNA 4 then started massaging her vagina where he should not be rubbing. Resident 2 stated CNA 4 rubbed her vagina outside and inside, then she felt his hand starting to go into her vagina. Resident 2 stated she realized what was happening and told CNA 4, It better be the end of it. Never again do I want a massage, at which point CNA 4 stopped. Resident 2 stated CNA 4's actions made her feel very uncomfortable because no doubt in my mind that the brief change by CNA 4 was different from a normal one. Resident 2 stated the incident made her feel angry and she felt CNA 4 took advantage of her. A review of CNA 4's employee file indicated that there was a grievance filed against CNA 4 by Resident 2 on 7/21/25. The grievance indicated the CNA was a little too friendly and [Resident 2] just wa [sic] the CNA to do her brief change and so she can go to sleep and Resident 2 requested to not have CNA 4 be assigned to her. The grievance did not mention a sexual touch by CNA 4. On 12/11/25 at 10:04 A.M., a follow up interview was conducted with Resident 2. Resident 2 was asked about the grievance she filed against CNA 4 on 7/21/25. Resident 2 was asked when the incident with CNA 4 had occurred. The resident stated it happened a few days before the grievance was filed (on 7/21/25). Resident 2 stated she did not include the sexual abuse encounter in the grievance. Resident 2 stated she regretted not including the sexual abuse committed by CNA 4 in the grievance because other residents could have been victimized by him, too. The resident stated she was especially worried about the non-verbal, vulnerable residents who could not speak up about abuse. Resident 2 stated when CNA 4 massaged her vagina, it was an unpleasant experience, and it felt sexual in nature. Resident 2 stated after this incident with CNA 4 on 7/21/25, I was on the edge as to who is going to be the CNA at night, worried that he was going to be my CNA again. Resident 2 stated CNA 4 changed her brief again one night in October. Resident 2 stated CNA 4 did not massage or insert his fingers into her vagina that time because she recognized him when he entered her room and told him, No massages, no nothing, just a change. A review of the CNA assignment for July through October 2025, indicated CNA 4 had provided care to Resident 2 on 7/14/25 and 10/21/25 during the NOC shift (11P.M. to 7A.M.). A review of Resident 2's therapy note dated 11/14/25, indicated, the therapist and Resident 2 discussed the recent Stressful incident with male staff and Resident 2 expressed feeling Worry during the therapy. A review of Resident 2's Care Plan Intervention initiated on 10/24/25, indicated Resident 3 refused certain CNAs without providing specific reasons. 3. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included a need for assistance with personal care. A review of Resident 3's MDS assessment dated [DATE], indicated the resident's BIMS was 15 out of 15.A review of Resident 3's History and Physical dated 12/7/24, indicated the resident had capacity to understand and make decisions. A review of Resident 3's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 18:45pm [6:45 P.M.], a report was received. [Resident 3] told the psychologist (a mental health professional who helps people understand their thoughts, feelings, and behaviors to manage life's challenges) that she heard the alleged situation of inappropriate behavior with another resident in the building.prompted her to share her own allegation.some months ago.After cleaning her.the CNA applied barrier cream.around the private area.that made her feel it was inappropriate. On 12/9/25 at 11:34 A.M., an interview was conducted with Resident 3. Resident 3 stated that CNA 4 touched her inappropriately on multiple days but could not remember the exact dates or times of the incidents. Resident 3 stated she remembered one incident when CNA 4 inserted a finger into her vagina after a brief change. Resident 3 stated this was a few months ago. Resident 3 stated she did not want her brief changed by CNA 4 anymore after the incident and would feel relieved when someone else was assigned as her CNA. Resident 3 stated when CNA 4 was alone with her, he touched her inappropriately. Resident 3 stated when he had another staff member with him, he would not touch her in the wrong way. Resident 3 stated she felt having CNA 4's fingers around or inside her vagina was sexual and wrong. Resident 3 stated she did not report the incident right away because she thought she was going crazy and questioned if the incident really happened. Resident 3 then stated she felt she was old enough to differentiate what was sexual and what was not. The resident stated she told herself that reporting was the right thing to do because CNA 4 should not be touching her the way he did. Resident 3 stated she was concerned there were other victims.A review of Resident 3's Psychiatry (medical doctors treating mental health) Progress Note dated 9/10/25, indicated, Resident 3 denied sleep disturbance, depressive symptoms, and anxiety symptoms.A review of Resident 3's therapy Progress Note dated 11/13/25, indicated, Resident 3 discussed about a recent negative encounter and Resident 3 expressed having anxiety, depressed mood/grief, fatigue, and sleep disturbance. The Progress Note indicated Resident 3 reported a safety concern. A review of Resident 3's therapy Progress Note dated 11/14/25, indicated, Resident 3 discussed thoughts and feelings surrounding stressful incident and expressed having anxiety, depressed mood/grief, helplessness, and worry. A review of Resident 3's therapy Progress Note dated 11/17/25, indicated, Resident 3 discussed about anxiety regarding recent decision and expressed having anxiety, fatigue, negative self-talk, and sleep disturbance. 4. A review of CNA 4's employee file indicated CNA 4 was hired on 1/28/25. There were two printed reference checks titled [Facility name] - Confidential Reference Check both dated 1/24/25 in CNA 4's employee file. The reference checks reflected CNA 4's past employment. The reference checks indicated the CNA .became lazy in PT [patient] care, unreliable.over confident [sic].became inconsistent and .caught sleeping on the job. Both previous employers indicated they would not rehire CNA 4. A review of Resident 1, 2, and 3's facility investigative summaries dated 11/16/25 and 11/17/25 indicated that the facility's review of CNA 4's three pre-employment references revealed only positives [sic] things to say about the employee. On 12/11/25 at 3:25 P.M., an interview was conducted with the director of nursing (DON) and administrator (ADM). The DON stated the facility did not have a policy regarding reference checks. The DON stated recruiters at HR (Human Resources) were responsible for the initial reference checks. The ADM further stated the facility did not have a paper written statement by CNA 4 regarding the three sexual abuse allegations. On 12/11/25 at 4:47 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD reviewed the facility's undated policy titled Administration and stated it was the material she used to educate the staff regarding abuse and abuse related topics. The DSD stated it was considered sexual abuse for a staff to rub and insert their fingers in a resident's vagina. The DSD stated CNA 4 received in-service regarding proper communication after Resident 2 filed the grievance on 7/21/25. The DSD stated she had no other grievance filed against CNA 4. The DSD reviewed CNA 4's pre-employment references dated 1/24/25 and stated she would hesitate to hire someone with such negative references. The DSD stated CNA 4 was not given any abuse in-services after the first sexual abuse report made by Resident 1 on 11/12/25 because he was sent home and suspended during the facility investigations for the three allegations and then he resigned effective 11/25/25. A review of CNA 4's Employee Resignation Form dated 11/25/25, indicated CNA 4 resigned from his CNA position at the facility effective 11/25/25. On 12/11/25 at 4:52 P.M., a concurrent interview and record review was conducted with the ADM. The ADM stated that he reached out to CNA 4 via text on his phone as he was previously asked for CNA 4's phone number. The ADM presented the text for review and stated CNA 4 had declined a phone interview with the surveyor. On 12/11/25 at 5:41 P.M., an interview and record review was conducted with the ADM and the DON. The DON stated she recognized there was a red flag when she received the report from Resident 1 on 11/12/25. The DON stated she would have had CNA 4 terminated when the third sexual allegation was reported to her, because of the magnitude of the allegations. The DON also stated if CNA 4 had not quit, he would have been terminated for the safety of the other residents. The DON and ADM reviewed CNA 4's two printed reference checks dated 1/24/25. The ADM was asked about the discrepancies between the three favorable reference checks mentioned in the facility's investigative summary report for Resident 1, 2, and 3 and the two unfavorable references contained in the CNA's personnel file. The ADM and DON reviewed the two unfavorable references dated 1/24/25 and stated they had never seen them. The DON stated that reviewing references was a part of onboarding process and if she had seen those reviews she would not have hired him. The ADM stated he called the HR recruiter and received positive comments on CNA 4's references during his investigation. The ADM stated the facility should not have hired CNA 4 because red flag references were indicators of someone whom the facility would not hire. On 12/18/25 at 10:13 A.M., an interview and record review was conducted with the DON, the ADM, and the facility's Clinical Consultant (CC). The ADM was asked what sexual abuse was. The ADM stated sexual abuse could be an act or word that was sexual in nature from one person to another. The ADM stated when a resident reported inappropriate touch or uncomfortable touch, the resident could mean that those touches felt sexual in nature, especially if the encounter happened during a peri care (care around genitals and anal area). A review of the facility's undated policy titled Administration, indicated, .it is the policy of this Facility that each resident has the right to be free from abuse., and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the right of the residents to be from abuse., and exploitation.A. SCREENING (Prospective Employees) .6. All employees.will be properly screened prior to working at the Facility.C. TRAINING.1. e. Reporting reasonable suspicion of a crime against a resident in accordance with Section 1150B of the Social Security Act; . Sexually aggressive behavior such as., inappropriate touching.Residents that require extensive nursing care.E. IDENTIFICATION 1. The Facility will assist staff in identifying abuse.and exploitation of residents.This includes identifying.sexual abuse.2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicator of abuse include, but are not limited to: . Occurrences, patterns, and trends that may constitute abuse.I. DEFINITIONS.Abuse is willful infliction.includes .sexual abuse.Willful.means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Exploitation means taking advantage of a resident for personal gain.Sexual abuse is non-consensual sexual contact of any type with a resident.

Based on interview and record review, the facility failed to ensure Resident 2's grievance corrective action was followed through when the facility assigned certified nursing assistant (CNA) 4 to the resident after Resident 2 requested not to assign CNA 4 to provide care to her as indicated in her grievance on 7/21/24.As a result of this deficient practice, Resident 2's request to not be provided care by CNA 4 was not honored and the resident was at risk for further abuse by CNA 4. Cross reference F600 and F656.Findings: On 11/26/25 at 10:19 A.M., an onsite investigation was conducted to investigate three Facility Reported Incidents (FRIs) alleging CNA 4 inappropriately touched Residents 2 and two other residents. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's Minimum Data Set assessment (MDS, a comprehensive assessment tool) dated 10/7/25, indicated the resident's brief interview of mental status was 15 out of 15, which indicated the resident was cognitively intact.A review of Resident 2's History and Physical dated 9/30/25, indicated the resident had capacity to understand and make decisions. A review of Resident 2's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 2100pm [9 P.M.], a report was received . [Resident 2] alleged that a male staff touched her inappropriately while.changing her brief. [Resident 2] heard the alleged situation of inappropriate behavior with another resident in the building. On 12/9/25 at 12 P.M., an interview was conducted with Resident 2. Resident 2 was asked about the incident with CNA 4 that she had reported to the facility on [DATE]. Resident 2 stated CNA 4 had changed her soiled brief. The resident stated CNA 4 told her that he was going to give her a massage which would make her feel better and help her go to sleep. Resident 2 stated CNA 4 then started massaging her vagina where he should not be rubbing. Resident 2 stated CNA 4 rubbed her vagina outside and inside, then she felt his hand starting to go into her vagina. Resident 2 stated she realized what was happening and told CNA 4, It better be the end of it. Never again do I want a massage, at which point CNA 4 stopped. Resident 2 stated CNA 4's actions made her feel very uncomfortable because no doubt in my mind that the brief change by CNA 4 was different from a normal one. Resident 2 stated the incident made her feel angry and she felt CNA 4 took advantage of her. A review of CNA 4's employee file indicated that there was a grievance filed against CNA 4 by Resident 2 on 7/21/25. The grievance indicated the CNA was a little too friendly and [Resident 2] just wa [sic] the CNA to do her brief change and so she can go to sleep and Resident 2 requested to not have CNA 4 be assigned to her. The grievance did not mention a sexual touch by CNA 4. On 12/11/25 at 10:04 A.M., another interview was conducted with Resident 2. Resident 2 was asked about the grievance she filed against CNA 4. Resident 2 was asked when the incident with CNA 4 had occurred. The resident stated it happened a few days before the grievance was filed (on 7/21/25). Resident 2 stated she did not include the sexual abuse encounter in the grievance. Resident 2 stated she regretted not including the sexual abuse committed by CNA 4 in the grievance because other residents could have been victimized by him, too. The resident stated she was especially worried about the non-verbal, vulnerable residents who could not speak up about abuse. Resident 2 stated when CNA 4 massaged her vagina, it was an unpleasant experience, and it felt sexual in nature. Resident 2 stated after the incident with CNA 4, I was on the edge as to who is going to be the CNA at night, worried that he was going to be my CNA again. Resident 2 stated CNA 4 changed her brief again one night in October. Resident 2 stated CNA 4 did not massage or insert his fingers into her vagina that time because she recognized him when he entered her room and told him, No massages, no nothing, just a change. A review of the CNA assignment for July through October 2025, indicated CNA 4 had provided care to Resident 2 on 7/14/25 and 10/21/25 during the NOC shift (11P.M. to 7A.M.). On 12/18/25 at 10:13 A.M., a phone interview and record review was conducted with the Director of Nursing (DON), the Administrator (ADM), and the facility's Clinical Consultant (CC). The DON stated CNA 4 being assigned to Resident 2 on 10/21/25 was an oversight on her part. The DON stated CNA 4 should not have been assigned to Resident 2 after the grievance indicated the resident refused to be cared by CNA 4. The facility's written form provided to their residents titled Resident Rights dated July 2017, indicated, .Safe Environment. You have a right to a safe.homelike environment. A review of the facility's policy titled Section: Resident Rights Subject: Grievance dated November 2025, indicated, .4. The grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated.

