Every finding on record at Mesa Verde Post Acute Care Center

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of five sampled residents (Residents 2 and 3) were accurate and complete. * The facility failed to ensure the Personal Effects Inventory Form for Resident 2 was reviewed and signed by the resident's representative and facility staff upon the resident's admission to the facility. * The facility failed to ensure the Personal Effects Inventory Form for Resident 3 was completed and signed by the resident's representative and facility staff upon the resident's admission to the facility. These failures had the potential to prevent the facility from accurately accounting for the personal effects and belongings of Residents 2 and 3.Findings: Review of the facility's P&P titled Personal Property dated 11/14/25, showed the following: - Upon admission the CNA or designee will conduct a personal property inventory of the resident's property. - The Personal Effects Inventory Form will be signed, placed in the medical record, and a copy of the signed form provided to the resident or the resident's representative. - Upon discharge, the resident or resident representative will review and sign the Personal Effects Inventory form to ensure all personal property is accounted form. - Upon discharge, Social Services staff contact the resident or resident representative and explain the belongings can only be stored at the facility for 30 days. 1. Medical record review for Resident 2 was initiated on 6/8/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident 2's Personal Effects Inventory Form (undated) showed the following items listed: Glasses, Galaxy phone, gray pants, black sweater, and white socks. The form was not signed by the staff or Resident 2's representative. On 6/8/26 at 1300 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings and stated the staff were supposed to list the resident's personal belongings on the Personal Effects Inventory Form and review it with the resident's representative. RN 1 stated if the inventory list was not completed, the facility could not track the residents' items and may be held responsible for lost belongings. RN 1 stated some items, such as hearing aids, could be very expensive. 2. Medical record review for Resident 3 was initiated on 6/8/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 5/19/26, showed Resident 3 had the capacity to understand and make medical decisions Review of Resident 3's medical record failed to show documented evidence a Personal Effects Inventory Form was completed for Resident 3 upon admission to the facility. On 6/8/26 at 1300 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings and stated Resident 3 did not have a Personal Effects Inventory Form completed upon admission to the facility. On 6/8/26 at 1600 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure the personal belongings for one of five sampled residents (Resident 1) were kept safe from loss or theft. * The facility failed to ensure the Personal Effects Inventory Form for Resident 1 was completed and signed by Resident 1's representative and facility staff upon Resident 1's discharge from the facility. This failure resulted in Resident 1 losing his personal belongings.Findings: Review of the facility's P&P titled Personal Property dated 11/14/25, showed the following: - Upon admission the CNA or designee will conduct a personal property inventory of the resident's property. - The Personal Effects Inventory Form will be signed, placed in the medical record, and a copy of the signed form provided to the resident or the resident's representative. - Upon discharge, the resident or resident representative will review and sign the Personal Effects Inventory form to ensure all personal property is accounted for. - Upon discharge, Social Services staff contact the resident or resident representative and explain the belongings can only be stored at the facility for 30 days. On 6/2/26 at 1004 hours, an interview was conducted with Family Member 1. Family Member 1 stated after Resident 1 was transferred to the acute care hospital, he was told by the staff that they could not find the resident's personal belongings. On 6/2/26 at 1545 hours, an interview was conducted with the SSA. The SSA stated he was unaware about the missing personal belongings for Resident 1 until Resident 1's representative called him on 5/18/26. The SSA stated he told Resident 1's representative the items had been discarded because the items were in the facility for over 30 days. Closed medical record review for Resident 1 was initiated on 6/2/26. Resident 1 was admitted to the facility on [DATE], and discharged on 3/26/26. Review of Resident 1's H&P examination dated 3/19/26, showed Resident 1 had the capacity to understand and make medical decisions. Review of Resident 1's MDS dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident 1's Personal Effects Inventory Form dated 3/18/26, showed Resident 1 signed the form, which listed one pair of shoes, one blue shirt, one pair of black pants, and one smartphone. Further review of Resident 1's Personal Effects Inventory Form showed the discharge review section of the form was blank. On 6/8/26 at 1225 hours, an interview was conducted with the Administrator. The Administrator stated the facility was unable to locate Resident 1's belongings and would reimburse Resident 1 for the lost items. On 6/8/26 at 1300 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 verified the above findings and stated the staff are required to complete the Personal Effects Inventory Form upon admission and discharge. RN 1 stated the forms must be signed and dated by both the staff and the resident or resident's representative. RN 1 stated upon discharge, the staff are supposed to verify all belongings are accounted for. RN 1 verified Resident 1's inventory list was not completed at discharge. On 6/8/26 at 1600 hours, a follow-up interview was conducted with the Administrator. The Administrator was informed of the above findings and stated the facility could only reimburse for the missing items listed on Resident 1's inventory list (clothing and shoes). On 6/15/26 at 1245 hours, an interview was conducted with Family Member 1. Family Member 1 stated the Administrator informed him the facility would reimburse him for Resident 1's missing personal belongings.

Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation guidelines were followed when:1. The cool down process for time, temperature control for safety (TCS) food, food that needs to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored correctly.2. One of one blender was not air dried. These failures posed the risk for foodborne illnesses in a highly susceptible resident population of 76 facility residents who received food prepared in the kitchen. Findings: Review of the facility matrix dated 9/15/25, showed 76 residents received food prepared in the facility kitchen. 1. According to the USDA Food Code 2022, Section 3-501.14 Cooling. (B) Time/Temperature Control for Safety Food shall be cooled within 4 hours to 41 degrees Fahrenheit (F) or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Review of the facility's document titled Cooling Monitor Log for September showed cool food prepared from ambient temperatures (such as tuna salad) must be cooled to 40 degrees Fahrenheit within four hours. Record temperature every hour. On 9/17/25 at 1446 hours, an interview and concurrent facility document review was conducted with [NAME] 2 and the DSS present. The facility's document titled Cooling Monitor Log dated September 2025 showed documentation on 9/16/25, for the tuna salad and egg salad. The Cooling Monitor Log did not include times the temperatures were taken for the tuna or egg salad. - The first temperature logged for the tuna salad showed 67 degrees F. There was no time documented on the Cooling Monitor Log for the first temperature of the tuna salad. The second temperature logged for the tuna salad showed 42 degrees F. There was no time documented on the Cooling Monitor Log for the second temperature of the tuna salad. There were no further temperatures logged for the tuna salad made on 9/16/25. - The first temperature logged for the egg salad showed 72 degrees F. There was no time documented on the Cooling Monitor Log for the first temperature of the egg salad. The second temperature logged for the egg salad showed 52 degrees F. There was no time documented on the Cooling Monitor Log for the second temperature of the egg salad. There were no further temperatures logged for the egg salad made on 9/16/25. [NAME] 2 and the DSS verified the last temperatures were documented after two hours but there was no time documented for any of the temperatures taken for the tuna or egg salad. [NAME] 2 and DSS verified the log was missing the times the temperatures were taken and both the tuna and egg salad were above 41 degrees F. [NAME] 2 and the DSS verified the temperatures for the tuna salad and egg salad should have been recorded every hour and up to four hours reaching 41 degrees F. The DSS stated both items had been discarded. On 9/18/25 at 1435 hours, an interview was conducted with the RD. The RD verified the TCS foods should be cooled down properly. 2. According to the USDA Food Code 2022, section 4-901.11, Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) shall be air dried. On 9/15/25 at 0828 hours, during the initial tour of the kitchen, an observation of a blender was conducted with [NAME] 1. The inside of the blender was observed wet and stored with the top on. [NAME] 1 verified the blender was not air dried. On 9/16/25 at 1405 hours, an interview was conducted with the RD. The RD verified the equipment and utensils should be air dried.