Based on interview and record review, the facility failed to thoroughly investigate and identify sexual abuse in the facility after conducting three investigations when:1. The facility unsubstantiated Resident 1's sexual abuse allegation against certified nursing assistant (CNA) 4.2. The facility unsubstantiated Resident 2's sexual abuse allegation against CNA 4.3. The facility unsubstantiated Resident 3's sexual abuse allegation against CNA 4.4. The facility's investigation into the allegations against CNA 4 indicated the CNA had only favorable pre-employment references when this was not correct. In addition, the facility failed to ask clarifying questions during the course of their investigations to fully understand the residents' allegations. As a result of the facility's failure to identify and substantiate sexual abuse through its own investigative process, residents were placed at risk for abuse. Findings: On 11/26/25 at 10:19 A.M., an onsite investigation was conducted to investigate three Facility Reported Incidents (FRIs) alleging CNA 4 inappropriately touched Residents 1, 2, and 3. 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include constipation, difficulty walking, and need for assistance with personal care. A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 11/28/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact.A review of Resident 1's History and Physical dated 11/10/25, indicated the resident had capacity to understand and make decisions. A review of Resident 1's facility investigative summary dated 11/16/25, indicated, .According to [Resident 1], during the NOC [night] shift on 11/11/25.she [Resident 1] had a large soft stool that needed to be cleaned. The CNA came in, introduced himself as [CNA 4] . and explained that he would change the brief.felt as if something brushed against her vaginal area. On 12/9/25 at 11:13 A.M., an interview was conducted with Resident 1. Resident 1 was asked about the allegation which the resident reported to the facility on [DATE]. The resident stated she told a nurse about her abdominal pain caused by her constipation in the early morning of 11/12/25. Resident 1 stated CNA 4 came into her room and told her he could help with her constipation around 3 A.M. The resident stated CNA 4 then removed the front part of her brief and she felt his fingers rubbing against her clitoris. The resident then stated she felt CNA 4's fingers going into her vagina. Resident 1 stated when CNA 4 rubbed her clitoris and inserted his fingers into her vagina, it felt sexual in nature and was uncomfortable. Resident 1 stated she felt humiliated and ashamed, and she was glad CNA 4 no longer worked at the facility. The resident stated she reported this incident to her husband and the facility later that day. Resident 1 stated she reported the incident because it felt wrong that CNA 4 was taking advantage of people like her sexually. The resident remembered and verbalized CNA 4's name and stated she was worried if there were other residents who had been abused by CNA 4. 2. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's MDS assessment dated [DATE], indicated the resident's BIMS was 15 out of 15.A review of Resident 2's History and Physical dated 9/30/25, indicated the resident had capacity to understand and make decisions. A review of Resident 2's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 2100pm [9 P.M.], a report was received . [Resident 2] alleged that a male staff touched her inappropriately while.changing her brief.[Resident 2] heard the alleged situation of inappropriate behavior with another resident in the building. On 12/9/25 at 12 P.M., an interview was conducted with Resident 2. Resident 2 was asked about the incident with CNA 4 that she had reported to the facility on [DATE]. Resident 2 stated CNA 4 had changed her soiled brief. The resident stated CNA 4 told her that he was going to give her a massage which would make her feel better and help her go to sleep. Resident 2 stated CNA 4 then started massaging her vagina where he should not be rubbing. Resident 2 stated CNA 4 rubbed her vagina outside and inside, then she felt his hand starting to go into her vagina. Resident 2 stated she realized what was happening and told CNA 4, It better be the end of it. Never again do I want a massage, at which point CNA 4 stopped. Resident 2 stated CNA 4's actions made her feel very uncomfortable because no doubt in my mind that the brief change by CNA 4 was different from a normal one. Resident 2 stated the incident made her feel angry and she felt CNA 4 took advantage of her. 3. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including need for assistance with personal care. A review of Resident 3's MDS assessment dated [DATE], indicated the resident's BIMS was 15 out of 15.A review of Resident 3's History and Physical dated 12/7/24, indicated the resident had capacity to understand and make decisions. A review of Resident 3's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 18:45pm [6:45 P.M.], a report was received. [Resident 3] told the psychologist that she heard the alleged situation of inappropriate behavior with another resident in the building.prompted her to share her own allegation.some months ago.After cleaning her.the CNA applied barrier cream.around the private area.that made her feel it was inappropriate. On 12/9/25 at 11:34 A.M., an interview was conducted with Resident 3. Resident 3 stated that CNA 4 touched her inappropriately on multiple days but could not remember the exact dates or times of the incidents. Resident 3 stated she remembered one incident when CNA 4 inserted a finger into her vagina after a brief change. Resident 3 stated this was a few months ago. Resident 3 stated she did not want her brief changed by CNA 4 anymore after the incident and would feel relieved when someone else was assigned as her CNA. Resident 3 stated when CNA 4 was alone with her, he touched her inappropriately. Resident 3 stated when he had another staff member with him, he would not touch her in the wrong way. Resident 3 stated she felt having CNA 4's fingers around or inside her vagina was sexual and wrong. Resident 3 stated she did not report the incident right away because she thought she was going crazy and questioned if the incident really happened. Resident 3 then stated she felt she was old enough to differentiate what was sexual and what was not. The resident stated she told herself that reporting was the right thing to do because CNA 4 should not be touching her the way he did. Resident 3 stated she was concerned there were other victims. 4. A review of CNA 4's employee file indicated CNA 4 was hired on 1/28/25. There were two printed reference checks titled [Facility Name] - Confidential Reference Check both dated 1/24/25 in CNA 4's employee file. The reference checks reflected CNA 4's past employment. The reference checks indicated the CNA .became lazy in PT [patient] care, unreliable.over confident [sic].became inconsistent and .caught sleeping on the job. Both previous employers indicated they would not rehire CNA 4. On 12/11/25 at 3:25 P.M., an interview was conducted with the director of nursing (DON) and the administrator (ADM). The DON stated the facility did not have a policy regarding reference checks. The DON stated recruiters at HR (Human Resources) were responsible for the initial reference checks. The ADM further stated the facility did not have a paper written statement by CNA 4 regarding the three sexual abuse allegations. On 12/11/25 at 4:47 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD reviewed CNA 4's pre-employment references dated 1/24/25 and stated she would hesitate to hire someone with such negative references. A review of Resident 1, 2, and 3's facility investigative summary indicated that the facility's review of CNA 4's three pre-employment references revealed only positives [sic] things to say about the employee. On 12/11/25 at 5:41 P.M., an interview and record review was conducted with the ADM and the DON. The DON stated she recognized there was a red flag when she received the report from Resident 1 on 11/12/25. The DON and ADM reviewed CNA 4's two printed reference checks dated 1/24/25. The ADM was asked about the discrepancies between the three favorable reference checks mentioned in the facility's investigative summary report for Resident 1, 2, and 3, and the two unfavorable references contained in the CNA's personnel file. The ADM and DON reviewed the two unfavorable references dated 1/24/25 and stated they had never seen them. The DON stated that reviewing references was a part of onboarding process and if she had seen those reviews she would not have hired him. The ADM stated he called the HR recruiter and received the three positive reviews on CNA 4's references during his investigation. The ADM stated the facility should not have hired CNA 4 because red flag references were indicators of someone whom the facility would not hire. On 12/18/25 at 10:13 A.M., a phone interview and record review was conducted with the DON, the ADM, and the facility's Clinical Consultant (CC). Regarding conflicting pre-employment reference reviews of CNA 4, the ADM stated he should have verified CNA 4's actual references as a part of his investigation, not verifying through a phone call with the facility's recruiters. The DON stated the three positive professional reference reviews indicated in the facility's investigational summary were not accurate. Then ADM was asked what sexual abuse was. The ADM stated sexual abuse could be an act or word that was sexual in nature from one person to another. The ADM stated when a resident reported inappropriate touch or uncomfortable touch, the resident could mean that those touches felt sexual in nature, especially if the encounter happened during a peri care (care around genitals and anal area). The DON reviewed Resident 1's facility investigative summary dated 11/16/25. The DON stated she did not clarify what Resident 1 meant by uncomfortable experience caused by CNA 4 during her investigative interview with the resident on 11/12/25.The DON reviewed Resident 2's facility investigative summary dated 11/17/25. The DON stated she did not clarify what Resident 2 meant when the resident expressed uncomfortable experience and touched her inappropriately by CNA 4 during her investigative interview with Resident 2 on 11/13/25.The DON reviewed Resident 3's facility investigative summary dated 11/17/25. The DON stated she did not clarify what Resident 3 meant by inappropriate touching by CNA 4 during her investigative interview with Resident 3 on 11/13/25. The DON stated because the facility did not clarify the vague expressions used in the resident's sexual abuse allegations such as inappropriate touch, the facility's investigations were not thorough. The DON stated that because of this reason, she could not affirm that the allegations were truly unsubstantiated. A review of the facility's undated policy titled Administration, indicated, .A. SCREENING (Prospective Employees) .6. All employees.will be properly screened prior to working at the Facility.C. TRAINING.1. e. Reporting reasonable suspicion of a crime against a resident in accordance with Section 1150B of the Social Security Act; . Sexually aggressive behavior such as., inappropriate touching.Residents that require extensive nursing care.E. IDENTIFICATION 1. The Facility will assist staff in identifying abuse.and exploitation of residents.This includes identifying.sexual abuse.2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicator of abuse include, but are not limited to: . Occurrences, patterns, and trends that may constitute abuse.F. INVESTIGATION.2. All allegations of abuse.and exploitation will be.thoroughly investigated by the Administrator or his/her designee. I. DEFINITIONS.Abuse is willful infliction.includes.sexual abuse.Willful.means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Exploitation means taking advantage of a resident for personal gain.Sexual abuse is non-consensual sexual contact of any type with a resident.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan in a timely manner after Resident 2 filed a grievance and requested certified nursing assistant (CNA) 4 to not be assigned to her. As a result of this deficient practice, Resident 2's request to not be provided care by CNA 4 was not honored and the resident was at risk for further abuse by CNA 4.Findings: On 11/26/25 at 10:19 A.M., an onsite investigation was conducted to investigate three Facility Reported Incidents (FRIs) alleging CNA 4 inappropriately touched Residents 2 and two other residents. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's Minimum Data Set assessment (MDS, a comprehensive assessment tool) dated 10/7/25, indicated the resident's brief interview of mental status was 15 out of 15, which indicated the resident was cognitively intact.A review of Resident 2's History and Physical dated 9/30/25, indicated the resident had capacity to understand and make decisions. A review of CNA 4's employee file indicated that there was a grievance filed against CNA 4 by Resident 2 on 7/21/25. The grievance indicated the CNA was a little too friendly and [Resident 2] just wa [sic] the CNA to do her brief change and so she can go to sleep and Resident 2 requested to not have CNA 4 be assigned to her. The grievance did not mention a sexual touch by CNA 4. On 12/11/25 at 10:04 A.M., an interview was conducted with Resident 2. Resident 2 was asked about the grievance she filed against CNA 4. Resident 2 was asked when the incident with CNA 4 had occurred. The resident stated it happened a few days before the grievance was filed (on 7/21/25). Resident 2 stated she did not include the sexual abuse encounter in the grievance. Resident 2 stated she regretted not including the sexual abuse committed by CNA 4 in the grievance because other residents could have been victimized by him, too. The resident stated she was especially worried about the non-verbal, vulnerable residents who could not speak up about abuse. Resident 2 stated the incident involved CNA 4, and that he had massaged her vagina during care and it was an unpleasant experience. Resident 2 stated the incident felt sexual in nature. Resident 2 stated after the incident with CNA 4, I was on the edge as to who is going to be the CNA at night, worried that he was going to be my CNA again. Resident 2 stated CNA 4 changed her brief again one night in October. Resident 2 stated CNA 4 did not massage or insert his fingers into her vagina that time because she recognized him when he entered her room and told him, No massages, no nothing, just a change. A review of the CNA assignment for July through October 2025, indicated CNA 4 had provided care to Resident 2 on 7/14/25 and 10/21/25 during the NOC shift (11P.M. to 7A.M.). A review of Resident 2's care plan ADL Self Care Performance Deficit related to UTI, Chest pain, pain to left shoulder, weakness, impaired mobility indicated Resident have preference on some CNAs over others without being specific on reasons why she refuse certain CNAs as an intervention. The care plan was initiated on 10/24/25. On 12/17/25 at 3:31 P.M., a record review was conducted with the Medical Record Director (MDR) through emails. The MDR reviewed Resident 2's care plan and stated the facility did not have a care plan developed in response to Resident 2's request to not have CNA 4 assigned to her when the grievance was filed on 7/21/25. On 12/18/25 at 10:13 A.M., a phone interview and record review was conducted with the Director of Nursing (DON), the Administrator (ADM), and the facility's Clinical Consultant (CC). The DON stated the facility did not develop a care plan promptly to honor Resident 2's request to not assign CNA 4 to her as indicated in the grievance filed on 7/21/25. A review of the facility's policy titled Care Planning/Care Conference dated January 2025, indicated, .4. Revision and update of care plan should transpire to accommodate resident needs.where IDT [Interdisciplinary Team, a group of health care professionals that coordinate resident care] will respect resident's decision.

Based on observation, interview, and record review the facility failed to properly cover a caramel (sugar or syrup heated until it turns brown) sauce in the walk-in refrigerator.This failure had the potential for promoting foodborne illnesses.Findings:On 8/27/2025 at 8:37 A.M., a concurrent interview with Dietary Aide (DA) 2 and observation of walk-in refrigerator was conducted. A pre-prepared food covered with wax paper was observed on the 2nd level of the refrigerator. A creamy off-white liquid was observed on top of the wax paper covering the prepared food. DA 2 stated that she had prepared a caramel sauce earlier in the day and had covered it with wax paper to be used later in the day. DA 2 stated that if pressure was applied to the wax paper, caramel sauce moved to the top of the wax paper. DA 2 confirmed that the liquid on top of the wax paper was caramel sauce. DA 2 stated that she should have covered the tray with plastic, but was not sure why the caramel sauce should have been covered by plastic wrap.On 8/28/2025 1:20 P.M., an interview with the Registered Dietician (RD) was conducted. The RD stated that the expectation is that the prepared food should be covered, labeled, and dated. The RD stated that prepared food should be covered to prevent contamination and foodborne illness.Record review of Food and Nutrition: Competency Checklist- Cook dated 2/3/24, indicated .Recognize signs of damage/contamination of supplies .met, co-signed by DA 2 and Supervisor (S 14) .Record review of the policy titled LABELLING AND DATING OF FOODS indicated that .All prepared foods need to be covered, labeled and dated.

Based on observation, interview, and record review the facility failed to evaluate and/or offered to help formulate (assist) an advanced directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) for three of eight residents (Resident 49, 113 and 114) reviewed.This deficient practice placed all 92 residents at risk of not having their medical care wishes honored in the event of a health emergency or if they become unable to communicate leading to unwanted treatments or confusion about their care preferences.Findings:1. A review of Resident 49's admission Record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses which included a history of Disorders of the Meninges ( The meninges are three protective layers of tissue that surround the brain and spinal cord, acting as a shock absorber).A record review of Resident 49's minimum data set (MDS - a federally mandated resident assessment tool) dated 8/11/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 13 points out of 15 possible points which indicated Resident 49 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 8/26/2025 at 3:03 P.M., a clinical chart review was conducted on Resident 49's electronic health record (EHR) and live chart. Resident 49 had a Physician Ordered Life Sustaining Treatment (POLST) in the chart without a check mark for an AD.On 8/27/2025 at 10:24 A.M., an interview was conducted with Resident 49, in Resident 49's room. Resident 49 stated he did not know what an AD was or signed a document regarding an AD. Resident 49 stated he did not think he was offered assistance to make one because he does not have one.On 8/27/2025 at 11:33 A.M., and clinical chart review was conducted on Resident 49's EHR. There was no initial Social Services Evaluation completed for an AD in Resident 49's chart.On 8/28/2025 at 1:22 P.M., an interview and record review was conducted with the Social Services Director (SSD), in the conference room. The SSD stated she was unable to find documentation that she conducted an admission evaluation for an AD on Resident 49 and therefore did not ask Resident 49 if he had an AD and/or assist Resident 49 to formulate and AD. The SSD stated it was important to provide information about an AD and ask if they had an AD to honor their health care decisions in advance in the event of not being able to communicate for themselves to preserve their rights. On 8/29/2025 at 10:14 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated all residents should be asked and/or their responsible parties (RP) during care conferences and discussed their AD status to keep current. The DON stated it was her expectation that all residents would be evaluated within 72 hours if they had or needed assistance to formulate an AD and be part of their clinical chart to honor their health care decisions should they become incapable of making their health care decisions. A review of the facility's policy and procedure titled, Advance Directive/POLST) (Undated), indicated .it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive 2. A review of Resident 113's admission Record indicated Resident 113 was admitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral vascular disease (conditions that affect blood flow to your brain).A record review of Resident 113's minimum data set (MDS - a federally mandated resident assessment tool) dated 8/27/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 14 points out of 15 possible points which indicated Resident 113 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 8/26/2025 at 11:32 A.M., a clinical chart review was conducted on Resident 113's electronic health record (EHR). There was no AD in Resident 113's EHR and no initial Social Services Evaluation completed for an AD in Resident 113's chart.On 8/27/2025 at 9:33 A.M., a clinical chart review was conducted on Resident 113's live chart. There was no AD in Resident 113's chart.On 8/27/2025 at 11:39 A.M., an interview was conducted with Resident 113, in Resident 113's room. Resident 113 stated he did not have an AD and was not offered to formulate and AD.On 8/28/2025 at 1:22 P.M., an interview and record review was conducted with the Social Services Director (SSD), in the conference room. The SSD stated she was unable to find documentation that she conducted an admission evaluation for an AD on Resident 113 and therefore did not ask Resident 113 if he had an AD and/or assist Resident 113 to formulate and AD. The SSD stated it was important to provide information about an AD and ask if they had an AD to honor their health care decisions in advance in the event of not being able to communicate for themselves to preserve their rights.On 8/29/2025 at 10:14 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated all residents should be asked and/or their responsible parties (RP) during care conferences and discussed their AD status to keep current. The DON stated it was her expectation that all residents would be evaluated within 72 hours if they had or needed assistance to formulate an AD and be part of their clinical chart to honor their health care decisions should they become incapable of making their health care decisions. A review of the facility's policy and procedure titled, Advance Directive/POLST (Undated), indicated .it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive 3. A review of Resident 114's admission Record indicated Resident 114 was admitted to the facility on [DATE] with diagnoses which included a history of intracranial abscess and granuloma (a pus-filled pocket of infected material in your brain).A record review of Resident 114's minimum data set (MDS - a federally mandated resident assessment tool) dated 8/20/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 114 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 8/26/2025 at 2:26 P.M., a clinical chart review was conducted on Resident 114's electronic health record (EHR). There was no AD in Resident 114's EHR and no initial Social Services Evaluation completed for an AD in Resident 114's chart.On 8/27/2025 at 10:09 A.M., an interview was conducted with Resident 114, in Resident 114's room. Resident 114 stated he did not know what an AD was and was not informed or spoke with staff about an AD.On 8/28/2025 at 1:22 P.M., an interview and record review was conducted with the Social Services Director (SSD), in the conference room. The SSD stated she was unable to find documentation that she conducted an admission evaluation for an AD on Resident 114 and therefore did not ask Resident 114 if he had an AD and/or assist Resident 114 to formulate and AD. The SSD stated it was important to provide information about an AD and ask if they had an AD to honor their health care decisions in advance in the event of not being able to communicate for themselves to preserve their rights.On 8/29/2025 at 10:14 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated all residents should be asked and/or their responsible parties (RP) during care conferences and discussed their AD status to keep current. The DON stated it was her expectation that all residents would be evaluated within 72 hours if they had or needed assistance to formulate an AD and be part of their clinical chart to honor their health care decisions should they (residents) become incapable of making their health care decisions.A review of the facility's policy and procedure titled, Advance Directive/POLST) (Undated), indicated .it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive

Based on observation, interview, and record review the facility failed to ensure the competency of one dishwasher for chlorine testing related to dishware when using the low temperature dishwasher.This failure increased the risk of foodborne illness.Findings:On 8/27/2025 at 8:37 A.M., a concurrent interview with Dietary Aide (DA) 1 and observation of low temperature dishwashing process was conducted. DA 1 stated the process for washing dishes with low temperature washer was as follows: .Rinse dishes of any debris, move load of dishes into washer. Observe rinsing temperature and log once a shift, rinsing temperature needs to be 120 F or greater. After load done check chlorine levels, they should be between 50-100ppm. DA 1 proceeded to check chlorine level with test strip of the water coming out of the machine. DA 1 stated that the importance of checking the chlorine level was to make sure that plates were sanitized by the machine appropriately. DA 1 did not check chlorine level on the newly washed plates . DA 1 was not sure why he should test chlorine level at plate level. On 8/28/25 at 1:20 P.M., an interview was conducted with the Registered Dietician (RD). The RD stated that the expectation for chlorine testing was to test the chlorine level at the plate level to ensure that plate was sanitized correctly by the low temperature dishwasher. The RD stated that dishware needed to be tested on the surface of plate to prevent foodborne illnesses. Review of Competency Checklist -Food Service Worker dated 11/17/23 for DA 1 indicated .Demonstrates correct sanitation of equipment, utensils, and surfaces.Met co-signed by DA 1 and Certified Dietary Manager (CDM).Review of policy titled DISHWASHING dated 2023 indicated .The chlorine should read 50-100 PPM on dish surface in final rinse.

Based on interview and record review, the facility failed to update an intervention for nutrition care plan for one of 21 sampled residents (51).This failure had the potential for Resident 51's nutritional care plan to be mismanaged.Findings:Resident 51 was admitted to the facility on [DATE] with diagnoses which included dysphagia (trouble swallowing) and a gastronomy tube (GT - tube inserted directly into the stomach, allowing for liquid food, fluids, and medications to be administered) per the facility's admission record.On 8/28/25 at 11 A.M., a concurrent interview and record review was conducted with licensed nurse (LN) 1 of Resident 51's medical record. A review of Resident 51's care plan for weight loss included an intervention for a weekly weight check. Per Resident 51's weight record, Resident 51's weight was checked once in August of 2025, on 8/4/25.On 8/29/25 at 1 P.M., a concurrent interview and record review was conducted with the director of nursing (DON). A review of Resident 51's Interdisciplinary Team (IDT - team of staff who oversees the resident's care using a team approach for assessment and care planning) meeting notes indicated that Resident 51 was to be on monthly weight checks because he was at the target weight range. The DON stated the care plan should have been updated to monthly weight checks, but it was not. The DON stated it was important for all residents' care plans to be updated to ensure that they are receiving the appropriate care.A review of the facility's undated policy titled Care Plan Acceleration, indicated that an individualized care plans are developed, updated and implemented to address the resident's needs.