Based on observation, interview, facility document, and facility P&P review, the facility failed to ensure the menus were followed for eight of eight residents (two final sampled residents, Residents 10 and 28, and six nonsampled residents Residents 15, 20, 24, 48, 54, and 59) who received a pureed diet when:1. The pureed Curry Lemon Chicken recipe was not followed;2. The pureed Peas with Onions recipe was not followed;3. The pureed Garlic [NAME] recipe was not followed; and4. The pureed starch recipe used for the pureed wheat rolls was not followed. This failure had the potential not to meet the residents' nutritional needs.Findings: Review of the facility's matrix dated 9/15/25, showed 76 of 77 residents consumed food prepared in the kitchen and eight of the 76 residents received a pureed diet. 1. Review of the facility's P&P titled Menus (undated) showed food served should adhere to the written menu. Review of the facility's document titled Recipe: Curry Lemon Chicken showed one portion size was three ounces of the chicken. Review of the facility's document titled Recipe: Pureed (IDDSI Level 4) Meats showed 12 servings; 12 servings of meat per regular recipe, 1.5 to 3 cups of warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary, 0 to 6 tablespoons of a stabilizer, such as instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. Directions: 1. Complete regular recipe. Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for pureed diets. 2. Puree on low speed to a past consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding I more as needed to achieve the desired consistency. May need to add more liquid to puree properly. 4. Add stabilizer to increase the density of the pureed food if needed. Breaded items or casseroles may not need stabilizer. If using commercial food thickener, check the can for directions on usage, otherwise see above for recommended amount of stabilizer. Taste and adjust seasoning (without salt), as needed. On 9/16/25 at 1033 hours, an observation for the pureed Curry Lemon Chicken was conducted with [NAME] 1. [NAME] 1 verified she was preparing nine servings of the pureed Curry Lemon Chicken and followed the pureed meat recipe for 12 servings. [NAME] 1 placed ten three-ounce portions of the Curry Lemon Chicken in the Robot Coupe (RC, a device used to puree foods). [NAME] 1 then added three cups of curry sauce and the chicken was cooked in with five heaping tablespoons of thickener to the RC. The mixture was blended and poured into a serving pan. 2. Review of the facility's document titled Recipe: Peas with Onions showed the portion size: 1/2 cup. Ingredients: frozen peas, pearl onions or fresh chopped onions, margarine, melted and seasonings of choice: dill or tarragon. Directions: 1. [NAME] peas well. 2. Wash vegetables well under cool running water. Saute onions in the margarine. 3. Combine peas, onions, margarine, seasonings, and toss lightly. Review of the facility's document titled Recipe: Pureed (IDDSI Level 4) Vegetables showed 12 servings of vegetables per recipe, 1/4 cup to 3/4 cup of warm fluid such as milk, or low sodium broth, and 6 to 12 tablespoons of a stabilizer, such as instant potatoes or commercial instant food thickener. Directions: 1. Complete regular recipe. Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for pureed diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or milk) if needed. See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 4. Puree on low speed, adding stabilizer where needed. See above for amounts. If using commercial food thickener, check the can for directions on usage. Taste and adjust seasoning (without salt), as needed. Review of the nutrition facts of the chicken flavored base used to cook the peas showed one teaspoon of chicken flavored base provided 970 mg of sodium. Preparation instructions: Add one teaspoon of base to eight ounces of boiling water. On 9/16/25 at 1044 hours, an observation for the pureed Peas and Onions was conducted with [NAME] 1. [NAME] 1 verified she was preparing nine servings of pureed Peas and Onions and followed the pureed vegetable recipe for 12 servings. Using a size 12 scoop (1/3 cup), [NAME] 1 added nine servings of peas to the RC. [NAME] 1 then added 2/3 cup of liquid to the peas in the RC. [NAME] 1 was asked what the liquid was, [NAME] 1 responded she cooked the peas in chicken broth. The pea and broth mixture was blended. [NAME] 1 then added six tablespoons of thickener to the RC and blended the mixture, and poured the mixture into a serving pan. On 9/16/25 at 1120 hours, an interview was conducted with [NAME] 1. [NAME] 1 stated she used regular chicken flavored base broth to cook the peas. 3. Review of the facility's document titled Recipe: Garlic [NAME] showed the portion size: 1/3 cup (12 scoop). Review of the facility's document titled Recipe: Pureed (IDDSI Level 4) Starch (Rice, Pasta, Polenta, Potatoes, etc.) showed 12 servings starch per regular recipe, 1.5 to 3 cups of warm milk, and 6 to 12 tablespoons of a stabilizer, such as instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. Directions: 1. Complete regular recipe. Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for pureed diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm milk. See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. May need to add more liquid to puree properly, if starch is already moist after being pureed, you may not need much added milk. Add stabilizer to increase the density of the pureed food if needed. If using commercial food thickener, check the can for direction on usage, otherwise see above for recommended amounts of stabilizer. Taste and adjust seasoning (without salt), as needed. On 9/16/25 at 1103 hours, an observation for the pureed garlic rice was conducted with [NAME] 1. [NAME] 1 verified she was preparing nine servings of the garlic rice and followed the pureed starch recipe for 12 servings. Using a size 12 scoop, [NAME] 1 added 11 scoops of garlic rice, 1.5 cups of milk and seven tablespoons of thickener to the RC and blended the mixture. [NAME] 1 then poured the puree garlic rice into a serving pan. 4. Review of the facility's document titled Cooks Spreadsheet dated 9/16/25, showed the pureed wheat roll should have received a #16 scoop (1/4 cup). On 9/16/25 at 1112 hours, an observation for the pureed wheat rolls was conducted with [NAME] 1. Using a size 16 scoop, [NAME] 1 placed 12 scoops of crumbled bread, two cups of milk, and 1.5 tablespoons of thickener into the RC and blended the mixture. [NAME] 1 then poured the puree bread into a serving pan. On 9/16/25 at 1120 hours, an interview was conducted with [NAME] 1. [NAME] 1 stated the breadcrumbs used for the pureed wheat roll was from the toasted bread. On 9/18/25 at 1435 hours, an interview was conducted with the RD. The RD verified the puree foods should be the regular recipe with the least amount of liquid and thickener. The RD verified the pureed recipes should be followed and regular broth should not be used in place of salt free broth when pureeing foods.

Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive person-centered plan of care to reflect the individual care needs for three of 19 final sampled residents (Residents 18, 21, and 28). * The facility failed to develop a care plan to address Residents 18 and 28's change in condition related to weight loss. * The facility failed to develop a care plan to address Resident 21's use of the antidepressant medication. These failures had the potential to cause inconsistent, inappropriate, and inadequate plans of care for the residents in a vulnerable population and result in suboptimal outcomes for the affected residents.Findings: Review of the facility's P&P titled Person Centered Care Planning dated 4/24/25, showed the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, timeframes to meet resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. - The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of the resident's admission. Review of facility's P&P titled Change in Condition dated 8/25/22, showed the licensed nurse will assess the change in condition and determine what nursing interventions are appropriate. For documentation, the licensed Nurse will document the following: - Update the care plan to reflect the resident's current status, if applicable. - A licensed Nurse will communicate any changes in required interventions to the care team members involved in the resident's care. 1. Medical record review for Resident 28 was initiated on 9/15/25. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28's Change in Condition dated 9/8/25, showed the resident had a weight loss of 24.4 lbs., 4% decrease over six months and 17.4 lbs., 10% decrease over three months. Review of Resident 28's plan of care failed to show documentation the care plan was developed to address Resident 28's change in condition related to weight loss on 9/8/25. On 9/17/25 at 1020 hours, an interview and concurrent medical record review for Resident 28 was conducted with RN 1. RN 1 verified there was no care plan developed to address Resident 28's change in condition related to weight loss on 9/8/25. 2. Medical record review for Resident 18 was initiated on 9/15/25. Resident 18's was admitted on [DATE], and was readmitted on [DATE]. Review of Resident 18's Change in Condition dated 7/11/25, showed Resident 18 had a weight loss of 8.2 lbs. in a week. Review of Resident 18's plan of care failed to show documentation the care plan was developed to address Resident 18's change in condition related to weight loss on 7/11/25. 09/16/25 at 1023 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified there was no care plan developed to address Resident 18's change in condition related to weight loss on 7/11/25. The MDS Coordinator stated there should have been a care plan developed to address the resident's weight loss. On 9/17/25 at 1058 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. 3. Review of the facility's P&P titled Person-Centered Care Planning revised 4/24/25, showed the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Furthermore, the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Medical record review for Resident 21 was initiated on 9/15/25. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 21's H&P examination dated 7/18/25, showed Resident 21 had the capacity to understand and make decisions. Review of Resident 21's admission MDS assessment dated [DATE], showed Resident 21 had a BIMS score of 15, indicating intact cognition. Review of Residents 21's Order Summary Report for September 2025 showed a physician's order dated 9/5/25, to administer bupropion HCL (antidepressant medication) 150 mg one tablet by mouth daily for depression manifested by low motivation on ADLs. Review of Resident 21's plan of care failed to show a care plan problem and interventions were developed to address Resident 21's use of the bupropion medication for depression. On 9/18/25 at 1001 hours, an interview and concurrent medical record review for Resident 21 was conducted with LVN 1. LVN 1 verified there was no care plan developed for Resident 21 's use of the bupropion medication and stated there should have been a care plan for the use of the antidepressant medication. LVN 1 stated the licensed nurses should have been monitoring for the signs and symptoms of Resident 21's depression and the care plan would show the goals and interventions for the resident. On 9/22/25 at 1313 hours, an interview and concurrent medical record review was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility staff and resident visitors were educated on safe food handling practices when food from the outside was brought to the facility for resident consumption. This failure had the potential for unsafe food handling which could lead to foodborne illness in the 76 residents who resided and consumed food in the facility. Findings: Review of the facility's matrix dated 9/15/25, showed 76 residents consumed an oral diet. Review of the facility's P&P titled Foods Brought in by Visitors revised 4/24/25, showed to assist the family/visitors to understand safe food handling practices (such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.). Review of the facility's in-service lesson plan and attendance record titled Food Brought by Visitors dated 1/17/25, showed the in-service was conducted by the DSD. The in-service included policy interpretation and implementation, which reviewed the policy specifics, however, the safe food handling practices were not included. On 9/16/25 at 0910 hours, an interview was conducted with RN 1. When asked how the visitors were educated on safe food handling practices, RN 1 stated the families were educated on the risks, benefits, where the facility stores the outside food, storage timeframe, and placing the name and date on the food items when stored in the refrigerator designated for the residents. When asked if she had received education on safe food handling, RN 1 stated an in-service on safe food handling was provided by the DSD. Review of the facility's admission Packet did not include the outside food policy or any information regarding safe food handling. On 9/17/25 at 1320 hours, an interview was conducted with the DSD. The DSD stated an in-service was provided to the facility staff, which included microwave use, labeling and dating outside food, timeframe of perishable food, and storage timeframe. The DSD stated the facility's P&P regarding outside food was provided to the families upon admission by the Admissions Director. On 9/17/25 at 1354 hours, an interview and concurrent facility document review was conducted with the admission Director. The admission Director verified the P&P regarding outside food was not included in the admission packet. The admission Director stated he physically handed the family members the P&P. The admission Director stated the topics discussed regarding safe food handling included labeling outside food and going over the policy process, but there was no specific safe food handling information discussed. On 9/18/25 at 1455 hours, an interview was conducted with the Administrator and DSS. The Administrator and DSS verified and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the residents' needs for two of 19 final sampled residents (Residents 9 and 12) and one nonsampled resident (Resident 71). * The facility failed to ensure the injection sites were rotated for the subcutaneous insulin medication administration for Resident 9. * The facility failed to ensure the administration of the divalproex delayed release tablet for Resident 12 was in accordance with