Based on observation, interview and record review the facility failed to ensure that interventions to prevent the development of pressure injuries (wounds caused from pressure to a bony prominence) for one of 12 sampled residents (Resident 23) was implemented.This failure had the potential for increased skin breakdown, infection and decreased physical and psychosocial well-being.According to the facility's admission Record, Resident 23 was admitted on [DATE] with diagnoses which included pressure-induced deep tissue damage (a type of pressure injury) of sacral region (the bottom of the spine), and functional quadriplegia (the inability to move all four limbs).During a review of the Minimum Data Set (MDS- an assessment tool), Resident 23 was dependent on staff for putting on and taking off footwear.Observations of Resident 23 were conducted which included:8/26/25 at 2:37 P.M., Resident 23 was sitting in her wheelchair, wearing socks.8/27/25 at 8:11 A.M., Resident 23 was sitting in her wheelchair, wearing socks.8/27/25 at 9:49 A.M., Resident 23 was sitting in her wheelchair, wearing socks.On 8/27/25 at 12:24 P.M., an observation was conducted of Resident 23 laying in bed, on her back. Resident 23 did not have boots on.On 8/27/25 at 3:31 P.M., a joint observation and interview was conducted with Licensed Nurse (LN) 3. LN 3 stated Resident 23 had a history of pressure injuries to both heels and had an order for Prevalon boots (specialized boots with a cushioned bottom designed to reduce pressure from heels) for both feet at all times. LN 3 stated, Prevalon boots are to help wounds heal by relieving pressure and prevent wounds from reopening. LN 3 confirmed Resident 23 was in bed without Prevalon boots, and without any pillows under her legs to float the heels.On 8/28/25 at 8:25 A.M., a joint interview and record review was conducted with LN 4. LN 4 stated Resident 23 had a physician's order for Prevalon boots on at all times, may remove for skin checks and hygiene every shift.On 8/29/25 at 9:51 A.M. an interview was conducted with the Director of Nursing (DON). The DON stated Prevalon boots were preventative and should have been on Resident 23 per the physician's order. The DON stated, we are tying to avoid new skin issues, and prevent wounds from reopening.A review of the facility's undated policy titled Wound Management indicated, Treatments ordered by the physician will be used as ordered.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 88) was free from unnecessary medications by administering olanzapine (a medication used to treat symptoms such as hallucinations or delusions in patients with serious mental illnesses) without an appropriate diagnosis. This failure had the potential for increased risks associated with the use of psychotropic medications (substances that affect the brain's activities and influence mental processes and behaviors) and excessive sedation. During a review of Resident 88's clinical record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (a stroke), major depressive disorder (a condition that causes a persistent feeling of sadness), and a history of falling.During a review of Resident 88's hospital record from the Department of Neurology, a letter dated 4/11/25 indicated, [Resident 88] has been followed in the Department of Neurology/Geriatrics. He has a diagnosis of Dementia: Vascular [a condition that causes a decline in memory, thinking, reasoning and judgement caused by multiple strokes].During a review of Resident 88's Minimum Data Set (MDS- an assessment tool) dated 7/4/25, the MDS indicated Resident 88 had a Brief Interview for Mental Status (BIMS- a tool to measure cognition) of 9, which indicated moderately impaired cognition.A review of Resident 88's Physician's Order dated 7/20/25 indicated, olanzapine 5 mg [millligrams- a unit of measurement] by mouth two times a day for psychosis [hallucinations, delusions, or incoherent speech or behavior].On 8/26/25 at 8:19 A.M., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 was sitting in a chair in the doorway of Resident 88's room. Resident 88 was observed with two other roommates. CNA 1 stated he was assigned as a hallway monitor to observe residents who are at risk for falling. CNA 1 stated Resident 88 was being closely observed because he keeps trying to get out of bed. CNA 1 stated Resident 88 had been asleep since his shift started. CNA 1 stated he did know if Resident 88 had any hallucinations or symptoms of psychosis.On 8/26/25 at 2:51 P.M. an interview was conducted with CNA 2. CNA 2 stated Resident 88 is able to communicate his needs, but .he seems confused sometimes.he has a tendency to try to get up [unassisted], he will all of a sudden say 'I need to go somewhere' and we need to redirect him. CNA 2 further stated Resident 88 had behaviors of irritability, and random surges of hunger.he stresses out. He will ask, 'Who is going to pay the bills right now? .' CNA 2 stated she had not seen any behaviors such as aggression or hallucinations from Resident 88.On 8/28/25 at 8:49 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 88 has had multiple falls at the facility due to behaviors, such as agitation. LN 1 stated, .[Resident 88] forgets that he cannot get out of bed anymore, so sometimes he does it by himself and loses his balance.he is agitated, which is his behavior. Every time the staff tries to assist him he tends to refuse, he will do a lot of swinging. LN 1 stated Resident 88 was on olanzapine .because he was continuously having the behavior of agitation. We give it based on diagnoses, we give it for people with Tourette's [a brain disorder that involves sudden movements, twitches, or sounds], schizophrenia or Traumatic Brain Injury [a serious injury that affects how the brain works]. LN 1 stated olanzapine would not be given to a resident who did not have these diagnoses because it's a form of chemical restraint if they get it without a diagnosis. LN 1 stated Resident 88 did not have a diagnosis of Tourettes, schizophrenia or TBI.On 8/28/25 at 11:52 A.M., a telephone interview was conducted with Resident 88's family member (FAM) 1. FAM 1 stated Resident 88 was very anxious and agitated when he was first admitted to the facility. FAM 1 stated, when he was getting agitated, its because he was a heavy smoker, and stopped suddenly. They put a nicotine patch on him and took it off. FAM 1 stated Resident 88 did not have schizophrenia, or any diagnosis of a serious mental health disorder besides depression. FAM 1 stated Resident 88 did have dementia, and was often confused, and often tried to stand up unassisted which resulted in multiple falls. FAM 1 stated Resident 88 was started on olanzapine to manage the agitation and to prevent him from attempting to stand up and falling.On 8/29/25 at 9 A.M., a telephone interview was conducted with the Psychiatric Nurse Practitioner (PNP). The PNP stated Resident 88 was diagnosed with dementia with psychosis (agitation related to dementia). The PNP stated Resident 88, had behaviors that were non re-directable.he has dementia. Our goal is to review to make sure we don't have a patient [on antipsychotics] without the appropriate diagnosis. However in [Resident 88]'s case we had no other option but to put him on [olanzapine] because he's hitting, screaming The PNP confirmed Resident 88 had dementia with psychosis, and did not have a diagnosis of schizophrenia. On 8/29/25 at 9:17 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, I was hesitant about the olanzapine [for Resident 88] because he didn't have a qualifying diagnosis for that.in July he was still having behaviors and I wanted to get him off olanzapine. Regulatory wise he doesn't have the diagnosis [of schizophrenia] and he does have dementia. The DON stated the Interdisciplinary Team (IDT- a group of professionals with different areas of expertise) decided to continue olanzapine to manage Resident 88's behaviors of agitation. The DON stated, We don't want to chemically restrain the patient. In [Resident 88]'s case, we discussed it with the family. The DON stated olanzapine was not indicated for a resident without an appropriate diagnosis. During a record review of the Care Plan Report, Resident 88's care plan dated 5/11/25 indicated, Psychotropic medications r/t [related to] Behavior management.Olanzapine Oral Tablet Black Box Warning [a warning placed on prescription medications to alert patients and healthcare providers about serious or life-threatening risks associated with the drug] .Warning: Increased mortality in elderly patients with dementia-related psychosis. Olanzapine is not approved for treatment of patients with dementia-related psychosis.A review of the facility's policy titled Chemical Restraints and Psychotropic Medication Management revised 4/2025 indicated, It is the policy of this facility to ensure that residents are free from chemical restraints imposed for purposes of discipline or convenience or that are not required to treat a specific condition as diagnosed and documented in the clinical record.Psychotropic medications.are to be administered only when required to treat the resident's medical symptoms and will be considered only after nonpharmacological interventions have been attempted and failed.Adequate Indications for use means that the medication administered is consistent with manufacturer's recommendations.

Based on observations, interviews, and record review, the facility failed to fix the following equipment for one of 21 sampled residents (Resident 78):1. right upper bed railing2. sliding glass door3. sliding screen door4. TV remoteThe failure to fix Resident 78's equipment did not create a homelike environment for Resident 78.Findings:Record review of admission Record indicated Resident 78 was admitted for diagnoses which included Acute Embolism (a medical condition where a foreign object, such as a blood clot travels through the bloodstream and lodges in a blood vessel, blocking its flow) and Thrombosis (a medical condition where a blood clot forms in a blood vessel) of Deep Vein of Lower Left Extremity(leg), Chronic Ulcer (an open sore) of Left Lower Leg, Muscle Weakness, Unsteadiness on Feet, Abnormalities of Gait ( a person's manner of walking) and Mobility, Cellulitis( a common bacterial skin infection that affects the deeper layers of the skin )of Left Lower Limb, Displaced Fracture (a break or crack in a bone) of upper end of Left Humerus (the bone of the upper arm), Open Wound Left Lower Leg.Record review of MDS section C Cognitive (thinking) Patterns indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition (thinking processes).Review of MDS section GG Functional Abilities.section GG0115. Functional Limitation in Range of Motion indicated .B. Lower extremity [hip, knee, ankle, foot] impairment on one side.On 8/26/25 at 11:35 A.M., during the initial pooling, an interview was conducted with Resident 78. Resident 78 stated .the right railing on her bed didn't lock, the sliding glass door didn't close or open and there is a little gap open that lets in air, the screen door is also stuck and there is a gap there, can't open or close either.On 8/26/25 at 11:44 A.M., a concurrent observation of Resident 78's room and interview were conducted with the Maintenance Assistant (MA). The MA confirmed Resident 78's right upper bed railing was not able to lock in upright position. The MA confirmed that the sliding glass and screen doors were stuck with about a 1-inch gap between edges of door and wall, and that the screen was put on backwards so it couldn't move. The MA stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. The MA stated that the importance of the bed railing working was to prevent accidents or falls. The MA stated that the importance of functional sliding glass door and screen was for security and to prevent unwanted pests from coming into resident's room. The MA stated that Resident's 78's room was not homelike at this time.On 8/26/25 at 11:50 A.M., a concurrent observation of Resident 78's room and interview with Licensed Nurse (LN) 11 was conducted. LN 11 confirmed Resident 78's right upper bed railing was not able to lock in position. LN 11 confirmed Resident 78's sliding glass door was stuck with a 1-inch gap. LN 11 confirmed Resident 78's sliding screen door was stuck with a 1-inch gap. LN 11 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. LN 11 stated that the importance of the bed railing funcitioning was to prevent accidents and falls. LN 11 stated that the importance of functional sliding glass door and screen was to provide security and prevent unwanted pests from coming into resident's room. LN 11 stated that Resident 78's room was not homelike.On 8/28/25 at 8:58 A.M., a follow-up interview was conducted with Resident 78. Resident 78 stated that the left bed railing was initially broken, and maintenance was aware that the right railing was also not functioning correctly, but he needed to get a part. I leaned on it once and it went down without any effort. It obviously had not been fixed, so I told the MA . In addtion, Resident 78 stated the volume on the TV did not work and her neighbor's tv was too loud and that she mentioned it to the MA, but they were having a hard time fixing it.On 8/28/25 at 9:05 A.M., an interview with LN 12 and record review of maintenance messaging system was conducted. LN 12 stated that when something is broken in a resident's room they use a program on the computer that messages maintenance about the broken equipment and they fix it. LN 12 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. LN 12 stated that the importance of Resident 78's bed railing functioning was to aid residents in getting up and preventing accidents and falls. LN 12 stated that the importance of functional sliding glass door and screen was to provide security and prevent unwanted pests from coming into resident's room. LN 12 stated that Residents 78's room was not homelike.On 8/28/2025 1:49 P.M. an interview with a Certified Nursing Assistant (CNA) 13 was conducted. CNA 13 stated that for broken equipment such as sliding glass door, bed railing, or tv remote she would call MA to fix whatever was broken. CNA 13 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. CNA 13 stated that the importance of the bed railing working was to prevent accidents and falls. CNA 13 stated that the importance of functional sliding glass door and screen was to provide security and prevent unwanted pests from coming into residents' room. CNA 13 stated that Resident 78's room was not homelike.08/29/2025 9:28 A.M., an interview with Plant Service Director (PSD) and record review of maintenance logs was conducted. The PSD stated that staff typically sent maintenance requests via their computer work orders. The PSD stated that they had routine bed and sliding glass door maintenance scheduled for certain beds each day. The PSD stated if maintenance was done on a bed that was not scheduled it would be documented on the log for that day. Review of bed maintenance log for 8/21/25 indicated 12 B-adjusted bedrails and 8/26/25 indicated 12 B- Replaced right rail. The PSD stated the importance of functioning bedrails was to prevent falls and accidents. The PSD stated the importance of functioning sliding glass doors and screens was to prevent pests from entering resident's rooms and security. The PSD stated that residents should feel comfortable and safe in their rooms, and it should be homelike, and that Resident 78's room was not homelike.0n 8/29/25 at 10:45 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the expectation was that residents should feel comfortable and safe in their room and that equipment should be functional. The DON stated that the importance of functioning sliding glass door and screen is for security and preventing pests from entering resident's room. The DON stated the importance of functioning bedrails was to prevent falls and accidents. The DON stated that the non-functional equipment in Resident 78's room was not homelike.Review of facility policy titled Physical Environment, undated, indicated .the facility must provide a safe, functional, sanitary, and comfortable environment for residents.Residents rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.Equipment.will be checked in a regular basis to ensure overall functionality.Review of facility policy Physical Environment, Environmental Conditions/Environmental Rounds, undated, indicated.Sliding doors in all residents rooms must be functional.Equipment and environmental conditions needing repair will be logged and acted upon at a reasonable timeframe, as appropriate.Review of policy Physical Environment, Environmental Conditions, undated, indicated .the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and public through monthly environmental rounds.Equipment.will be checked in a regular basis to ensure overall functionality.