the best practice standards. * The facility failed to ensure the administration of the controlled medication for Resident 71 was documented on the EMAR. These failures had the potential to negatively affect the residents' health condition and well-being. Findings: Review of the facility's P&P titled Subcutaneous Medication Administration dated 12/2015 showed to administer a parenteral medication into the subcutaneous (under the skin) tissue in order to promote slow medication absorption and prolong medication action. Prepare medication as follows: - Select an appropriate site for injection. - Document the injection site on the MAR along with the site used. According to the Insulin Lispro (medication used to treat high blood sugar) Injection Package Insert dated 9/2023 showed for subcutaneous injection, administer insulin lispro by subcutaneous injection, rotate injection sites to reduce risk of lipodystrophy (loss of fat) and localized cutaneous amyloidosis (skin condition characterized by accumulation of abnormal proteins in the skin). Medical record review for Resident 9 was initiated on 9/15/25. Resident 9 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 9's Order Summary dated 9/16/25, showed to administer insulin lispro solution subcutaneous before meals and at bedtime, inject as per the sliding scale: if 0 -150 = 0 no insulin; 151 - 200 = 2 units,; 201- 250 = 4 units; 251 - 300 = 6 units; 301- 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units, and call MD. Review of Resident 9's Location of Administration Report for August 2025 for the insulin lispro injection showed the injection sites were not rotated on the following dates and times: - on 8/6 at 2149 hours, 8/7 at 1156 hours, and 8/7/25 at 1630 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant. - on 8/16 at 1137 hours and 8/16/25 at 1940 hours, the insulin lispro medication was administered subcutaneously to the right lower quadrant. - on 8/17 at 1158 hours and 8/17/25 at 1653 hours, the insulin lispro medication was administered subcutaneously to the left lower quadrant. - on 8/21 at 1147 hours, and 8/21/25 at 1707 hours, the insulin lispro medication was administered subcutaneously to the left lower quadrant. - on 8/24 at 1130 hours and 8/24/25 for 1644 hours, the insulin lispro medication was administered subcutaneously to the left lower quadrant. - on 8/26 at 1703 hours, 8/26 at 2102 hours, 8/27 at 1140 hours, and 8/27/25 at 1707 hours, the insulin lispro medication was administered subcutaneously to the left lower quadrant. - on 8/31 at 1143 hours and on 8/31/25 at 1634 hours, the insulin lispro medication was administered subcutaneously to the left lower quadrant. On 09/16/25 at 1019 hours, an interview and concurrent medical record review for Resident 9 was conducted with the MDS Coordinator. The MDS Coordinator was informed of the above subcutaneous insulin lispro medication injection sites for Resident 9. The MDS Coordinator verified the subcutaneous injection sites for the insulin lispro medication should be rotated to prevent complication on the injection sites. On 09/17/25 at 1058 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Review of facility's P&P titled Medication Administration revised 6/26/25, showed the medications are administered according to physician orders, current best practices, and federal and state regulations to ensure residents received medications in a safe manner. In addition, the P&P showed the time and dose of the medication or treatment administered to the resident will be recorded in the resident's individual medication recorded by the person who administered the medication or treatment. Medical record review for Resident 71 was initiated on 9/16/25. Resident 71 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 71's MDS assessment dated [DATE], showed the resident's BIMS score was 15, indicating intact cognition. Review of Resident 71's Order Summary Report dated 9/16/25, showed a physician's order dated 8/29/25, to administer hydrocodone-acetaminophen (Norco - controlled pain medication) 5-325 mg one tablet by mouth every six hours as needed for moderate pain (pain level of 4 -7, using the 0-10 pain scale; zero meaning no pain and 10 meaning worst pain). Review Resident 71's Individual Narcotic Record showed the Norco 5-325 mg medication was removed and signed out on 9/11 and 9/12/25 at 2100 hours. Review of Resident 71's MAR for September 2025 failed to show the documentation of the administration for hydrocodone-acetaminophen 5-325 mg medication on 9/11 and 9/12/25 at 2100 hours. On 9/16/25 at 0957 hours, an interview and concurrent medical record review for Resident 71 was conducted with LVN 1. LVN 1 verified the above findings. On 9/22/25 at 1059 hours, an interview and concurrent medical record review for Resident 71 was conducted with the DON. The DON verified the Norco medication was dispensed on 9/11 and 9/12/25 at 2100 hours, however, there was no documentation on the resident's MAR to show the Norco was administered to the resident on the above dates. The DON further stated when the resident required pain medication, the licensed nurse would assess the resident, check the physician's order, dispense the medication, document the removal of the narcotic medication on the Individual Narcotic Record, administer the pain medication to the resident, then document the administration on the MAR. The DON was informed and verified the above findings. 