The facility did not ensure safety with bed rails and proper use of a hoyer lift for two of 21 sampled residents (Resident 78 and Resident 23) according to the facilities policies and procedures. Findings: During a review of the facility documents, the admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time), and functional quadriplegia (the inability to move all four limbs). During a review of the Minimum Data Set (MDS- an assessment tool) dated 7/3/25, Resident 23 had a Brief Interview for Mental Status (BIMS- a tool to assess thinking skills) score of three, which indicated impaired cognition. The MDS indicated Resident 23 was dependent on staff to transfer to and from a bed to a wheelchair. During an observation conducted on 8/26/25 at 10:41 A.M., Resident 23 was observed inside her bedroom, laying in bed on top of a blue hoyer sling (a hammock-like device used with a hoyer lift to support a resident during transfers). Certified Nursing Assistant (CNA) 2 was observed entering Resident 23's room with a hoyer lift, then closed the door. During an observation conducted on 8/26/25 at 10:45 A.M., Resident 23 was observed sitting inside her bedroom, in her wheelchair. CNA 2 was observed wheeling the hoyer lift from Resident 23's bedroom to the hallway. On 8/26/25 at 10:49 A.M., an interview was conducted with CNA 2. CNA 2 stated she transferred Resident 23 from the bed to the wheelchair using the hoyer lift, without assistance from another staff member. CNA 2 stated, I don't really need help with anybody. [Resident 23] helps me connect the sling to the hoyer lift. CNA 2 stated, [Resident 23] is not heavy, so I can use the hoyer lift by myself. On 8/27/25 at 12:24 P.M., an interview was conducted with CNA 3. CNA 3 stated, [Resident 23] is a 2-person transfer. We use a hoyer lift with two people. We would never use a hoyer lift alone for safety. CNA 3 stated transferring a resident using a hoyer lift required 2 staff members to ensure the hoyer sling was properly connected to the machine. CNA 2 stated, If [the hoyer sling] is not hooked up correctly [Resident 23] could slip out of the sling. You should have a second person to watch that, to make sure the resident is in the lift correctly. CNA 2 stated the first staff member maneuvered the lift, while the second staff member ensured the resident was safe while being lifted and, .to watch their head and toes .you don't want the forehead to hit the machine.for safety. On 8/29/25 at 9:51 A.M., an interview was conducted with the Director of Nursing (DON).The DON stated it was her expectation for hoyer lifts to be used by two staff members at all times while transferring a resident. The DON stated staff should never attempt to use a hoyer lift to transfer a resident without assistance. The DON stated, Staff can't do it alone because it's difficult to maneuver the hoyer lift, and we have to protect the residents from injuries. A review of the facility's undated policy titled Routine Procedures, Hoyer Lift indicated, Assistance of two personnel will be used with Hoyer Lift. 2. Record review of admission Record indicated Resident 78 was admitted for diagnoses which included Acute Embolism (a medical condition where a foreign object, such as a blood clot travels through the bloodstream and lodges in a blood vessel, blocking its flow) and Thrombosis (a medical condition where a blood clot forms in a blood vessel) of Deep Vein of Lower Left Extremity(leg), Chronic Ulcer (an open sore) of Left Lower Leg, Muscle Weakness, Unsteadiness on Feet, Abnormalities of Gait ( a person's manner of walking) and Mobility, Cellulitis (a common bacterial skin infection that affects the deeper layers of the skin )of Left Lower Limb, Displaced Fracture (a break or crack in a bone) of upper end of Left Humerus (the bone of the upper arm), Open Wound Left Lower Leg. Record review of Minimum Data Set (MDS-an assessment tool) section C Cognitive(thinking) Patterns indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition (thinking processes). Record review of MDS section J Health Conditions indicated Residents 78: 1. Fell with the last month prior to admission/entry or reentry, 2. Fell any time in the last 2-6 months prior to admission/entry or reentry, 3. Fell in the 6 months prior to admission/entry or reentry. Review of MDS section GG Functional Abilities . Functional Limitation in Range of Motion indicated .B. Lower extremity (hip, knee, ankle, foot) impairment on one side. On 8/26/25 at 11:35 A.M., during the initial pooling, an interview was conducted with Resident 78. Resident 78 stated .the right railing on her bed didn't lock. On 8/26/25 at 11:44 A.M., a concurrent observation of Resident 78's room and interview were conducted with the Maintenance Assistant (MA). Resident 78's right upper bed railing was not able to lock in upright position. The MA stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. The MA stated that the importance of railing working was to prevent accidents and falls. On 8/26/25 at 11:50 A.M., a concurrent observation of Resident 78's room and interview with Licensed Nurse (LN) 11 was conducted. Ln 11 confirmed Resident 78's right upper bed railing was not able to lock in position. LN 11 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. LN 11 stated that the importance of the bed railing working was to prevent accidents and falls. On 8/28/25 at 8:58 A.M., a follow-up interview was conducted with Resident 78. Resident 78 stated that .the left bed railing was initially broken, and maintenance was aware that the right railing was also not functioning correctly, but he needed to get a part. I leaned on it once and it went down without any effort. It obviously had not been fixed, so I told the MA. On 8/28/25 at 9:05 A.M., an interview with LN 12 and record review of maintenance messaging system was conducted. LN 12 stated that when something is broken in a resident's room, they use a program on the computer that messages maintenance about the broken equipment and they fix it. LN 12 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. LN 12 stated that the importance of the bed railing working was to prevent accidents and falls. On 8/28/2025 1:49 P.M., an interview with Certified Nursing Assistant (CNA) 13 was conducted. CNA 13 stated that for broken equipment such as sliding glass door, bed railing, or tv remote she would call MA to fix whatever was broken. CNA 13 stated that the expectation was all equipment in resident's' room should be functional for their safety and comfort. CNA 13 stated that the importance of railing working was to prevent accidents and falls. 08/29/2025 9:28 A.M., an interview with Plant Service Director (PSD) and record review of maintenance logs was conducted. The PSD stated that staff typically sent maintenance requests via their computer work orders. The PSD stated that they had routine bed and sliding glass door maintenance scheduled for certain beds each day. The PSD stated if maintenance was done on a bed that was not scheduled it would be documented on the log for that day. Record review of bed maintenance log for 8/21/25 indicated 12 B-adjusted bedrails and 8/26/25 indicated 12 B- Replaced right rail. The PSD stated that bed rails should function properly to prevent falls and accidents. On 8/29/25 at 10:45 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the expectation was that residents should feel comfortable and safe in their room and that equipment should be functional. The DON stated the importance of functioning bedrails was to prevent falls and accidents. Review of facility policy Quality of Life, Fall Prevention, undated, indicated It is the policy of this facility.implement actions to reduce the incidence of additional falls and minimize potential for injury. Facility did not provide a policy and procedure for Accidents.

Based on observation, interview and record review the facility did not practice infection control according to facility policies and procedures and standards of practice. These failure had the potential to increase the spread of infection. Findings: On 8/26/25 at 8:02 A.M., an interview was conducted with the Infection Preventionist (IP) during a recertification survey. The IP stated a resident tested positive for Covid-19 (a contagious respiratory virus) on 8/19/25. The IP stated the facility was considered to be in an outbreak because two more residents tested positive for Covid-19, bringing the total to 3 Covid-19 positive residents. The IP stated the outbreak was reported to County Epidemiology (professionals that work to identify and evaluate diseases to protect the health of the community), but not to the state agency. The IP stated he was still new to the position but would ask the previous IP which entities to report outbreaks. On 8/27/25 at 8:39 A.M. an interview was conducted with LN 2. LN 2 stated she was the previous IP at the facility. LN 2 stated she had reported outbreaks to County, but did not know a separate report needed to be sent to the state agency. The IP stated, We were reporting [Covid-19 outbreaks] to everyone but [the state agency.] The IP stated she reviewed the facility's policy, and We should have reported outbreaks to state.to make sure everyone is safe. On 8/29/25 at 9:51 A.M. an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation that Covid-19 outbreaks were reported to the state licensing agency. The DON stated it was important to report Covid-19 outbreaks, .because we want to make sure we're following the right thing, the right regulation and guidance from [the state agency] to prevent new infections and the spread of Covid. During a review of the facility's undated Infection Prevention and Control plan, the document indicated, THE ELEMENTS OF THE INFECTION PREVENTION AND CONTROL PLAN INCLUDE.reporting of communicable diseases per CDC guidelines. During a review of the facility's policy titled Emerging Infectious Disease (EID): Coronavirus Disease revised 11/2022 the document indicated, It is the policy of this facility implement [sic] recommended appropriate infection control strategies, guidance and standards from the local, State and Federal agencies for an EID event. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included dysphagia (trouble swallowing) and a gastronomy tube (GT - tube inserted directly into the stomach, allowing for liquid food, fluids, and medications to be administered) per the facility's admission record. A review of Resident 9's physician's orders indicated there was an order on 8/27/25 for the patient to be on Enhanced Barrier Precautions (EBP -an infection control strategy in nursing homes that involve wearing gowns and gloves during high-contact resident care activities to prevent the spread of infection). On 8/28/25 at 8:30 A.M., an observation and interview was conducted with Licensed Nurse (LN) 3 during a medication administration of Resident 9. A signage posted outside of Resident 9's room indicated that a resident in the room was on EBP and included instructions to wear gown and gloves while providing care with high contact activities with residents with feeding tubes. On 8/28/25 at 8:35 A.M, LN 3 prepared Resident 9's medications. Prior to entering Resident 9's room, LN 3 did not put a gown on. On 8/28/25 at 8:42 A.M., LN 3 stated she was completed with Resident 9's medication administration. LN 3 stated she forgot to wear a gown and stated she should have because Resident 9 was on EBP. LN 3 stated it was important to wear a gown to prevent the spread of infection. On 8/29/25 at 8:45 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated LN 3 should have worn a gown while providing care with a residents on EBP. A review of a facility policy titled IPCP Standard and Transmission-Based Precautions, dated 6/2025, indicated that .C. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:.device care or use.feeding tube.

Based on interview, and record review, the facility failed to provide proper discharge planning to ensure a safe and coordinated discharge for one of three sampled residents (Resident 1) during a complaint investigation. This deficient practice placed Resident 1 at risk for an unsafe discharge and re-hospitalization . Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of visuospatial deficit and spatial neglect following cerebral infarction (trouble with seeing and understanding where things are in space after a brain attack also known as stroke). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 5/13/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 5/21/25 at 11:12 A.M., an interview and record review was conducted with the Director of Rehab (DOR). The DOR stated Resident 1 received rehab services for physical therapy (PT), occupational therapy (OT) and speech therapy (ST) for cognition. The DOR stated Resident 1 ' s prior level of function (PLOF) was independent with ambulation. The DOR stated OT discharge summary dated 5/5/25 indicated: .Pt [patient] has poor functional mobility and requires Max A [maximum assistance: Helper does MORE THAN HALF the effort] . .Poor dynamic standing balance Fair static standing balance . .Pt. will demonstrate improved (good) balance and stability during activities, allowing for safe and independent participation in daily routines .Poor static/dynamic balance . .D/C [discharge] recs [recommendations] .24 hour care and walker with tray . The DOR stated, this would call for care giver training [record review above]. The DOR stated he was unable to find documentation if Resident 1 ' s MD (Medical Doctor) was notified regarding OT recommendations for 24 hour care and did not see documentation if Resident 1 ' s girlfriend (GF) would be the care giver of Resident 1. The DOR stated he was unable to find documented evidence if any care giver training with Resident 1 ' s GF and/or other care giver for Resident 1 ' s care with rehab. The DOR stated Resident 1 ' s GF was supportive and did not indicate if she would be the primary care giver after Resident 1 ' s discharge. The DOR stated caregiving training was important because this would assist with transition of care to home for Resident 1 and would be a safety issue because Resident 1 ' s GF probably would not know how to care for him if it ' s above what she can do. The DOR stated Resident 1 ' s last coverage date (LCD) was issued on 5/12/25 and was discharged on [DATE]. On 5/22/25 at 11:39 A.M., an interview and record review was conducted with the Case Manager (CM). The CM stated Resident 1 was able to ambulate with supervision using a walker on 5/2/25 at 300 ft anon 5/9/25 at 90 ft this information was sent to Resident 1 ' s insurance company who gave him a LCD. The CM stated ambulation alone should not be the basis of a safe discharge. The CM stated she did not offer a tray as recommended by OT because this was an out-of-pocket expense that Resident 1 would have probably refused. The CM stated caregiver training and housing would be arranged by the Social Services Director (SSD). The CM stated Resident 1 discharged home without 24 hour care with home health for PT/OT/RN and home health assistant. A clinical chart review was conducted on Resident1 ' s PT discharge summary dated 5/12/25 that indicated .Prior Living Description: Pt reports living in a home with a roommate that most likely will not be able to help with activities if needed . On 5/22/25 12 P.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated the SSD documented that she tried calling Resident 1 ' s GF on May 11, 2025, and May 12, 2025 and was unsuccessful but Resident 1 was able to contact GF that day who stated she would be with Resident 1 on his discharge day. The DON stated on Resident 1 ' s discharge day that his GF was not available. A review on Resident 1 ' s clinical record indicated, no documentation of MD notification for unsuccessful attempts made by SSD to arrange for a safe discharge and OT recommendations for 24 hour caregiver. On 5/22/25 at 12:42 P.M., an interview was conducted with the DON. The DON stated they should have facilitated a safe discharge by making proper arrangements with Resident 1 ' s care giver to ensure a safe discharge plan was in place for care giver training. The DON stated it was important to notify Resident 1 ' s Physician with barriers (OT recommendations for 24 hour care) to discharge and notify appropriate entities to facilitate a safe discharge and prevent re-hospitalization s. A review of the facility's policy and procedure titled ADMISSION, TRANSFER and DISCHARGE undated, indicated, .The Facility shall permit each resident to remain in the Facility, and not transfer or discharge the resident from the Facility unless; .The safety of individuals in the Facility is appropriate because the resident ' s health has improved sufficiently so the resident no longer needs the services provided by the Facility .

Based on observations, interviews, and record reviews, the facility failed to follow their policies and procedures for investigating missing items to protect the personal property for one reviewed resident (Resident 1) during a complaint investigation. This deficient practice placed all 91 residents at risk for loss of personal belongings and potential exploitation (taking advantage of a resident for personal gain), especially those with impaired cognition (memory or thinking). Findings: A review of Resident 1's Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of cognitive communication deficit (CCD-understanding what others say and organizing thoughts) and right ear hearing loss. A record review of Resident 1s minimum data set (MDS - a federally mandated resident assessment tool) dated 4/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of six points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 4/30/25 12 P.M., an interview was conducted with the Quality Assurance (QA) Nurse. The QA nurse stated on 4/4/25 a Facility Reported Incident (FRI) was previously reported due to Resident 1's allegation of missing money. The QA nurse stated Resident 1 was unsure if she had the missing money with her. The QA nurse stated they investigated the missing money which concluded Resident 1 did not have the missing money with her when she came to the facility per Resident 1 ' s personal belongings list. On 4/30/25 at 12:13 P.M., An interview and record review was conducted with the Social Services Director (SSD). The SSD stated she was informed on 4/17/25 by the nursing staff of the missing gray bag. The SSD stated the nursing staff was not able to place Resident 1 ' s hearing aids in her ear which alerted them [nursing staff] that Resident 1 ' s gray bag was missing because the hearing aids was stored inside Resident 1 ' s gray bag. The SSD stated she spoke with Resident 1 who told her that she had given her gray bag to her personal caregiver (not employed at facility). The SSD stated Resident 1 had told her the contents of the bag which included Resident 1 ' s house keys, phone charger, and hearing aids. The SSD stated Resident 1 ' s personal caregiver had access to her apartment because she had Resident 1's house keys. The SSD stated that she had only met Resident 1 ' s personal caregiver twice because she would come to the facility after hours to visit Resident 1. The SSD stated she did not contact Resident 1 ' s personal caregiver to ask about the gray bag because Resident 1 ' s personal caregiver was not listed on Resident 1 ' s clinical record and only knew her first name. The SSD stated because she lacked Resident 1 ' s personal caregiver ' s information she was unable to ask if the hearing aids could be returned to Resident 1. The SSD stated she had reached out to Resident 1 ' s [SENIOR LIVING FACILITY NAME] to replace Resident 1 ' s hearing aids and further stated it ' s a referral process so it takes a while but provided a fax report on 4/18/25 for an Audiology [hearing] ENT [ears, nose, throat] specialist consult. On 4/30/25 at 12:45 P.M., an interview was conducted with the SSD, QA Nurse and Operations Manager (OM). The OM stated it was important that they obtained [First Name of Resident 1 ' s personal Caregiver] information and question how much involvement she had with Resident 1. The QA stated that there was no further information found on [First Name of Resident 1 ' s personal Caregiver]. On 4/30/25 at 12:48 P.M., a record review was conducted on the SSD Missing Items binder. There was no recorded investigation regarding Resident 1 ' s missing gray bag or hearing aids. On 4/30/25 at 12:52 P.M., an interview was conducted with Resident 1, in Resident 1 ' s room. Resident 1 stated she had a missing gray bag and stated [First Name of Resident 1 ' s personal Caregiver] can give you much information about this. Resident 1 stated she did not give her gray bag to [First Name of Resident 1 ' s personal Caregiver]. Resident 1 stated the bag had diapers, wallet and hearing aids was in that purse and it was brand new and another box with a charger. Resident 1 stated her hearing aids have not been used since the day her gray bag went missing (4/17/25). On 4/30/25 at 2:17 P.M., an interview and record review was conducted with the QA Nurse. The QA nurse stated Resident 1 went to the hospital on 4/5/25 and returned on 4/10/25. The QA nurse stated that a new inventory list was made when Resident 1 returned from the hospital. A review of Resident 1 ' s Inventory of Personal Effects dated 4/10/25 included: - bag-gray - keys - charger for hearing aids - id [identification] card - two hearing aids checked off. On 4/30/25 at 4:26 P.M., an interview was conducted with the QA Nurse. The QA Nurse stated his expectations were for the SSD to follow up with [First Name of Resident 1 ' s personal Caregiver] since Resident 1 has cognitive impairments to verify if the bag was given to her or was still missing. The QA nurse stated Resident 1 has hearing impairments and without the use of hearing aids this could have affected Resident 1 ' s quality of life to cause communication barriers, and confusion. On 4/30/25 4 P.M., receipt reviewed of generic hearing aids purchased for $54.11 by OM on 4/30/25. On 5/1/25 at 11:15 A.M., an interview was conducted with the DON. The DON stated Resident 1 has severe cognitive impairments and may forget at times that can affect her memory and may not realize she ' s [Resident 1] being taken advantaged of by a person who is supposed to be caring for her. The DON stated it was her expectation that the SSD to follow the facility ' s missing items policy and procedures and to protect Resident 1 from risks of exploitation. A review of the facility's policy and procedure titled [Facility Name] POLICY/PROCEDURE SECTION ADMINISTRATIVE SUBJECT THEFT & LOSS undated, indicated, 1. Loss or theft of resident property worth $25.00 or more will be documented and reported to the administrator (or designee) for investigation, police reporting or other appropriate action .2. Completed Theft and Loss investigation reports will be filed in a binder which will be retained in the Social Service Department Office .

Based on interview, record review, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I assessment was coded accurately for 1 (Resident #10) of 3 sampled residents reviewed for PASRR. Findings included: A facility policy titled, Policy/Procedure with a Subject titled PASRR, dated 05/01/2023, revealed, It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. The policy further revealed, 2. After admission, the Interdisciplinary Team (IDT), will review follow up determinations for Level I positive, and/or if Level II is required and pending evaluation. 3. An IDT member will determine if a Resident Review (RR) is required. 4. Based upon the final determinations, the facility will ensure proper referral to state agencies for the provision of specialized services to residents with ID/RC (Intellectual disability or Related Condition) or SMI (Serious Mental Illness). 5. Social Services shall contact the appropriate State Agency for referral of specialized care and services as needed. An Admission Record revealed the facility admitted Resident #10 on 03/24/2023. According to the Admission Record, the resident had a medical history that included schizoaffective disorder and bipolar disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/2023, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had diagnoses of schizoaffective disorder and bipolar disorder. Resident #10's hospital History and Physical Note, dated 03/11/2023, revealed, under the Assessment/Plan section of the note, a Problem List included the diagnoses of bipolar disorder and schizoaffective disorder. Resident #10's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 03/29/2023, revealed, under the Section III - Serious Mental Illness - Definition portion, for question 10. Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? the answer was marked No, deeming the PASRR Level I as Negative, with No Serious Mental Illness, and a Level II - Not Required. During an interview on 06/13/2024 at 11:03 AM, Social Services (SS) Staff #1, who was also the Admission Coordinator, stated she requested a PASRR from the hospital during the admission process, and it was sent to the facility via an electronic file exchange. She stated she reviewed the PASRR, and if they were deemed positive, the Director of Nursing (DON) would then review the PASRR to start a resident review. She stated if there were issues regarding the diagnoses or status of the PASRR, the DON maintained communication with the state office that generated them. SS Staff #1 further stated Resident #10's PASRR was completed in March 2023, and she did not start in her position at the facility until May 2023. During an interview on 06/13/2024 at 11:07 AM, the DON stated SS Staff #1 requested the PASRR because it was a requirement for admission. The DON stated if there were medications or diagnoses that triggered when she received the PASRR, she reviewed it with the resident's chart and if referrals were needed then she would initiate those referrals. The DON further stated Resident #10's PASRR was incorrect. The DON stated at the time Resident #10's PASRR was generated, the facility did not have a good process in place. She further stated her expectation was for a designee to review the PASRR for accuracy and if there were discrepancies in the clinical documentation, it should be given to her for review. The DON stated if the PASRR was not correct, she would apply for a resident review or a reconciliation until the evaluation was corrected. The DON stated if the resident had a positive Level I PASRR, the facility would start looking for the State to send them a determination letter. During an interview on 06/13/2024 at 12:06 PM, the Administrator stated he understood very little about the PASRR process; however, his expectation was for staff to receive the required documents, and if they were not correct, to get them corrected to be accurate

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure a significant change Minimum Data Set (MDS) was submitted timely for 1 (Resident #53) of 18 resident MDSs reviewed. Findings included: A facility policy titled, Policy/Procedure- Resident Assessment Instrument, revised 10/01/2023, specified, The Long-Term Care Facility Resident Assessment Instrument 3.0 (RAI) User's Manual Version 1.18.11 October 2023 will be the source guidance for the RAI Process. A Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated 10/2023, specified, An SCSA [significant change in status assessment] is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. Further review revealed, The CAAs [care area assessment] completion dated (item V0200B2) must be no later than 14 days after the ARD [assessment reference date] (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for SCSA were met. An Admission Record revealed the facility admitted Resident #53 on 01/22/2024. According to the Admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke), chronic obstructive pulmonary disease, hemiplegia and hemiparesis (paralysis affecting only one side of the body), and sepsis (infection of the blood stream). An admission MDS, with an ARD of 01/28/2024, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #53 did not receive hospice services. Resident #53's care plan included an undated focus area that indicated the resident had a terminal prognosis due to cerebral infarction. Interventions directed staff to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Resident #53's Order Summary Report with active orders as of 06/13/2024 revealed an order dated 05/16/2024 for admission to hospice services. Resident #53's hospice services POC [plan of care] Summary, as of 06/12/2024 revealed an order dated 05/16/2024 for admission to hospice services on 05/16/2024 under routine level of care due to cerebral infarction. Resident #53's significant change MDS, with an ARD of 05/29/2024, revealed the assessment was not complete. Further review revealed the section titled Signature of RN [registered nurse] Assessment Coordinator Verifying Assessment Completion was blank. During an interview on 06/13/2024 at 10:14 AM, the MDS Nurse stated the MDS was complete when it was signed by the Director of Nursing (DON). The MDS Nurse stated Resident #53's significant change MDS should have been completed by 05/29/2024. She confirmed the MDS was not completed on time. During an interview on 06/13/2024 at 11:07 AM, the DON stated the MDS was considered complete when she had signed it. The DON stated Resident #53's significant change MDS should have been completed and submitted by 05/30/2024. She added it was not completed on time. During an interview on 06/13/2024 at 12:02 PM, the Administrator stated he expected the MDS to be completed and submitted on time.

Based on interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 (Resident #41) of 18 sampled residents reviewed for MDS accuracy. Findings included: A facility policy titled, Policy/Procedure - Resident Assessment Instrument, updated on 10/01/2023, revealed, 8. Each person completing a section of the MDS attests to its accuracy by affixing his/her electronic signature to that section of the MDS. An Admission Record revealed the facility admitted Resident #41 on 05/19/2024. According to the Admission Record, the resident had a medical history that included cellulitis of left lower limb, local infection of the skin and subcutaneous tissue, and homelessness. An admission MDS, with an Assessment Reference Date (ARD) of 05/24/2024, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was cognitively intact. The MDS indicated the resident did not currently use tobacco. Resident #41's Progress Notes, revealed a note dated 05/23/2024 that indicated a nicotine transdermal patch for smoking cessation was not applied due to the resident was smoking. During an observation on 06/11/2024 at 1:23 PM, Resident #41 was observed outside smoking in the designated smoking area. There was a staff member present, and the resident was able to light and smoke a cigarette safely and independently. During an interview on 06/13/2024 at 10:16 AM, the MDS Nurse stated she was responsible for answering the section of the MDS that asked if the resident had current tobacco use. The MDS Nurse stated that Resident #41 was not marked as a current tobacco user on their admission MDS and that was an inaccuracy on her part. During an interview on 06/13/2024 at 11:17 AM, the Director of Nursing (DON) stated she was responsible for the overall accuracy of the MDS as the Registered Nurse (RN) signer. She stated her expectation was for residents who smoked to be triggered on the MDS. She also stated the MDS should be complete and accurate. During an interview on 06/13/2024 at 12:02 PM, the Administrator stated his expectation was for the MDS to be completed timely and accurate.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure a care plan was completed for diuretics for 1 (Resident #53) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Policy/Procedure- Nursing Administrative with a Subject titled Comprehensive Assessment, revised in 03/2021, specified, All problems, goals, and interventions will be documented in the Resident's Comprehensive Care Plan. An Admission Record revealed the facility admitted Resident #53 on 01/22/2024. According to the Admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke), chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, and hypertension. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2024, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident received a diuretic. Resident #53's Order Summery Report with active orders as of 06/13/2024, revealed an order dated 05/16/2024 for Lasix (furosemide, diuretic) 40 milligram (mg), one tablet as needed for edema, once a day. Resident #53's comprehensive care plan revealed no documentation that a care plan was completed for the use of a diuretic. During an interview on 06/13/2024 at 10:14 AM, the MDS Nurse stated she was the one that should have created a care plan when the order was entered for Resident #53's diuretic. She stated the care plan was needed because it helped the staff to monitor for signs and symptoms of edema. During an interview on 06/13/2024 at 11:07 AM, the Director of Nursing (DON) stated the care plans should be compared to the resident charts and should match. She added that the diuretic should have been care planned for Resident #53.

Based on interview and record review, the facility failed to follow their own policy regarding receipt of narcotics (controlled substance) for 1 of 2 sampled residents. This failure occurred when a licensed nurse did not check or inventory medications which included narcotics delivered by the pharmacy to the facility. As a result, the whereabouts of Resident 1's narcotic medication was not known. This deficient practice had the potential to delay pain medication administration, could affect residents ' safety and created an opportunity for drug diversion. Findings: Resident 1's record was reviewed. Per the undated facility Admission document, Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (partial paralysis on one side of the body) and stiffness of bilateral ankles. A record review on 5/21/24 was conducted. Per the facility's document titled: Packing Slip Proof of Delivery, dated 5/16/24, LN 3 signed for receipt of 30 tablets of Hydroco/Apap-5-325mg (Norco) for Resident 1. Resident 1 was interviewed on 5/21/24 at 10:30 A.M. Resident 1 stated he requested Norco (a narcotic pain medication) on 5/18/24 at around 12 P.M. Resident 1 stated, the Licensed Nurse 1 (LN1) said the medication was not available because the facility had to reorder the pain medication from the pharmacy. Resident 1 stated pain medication was administerd from the facility ' s emergency kit. An interview on 5/21/24 at 10:45 A.M., with LN1 was conducted. LN1 stated licensed staff must check the pharmacy bag and make sure everything was accounted for and keep a record on the delivery receipt. LN 1 stated narcotics were ordered usually 2-3 days ahead of time before the medication was exhausted. An interview with LN 2 was conducted on 5/21/24 at 11:05 A.M. LN 2 stated medications delivered should be reconciled with the pharmacy delivery manifest. LN 2 stated licensed staff must take everything delivered from pharmacy out of the bag to make sure we have everything. The next step is for the licensed staff to compare with the pharmacy delivery manifest and then sign for them. A phone interview with LN 3 was conducted on 5/22/24 at 4:24 P.M. LN 3 stated she did not check each medication from the bag delivered from the pharmacy (on 5/16/24) but did sign for everything delivered from pharmacy. LN 3 stated she should have checked the bag from the pharmacy before she signed the manifest to make sure every medication was there. LN 3 stated the facility policy was to have a licensed nurse to check and sign for receipt of medications including narcotics. A joint record review and interview was conducted on 5/22/24 with the Director of Nursing (DON). Review of: Policy / Procedure -Nursing Clinical revised 5/20/2024 .#5 A second person licensed nurse will cosign the narcotic count sheet and delivery manifest upon receipt of controlled medication from pharmacy. The DON stated two licensed nurses should have checked and signed for Resident 1's delivered medications, including narcotics from the pharmacy. A phone interview with the Pharmacist (PH) was conducted on 5/23/24 at 8:30 A.M. The PH stated according to the manifest, Resident 1's narcotic medication (Hydroco/Apap 5-325 mg, 30 tabs) was delivered to Resident 1's facility and was received and signed out by the facility ' s licensed nurse, (LN 3) on 5/16/24. The PH then stated, later another facility had called the pharmacy and reported possession of Resident 1's narcotic medication. The PH stated Resident 1's narcotic medication had been returned to the pharmacy and was later found next to the refuse bin /pile. The PH stated the refuse/pile had not been checked for a few days. An interview with the Director of Nursing was conducted on 5/23/24 at 11:55 A.M. The DON stated on 5/18/24 the facility had initiated an audit of all medication carts, intravenous (medication delivered through a plastic tube to a vein) carts, treatment carts and medication rooms but was unable to locate Resident 1's narcotic medication. The DON stated licensed nurses should check one by one anything that comes from the pharmacy especially narcotic medications.

Based on observation, interview, and record review, the facility failed to implement a comprehensive systematic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, for 4 of 19 sampled residents when: 1. The facility failed to identify an unplanned significant weight loss for Resident 9 2. The facility failed to ensure that the dietitian evaluated Resident 31's nutritional status, in order to recommend nutritional interventions prior to an unplanned, significant weight loss, 3. The facility failed to provide additional protein as ordered, for Resident 69 4. The facility failed to provide dining cueing for Resident 48 as was a planned approach to maintain acceptable parameters of nutritional status. As a result, the facility's system was not effective at identifying an unplanned significant weight loss. In addition, the facility staff were not effective at capturing slow insidious weight loss prior to significant unplanned weight loss. Therefore, the facility failed to ensure timely notification to the physician. The staff were not consistent, and clear in determining residents' overall goals regarding nutritional assessments. The facility failed to consistently ensure that planned nutrition interventions to address identified nutritional concerns, were implemented as ordered. The facility failed to identify and address slow weight change, prior to the weight change/loss becoming an unplanned significant weight loss. was identified during a 2013 survey. This is a repeated failure. Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4) Findings: 1.On 7/21/15 at 10:00 A.M., Resident 9's medical record was reviewed. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Concurrently, a record review of Resident 9's Weight Summary noted the following weight: 7/30/14 - 186.4 - pounds 9/1/14 - 182.4 - pounds 10/1/14 - 180 pounds 11/1/14 - 182 pounds 11/27/14 - 182 pounds 12/24/14 - 182 pounds 1/7/15 - 182 pounds 1/16/15 - 179.4 pounds 2/20/15 - 171.8 pounds 3/20/15 - 176.6 pounds 4/8/15 - 171.9 pounds 4/12/15 - 178.5 pounds 4/19/15 - 175.4 pounds 4/26/15 - 175.4 pounds 5/10/15 - 172.8 pounds 5/24/15 - 170.1 pounds 6/8/15 - 168.8 pounds 6/26/15 - 169.4 pounds 7/1/15 - 160 pounds 7/10/15 - 161.3 pounds 7/21/15 - 169.2 pounds On 7/21/14 at 11:00 A.M., the facility's registered dietitian (RD 1) reviewed Resident 9's medical record, including the weight summary, and stated, There was a 5% significant weight loss in a month starting on 7/1/15. I monitor the weights and she did not trigger for an RD review prior to July 2015 because her weight had not reached a weight loss of 2% in a week or 5% in a month. RD 1 was asked if her overall weight loss was a concern when Resident 9 had lost 22 pounds from 1/7/15 to 7/1/15, and RD 1 stated, No, no concern. RD 1 was asked again if the weight loss of 22 pounds was a concern, and RD 1 stated, No because there was not a significant weight loss until 7/1/15, and her weight had been stable. Concurrently, RD 1 verified that there had not been a nutrition reassessment by a registered dietitian, nor a nutrition intervention recommendation until 7/11/15, after Resident 9 had experienced a 11% unplanned body weight loss since 1/7/15 to 7/1/15. On 7/11/15 per the Registered Dietitian Note, .lost 20.7# (pounds) x 6 mo (months) ., wt (weight) loss unplanned/desired given high bmi (body mass index - BMI is a measure of body) ., res. (resident) at risk of wt loss/ r/t (related to) colon obstruction .,plan -clarify diet: fortified (strengthened or protected) mech (mechanical - [MEDICATION NAME] consistency than regular foods) soft diet. Add 4 oz (ounces) shakes bid (two times a day) at L-D (lunch and dinner) x 30 days d/t (due to) wt loss. add 4 oz fiber water at bkft (breakfast) to up fiber. [MEDICATION NAME] (a protein component in blood), TSH ([MEDICAL CONDITION] stimulating hormone) to check status . On 7/27/15 at 11:25 A.M., the director of nursing (DON) reviewed Resident 9's physician orders, and verified that a fortified diet and 4 ounce health shake at lunch and dinner were not ordered until 7/17/15, six days after the RD provided recommendations to address a 11% significant weight loss. Concurrently, the DON acknowledged that the nutrition interventions were not implemented in a timely manner. The DON stated there was not a tracking mechanism to determine where the communication breakdown could have been that may have contributed to the delay, and stated, We have to work on that. On 7/21/15 at 12:53 P.M., RD 1 reviewed a weight committee IDT (interdisciplinary team) note for Resident 9 that she had attended, dated 7/16/15, which indicated, IDT met to discussed wt gain 3.7 lbs (pounds) x 1 week = 2.2% significant desired planned expected. Wt status remains above IBW (ideal body weight) = 115 +/- 10% BMI =29.3 (moderately overweight). Resident continues to eat well now consuming 50-100% with meals ., monitor one more weekly wts if stable then change to monthly . Concurrently, RD 1 was asked to review Resident 9's nutrition care plan initiated on 4/13/15 which indicated, Has nutrition problem or potential nutritional problem r/t [MEDICAL CONDITION](high blood pressure),.intestinal obstructions, hemi-side [MEDICAL CONDITION].(stroke) Wt status above IBW = 115+/-10% BMI =31.7 (overweight) .1/7/15-7/11/15 wt loss 7.5# x 1 mo 4% and lost 10.6# (6% since readmit. Unplanned yet desired given wt above range. Lost 20.7# 11% since 1/7/15. 7/15/15 wt gain 3.7 lbs x 1 week =2.2%. Significant expected/desired planned wt status remains above IBW = 115+/-10% BMI =29.3 Concurrently, RD 1 was asked what the overall nutrition and weight goal was for Resident 9, as the notes above seemed to conflict with one another. RD 1 stated, The IBW means I wouldn't want her to be below 104 pounds and I wouldn't want her to be above 126 pounds. When the RD was asked again what the weight goal was for Resident 9 as it was noted fortified and health shakes were recommended by RD 1 on 7/11/15 due to weight loss, RD 1 stated, I want to stabilize her at her current weight at 169 pounds. RD 1 was asked if the IBW was applicable to Resident 9 who was [AGE] years old with a noted nutritional problem per the care plan, and she stated, It's just a method that I'm used to documenting. I would not want her to get to her IBW. RD 1 was asked if the significant weight loss which continued with gradual weight loss was a planned weight loss, RD 1 stated, I need to review the medical record and get back to you. On 7/21/15 at 4:46 P.M., RD 1 stated, I reviewed the medical record and it was an unplanned weight loss. On 7/22/15 at 9:36 A.M., the DON was asked to review Resident 9's Weight Summary to determine the percentage of weight loss that occurred from 1/7/15 at 182 pounds to 2/20/15 at 171.8 pounds, and the DON stated, That's a 5.6% significant weight loss. The DON was asked if the facility had identified the significant weight loss, and reported to the physician. The DON reviewed Resident 9's medical record, and stated, There is no documentation around that. We missed it. I would have expected an interdisciplinary team to conduct a weight variance meeting to look into reasons for the weight loss. I would have expected the doctor and responsible party to have been notified. Further, I would have expected the trend in continued weight loss to have been monitored and addressed. Concurrently, a review of Resident 9's discharge to the hospital for a [DIAGNOSES REDACTED]. Resident 9 was in the hospital from 4/6/15 to 4/12/15, and from 6/22/15 to 6/25/15 due to colon obstruction. The DON acknowledged that the facility had not identified the significant unplanned weight loss that occurred in February 2015 to determine what the facility may had been able to recommend to prevent or decrease the amount of weight loss prior to the discharge to the hospital that occurred in April 2015. On 7/22/15 at 10:13 A.M., the DON reviewed a nursing progress note, dated 4/23/15, which noted Resident 9 states she is having difficulty swallowing. She currently has orders for regular mechanical soft diet. Resident would like to have meals grounded texture. Notified Dr. (name of doctor) .pending call back at this time. The DON stated the diet order change was obtained on 4/28/15 of Mechanical soft, ground diet, thin liquids, five days after the resident reported she had difficulty swallowing. The DON acknowledged that the diet order change was not completed in a timely manner. In addition, the DON stated she would have expected a nursing assessment to have been completed at that time due to resident reported difficulty with swallowing, and stated,There is no documentation that nursing addressed the issue of a reported swallow difficulty other than call the doctor for a diet order change. On 7/22/15 at 3:02 P.M., RD 1 was asked to review Resident 9's weight record from 1/7/15 at 182 pounds to 2/20/15 at 171.8 pounds, and RD 1 stated, That's a 5.6% significant weight loss. RD 1 verified that she had not identified a significant weight loss for Resident 9 until 7/1/15, and stated, I verified a 5% significant weight loss in a month for the first time in July 2015. RD 1 was asked had she identified the significant weight loss 5 months earlier when it occurred if she would have changed her nutrition care plan, RD 1 stated, I would try to stabilize her weight by observing her eat and updating her food preferences. Had I identified the significant weight loss earlier I would have reviewed potential causes for weight loss. My usual practice when reviewing weight loss is to consider a variety of things such as to send to restorative nursing program for cueing, may refer to speech or social services, review consumption of food intake, liberalize diet, recommend either an [MEDICATION NAME] or pre-[MEDICATION NAME], I don't know what happened. RD 1 reviewed Resident 9's diet order that was ordered on [DATE] that indicated Low cholesterol/low fat mechanical soft diet, and stated, I would have recommended to liberalize the diet back in February had I known she had a significant weight loss. Concurrently, RD 1 was asked to review a registered dietitian note written by RD 1, dated 4/18/15, that indicated, Dx (diagnosis) - intestinal obstruction .diet - mech (mechanical) soft. Intake 50 - 100%.no [MEDICAL CONDITION] .weight - 178.5#., 103 -127#.bmi - 31.7 ., A (assessment) = high BMI - intake varies ., Plan - continue diet and plan of care. No low cal (calorie) regimen needed this time d/t (due to) adjustment and varied intake . RD 1 was asked to explain her note, and she stated, Even though she was with high bmi and was above her ideal body weight of 103 - 127 pounds I did not want to recommend a low calorie diet then because she just came back from the hospital so I wanted her to adjust first. Concurrently, RD 1 was asked to review a dietary progress note completed by the dietary services supervisor (DSS), dated 4/29/15, which included a note of, Resident diet changed by Kaiser Order on 4/28/15 to regular ground texture due to episode of coughing. Resident diet downgrade. Will refer to ST (speech therapy) prn.refer to RD. Monitor p.o. (by mouth) intake and tolerance. At that time per the Weight Summary, the resident weighed 175.4 lbs as of 4/26/15. The RD stated, I didn't know about the referral. RD 1 verified that an RD had not followed up on Resident 9 until 7/11/15, three months after the DSS referred to the RD. The next dietary progress note was completed by the DSS on 6/25/15, not by the RD. The DSS note indicated, Nutrition wt update: resident wt continuous to be stable no significant wt changes noted. Remains above IBW = 115 =/-10%. BMI =29.9. Will change to monthly wt. f.u (follow up) prn (as needed). At that time, Resident 9 weighed 168.8 pounds as of 6/8/15 which was a six pound further weight loss from the previous DSS note. On 7/27/15 at 10:00 A.M., RD 2 reviewed the dietary progress notes as indicated above, and stated, The DSS should not have determined that the resident had stable weight during the 6/25/15 dietary review, and should have referred to the RD. In addition, RD 2 verified that noting remains above IBW should not have been a factor in the facility's IDT determinations for nutrition related action plan, which would include monitoring of weight, as it is not standards of practice for geriatric nutrition. We would want to maintain current weight. On 7/22/15 and 10:13 A.M., during a concurrent interview and record review with the DON, the DON verified Resident 9 had experienced an unplanned significant weight loss of 5.6% from January 2015 to February 2015, which had not been identified by the facility, and therefore had not been reported to the physician. The resident had begun to lose weight again around April 2015 in which time she also had nausea and vomiting per nursing notes dated 4/5/15, and was sent to hospital on [DATE], and returned on 4/12/15 with [DIAGNOSES REDACTED]. On 4/26/15 at the facility Resident 9 weighed 175.4 pounds. At the facility, in May 2015 Resident 9 had slow weight loss and then weighed 168.8 lbs on 6/8/15. The DON acknowledged the facility continued to not address the further slow weight change after an initial significant weight loss that occurred at the facility from January 2015 to February 2015. The DON stated that she would have expected the facility to identify the weight changes in order to review potential underlying causes and to investigate any potential interventions as an interdisciplinary team. The DON verified the first IDT weight committee was conducted for Resident 9 on 7/11/15 after an 11% significant weight loss in 6 months per the Weight Committee IDT note, dated 7/11/15. The DON verified the physician was not notified of significant weight loss, and further weight loss, until 7/17/15. The DON stated that the facility had not determined underlying causes and potential interventions early on prior to a 11% significant, unplanned weight loss. The facility's policy and procedure (revised 5/2007) titled Nutrition (Policy Number: NACT 20) indicated, Policy: It is the policy of this facility to ensure that all resident maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrate that this is not possible. Purpose:.Weight Loss; Significant weight loss (5% in one(1) month, 7.5% in three (3) months, or 10% in six (6) months, as well as unplanned weight loss and does not trigger review of the Nutritional Status RAP (Resident Assessment Protocals), should be addressed in the care plan. Facility approaches to address weight loss may include an ongoing search for the causes(s) of weight loss, unless the facility determined that the cause is known or the search for the cause has been exhausted or should be limited. Documentation reflects the reason why the search for the cause(s) was limited or discontinued. Once the cause(s) is/are identified, relevant care plan decisions are made and documented. Ongoing interventions are evaluated and modified as needed ., Dietary Evaluation; 2. Once the resident has been evaluated for nutrition status, the Nurse Supervisor and Dietary Supervisor will determine if there is a significant change in the resident's condition and initiate RAI (Resident Assessment Instrument) process. If so, additional nutrition will be offered to those residents including all high risk residents. Options include, but are not limited to, Super Cereal, large portions, between meal snacks, and commercial nutritional supplements ., Clinical Evaluation; 2. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the ID team to determine the cause of weight loss/gain and intervention required. Family member/responsible party and attending physician will be notified by the Unit Manager. The dietitian will be notified by the Dietary Clinical Assistant ., 5. Any resident meeting the criteria for weight loss and any resident at risk will be weighed weekly with the weight entered in the weekly weight progress notes. Weekly weights will be reviewed each week during resident care plan conference . According to accepted standards of practice, Among older people, weight loss is associated with frailty, functional impairments, immune disorders, pressure ulcers, [MEDICAL CONDITION], cognitive impairment, low quality of life, and increased mortality. Research indicates it is critical that any weight loss in older adults be prevented. (Source: Position of the American Dietetic Association: Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long-Term Care, Journal of the American Dietetic Association, December 2005). Involuntary weight loss can lead to muscle wasting, decreased immunocompetence (the ability of the body to produce a normal immune response following exposure to an [MEDICATION NAME]), depression and an increased rate of disease complications. Various studies have demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of [DIAGNOSES REDACTED].aafp.org/afp AMERICAN FAMILY PHYSICIAN. 2. On 7/23/15 at 2:04 P.M., Resident 31's medical record was reviewed. Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Concurrently, a record review of Resident 31's Weight Summary noted the following weight: 9/1/14 - 100 pounds 9/11/14 - 96 pounds 10/1/14 - 99.4 pounds 11/1/14 - 99 pounds 12/21/2014 - 103 pounds 12/22/14 - 100 pounds 1/21/15 - 100.2 pounds 2/17/15 - 95.6 pounds 3/15/15 - 96.6 pounds 4/8/15 95.5 pounds May 2015 (exact date not specified on RNA (Restrative Nursing Assistant) monthly weight sheet) - 87.2 pounds 5/25/15 - 89.5 pounds 5/31/15 - 88.5 pounds 6/8/15 - 89 pounds 7/1/15 - 94.2 pounds On 7/23/15 at 3:30 P.M., the facility's consultant registered dietitian (RD 2) reviewed Resident 31's medical record, and stated, An RD should have completed a nutrition annual follow up toward end of February 2015, and did not. RD 2 stated she would have expected an RD to have identified the five pound weight loss that occurred from January to February 2015, in order to evaluate potential causes and approaches to stabilize nutritional status to help prevent a significant unplanned weight loss. Concurrently, RD 2 verified that the first nutrition review conducted by a RD for the year 2015 was completed on 5/7/15, after Resident 31 had lost 13% body weight since 1/21/15. The RD note, dated 5/7/15 indicated, weight note: 5/2/15 -87.2#.A (assessment) = weight loss 8.3# x 1 mo (month), wt loss of 13# x 3 mo. (13%) wt loss of 15.8# x 5 mo (15%)/unplanned/undesired/unexpected r/t (regard to) varied intake, .res. takes her supplements as ordered .res. intake is less than needs/ Plan - continue shakes tid (three times a day), liquid protein qd (every day). Start mvi/min (vitamin with minerals), add fortified foods w/meals. RNA dining program to increase cueing w/meals. Offer med pass 2.0 120 cc at Hs (bedtime). Change diet to regular w/chopped meat to increase acceptance and ease in chewing. [MEDICATION NAME] to check status. Refer to SSD (social services director) and ST. (speech therapy) to check status. On 5/21/15 per a Registered Dietitian Note: Meal rounds observation: this res. falls asleep at meal times, not easily arousable, fed by staff, and cued to eat, Seen SSD for med adjustment. Supplements as recommended by RD dated 5/7/15 are all in placed and accepted per record. Plan -refer to ST for appropriate texture. Start fortified foods w/ (with) meals. On 7/27/15 at 10:25 A.M., the dietary services supervisor provided a copy of the dietary departments monthly weights cheat sheet that was utilized by an RD (RD 1) and the DSS to monitor the residents weights. The monthly weights sheet for Resident 31 indicated a weight of 100.2 pounds in January, and 95.6 pounds in February 2015 with a notation of decrease 4.5% zero significant. On 7/21/15 at 10:42 A.M., RD 1 stated that she reviewed all residents weights independently of a nurse referral, and stated, I monitor for a 2% weight loss in one week if a resident has an order for [REDACTED]. A review of the quarterly minimum data set (MDS -assessment tool), dated 6/16/15, indicated that Resident 31 was 64 and weighed 89 pounds. Under the K0300 section of the MDS indicated that Resident 31 had a Loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on physician-prescribed weight-loss regimen. The facility's policy and procedure (revised 5/2007) titled Nutrition (Policy Number: NACT 20) indicated, Policy: It is the policy of this facility to ensure that all resident maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrate that this is not possible. Purpose: .Weight Loss; Significant weight loss (5% in one(1) month, 7.5% in three (3) months, or 10% in six (6) months, as well as unplanned weight loss and does not trigger review of the Nutritional Status RAP, should be addressed in the care plan. Facility approaches to address weight loss may include an ongoing search for the causes(s) of weight loss, unless the facility determined that the cause is known or the search for the cause has been exhausted or should be limited. Documentation reflects the reason why the search for the cause(s) was limited or discontinued. Once the cause(s) is/are identified, relevant care plan decisions are made and documented. Ongoing interventions are evaluated and modified as needed ., Dietary Evaluation; 2. Once the resident has been evaluated for nutrition status. The facility's undated policy and procedure titled Nutrition Assessment And Documentation indicated, 1. All resident/patients will receive a comprehensive nutritional assessment by the Registered Dietitian (RD) and integrated in the patient care plan. 2. The nutritional assessment may include the following: a. Observation of the resident/patient during meal times, b. Interview and observation to determine food tolerances, likes, dislikes and allergies [REDACTED].) This information may be obtained from the speech therapist, d. Review of medical history from resident/patient medical record to include laboratory tests, anthropometric (used to evaluate the interaction of workers with tasks, tools) measurements, and clinical findings, e. Review of medications and food medication interactions if relevant to diet therapy or nutritional status, g. Summary of findings., h. Recommendations, goals of plan of care, monitoring and evaluation. 3. On 7/23/15 at 8:03 A.M., Resident 69's medical record was reviewed. Resident 69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Registered Dietitian Note, dated 6/18/15, indicated, skin note: sacrum st 2 (stage 2 pressure ulcer -skin breaks open)., Plan - increase protein serving w/meals. continue plan of care. A nursing progress note, dated 6/24/15, indicated, Called MD regarding RD recommendation to increase protein servings with meals and to give meat x 2 on B-L-D (breakfast, lunch and dinner). Okayed by MD. Orders noted and carried out. RP (responsible party) made aware. The RD recommendation was communicated to the physician six days later. Per physician orders, dated 6/24/15, meat x 2 B-L-D. On 7/23/15 at 10:11 A.M., the dietary services supervisor (DSS) provided the meal tray ticket for Resident 69 which indicated the following diet order: LCS (low concentrated sweets), M/S (mechanical soft) chopped with extra gravy moist, 8 oz (ounces) water, 8 oz whole milk, 4 oz juice, 4 oz sugar free health shake to be given at breakfast, lunch and dinner. There was no indication on the meal tray ticket that dietary provided double portion of meat with meals. Concurrently, the DSS was asked to review the physician's orders [REDACTED]. The order was not communicated to dietary. The DSS verified that the kitchen had not provided double meat portions for breakfast, lunch, and dinner since it had been ordered on [DATE]. The facility's undated policy and procedure titled Diet Orders For New Admissions, Diet Changes, NPO, Or Hold Meals indicated, 2. The facility will serve diets as ordered by the physician. 4. Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 48 had a Brief Interview for Mental Status score of 10 (on a scale of 00 to 15, with 15 being most cognitively intact) per the Minimum Data Set, dated 6/1/15. A review of Resident 48's record titled Medication Review Report dated July 2015, included a physician order [REDACTED]. An observation was conducted on 7/21/15 at 12:31 P.M. in the facility dining room. Resident 48 was sitting in his wheelchair in front of a table. His lunch tray was on the table. Resident 48 was staring straight ahead. An observation was conducted on 7/22/15 at 11:58 A.M. in the facility dining room. Resident 48 was sitting in his wheelchair in front of a table, taking bites of his meal with long pauses between self-feeding. An interview was conducted on 7/22/15 at 12:12 P.M. with RNA 5. RNA 5 stated, I think he's (Resident 48) lost weight, so we need to cue or encourage him to eat. An interview was conducted on 7/22/15 at 2:51 P.M. with RNA 5 in the north nursing station. RNA 5 stated, We just started to cue him (Resident 48) to eat this week. We didn't know about it until Monday (referring to 7/20/15). An interview was conducted on 7/23/15 at 3:49 P.M. with licensed nurse (LN) 7. LN 7 stated that she had received the order for Resident 48 to have RNA dining cueing, and provided a copy of the order to rehab, who was supposed to tell it to RNA. LN 7 stated this was the normal process for communicating orders to the RNAs. A review of Resident 48's record flowsheet for Intervention: RNA dining to increase cueing with meals with a look back of 30 days for the month of June/July 2015 was conducted. This record included documentation of 3 separate times when Resident 48 had been monitored or provided with dining cueing on 7/8/15, 7/16/15, and 7/20/15. An interview was conducted on 7/22/15 at 4:32 P.M. with the Director of Staff Development (DSD). The DSD stated that the documentation and monitoring for RNA dining cueing started on 7/8/15. The DSD stated that the dining cueing should have been implemented when it was ordered by the physician on 6/24/15. An interview was conducted on 7/23/15 at 3:00 P.M. with the Director of Nursing (DON). The DON stated that the licensed nurse who got the order for RNA dining cueing from the physician did not notify rehab therapy or the RNA, so the cueing was not started until 7/8/15. The DON could not explain why there was no other documentation other than the 3 days, for the RNA dining cueing after it was already known on 7/8/15. The DON stated They just didn't document except for those 3 times. The DON acknowledged that the RNA dining cueing had not been provided or implemented consistently since ordered on [DATE].