3. According to the National Library of Medicine, divalproex sodium (mood stabilizer medication) delayed-release tablets should be swallowed whole. Do not split, chew or crush them. Medical record review for Resident 12 was initiated on 9/17/25. Resident 12 was admitted to the facility on [DATE]. On 9/19/25 at 0854 hours, a medication administration observation for Resident 12 was conducted with LVN 3. LVN 3 prepared and administered the following medications to Resident 12: - one bottle of fluticasone (to treat allergic rhinitis) nasal spray;- one tablet of loratadine (allergy medication) 10 mg;- one tablet of divalproex delayed release 500 mg; and - one tablet of quetiapine fumarate (antipsychotic medication) 25 mg. During the medication preparation, LVN 3 was observed separately crushing the loratadine, divalproex, and quetiapine medications with the medication crusher. LVN 3 was observed administering Resident 12's crushed medications with apple sauce. Resident 12 was then observed swallowing the applesauce containing the medications. On 9/19/25 at 0915 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 3. LVN 3 verified she crushed the divalproex delayed release medication for Resident 12. LVN 3 stated a delayed release medication was when a medication slowly released the effects of the medication to the resident. LVN 3 further stated she should not have crushed the delayed release medication because it would alter how the medication was released in the body. On 9/22/25 at 1315 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the failed to ensure the appropriate dialysis care was provided for one of two final sampled residents (Resident 2) reviewed for dialysis services. * The facility failed to ensure Resident 2's physician's order for 1500 ml fluid restriction was followed and carried out accordingly. In addition, the facility failed to monitor the resident's fluid intake accurately. This failure had the potential for the resident to not be provided with the appropriate care and treatment, and possibility experience medical complications related to dialysis. Findings: Review of the facility's P&P titled Fluid Restrictions revised on 4/21/22, showed the purpose of this policy is to ensure the adequate provision of care and comfort measures for the residents who are in fluid restrictions. Under the Procedures section, included the licensed nurses would do the following:- Initiate strict intake measurements per physician's order.- Record any fluids given on the Intake and Output record.- Total the amount of fluid each 24 hours and compare it against the Fluid Restriction Guidelines.- When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. - Review the intake and output summary weekly and address the adequacy of fluids and accuracy of documentation. Medical record review for Resident 2 was initiated on 9/16/25. Resident 2 was admitted to the facility on [DATE], with a diagnosis of end stage renal disease (condition when the kidneys can no longer adequately filter waste and excess fluids from the blood) and required hemodialysis. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 was cognitively intact. Under Section O of the assessment, Resident 2 was coded as having dialysis. Review of Resident 2's Fluid intake Task dated from 9/3 through 9/16/25, showed the documented daily fluid intake (only the meal trays during meals) from the CNA's ranged from 250 to 720 ml per day, which showed the prescribed fluid restriction was not met. In addition, there were some days with a missing fluid intake data. For example:- on 9/3/25, Resident 2 had a total fluid intake of 510 ml;- on 9/7/25, Resident 2 had a total fluid intake of 250 ml and had missing fluid intake data on different times of the day; and - on 9/14/25, Resident 2 had a total fluid intake of 310 ml and had missing fluid intake data on different times of the day. Review of Resident 2's Order Summary Report dated 9/16/25, showed a physician's order dated 8/23/25, for fluid restriction of 1500 ml per day as follows:* Dietary department to provide 720 ml of fluid, and* Nursing department to provide 780 ml of fluid: - 130 ml for the 11 am - 7 pm shift; - 400 ml for the 7 am - 3 pm shift; and - 250 ml for the 3 pm - 11 pm shift. Further review of Resident 2's medical record failed to show other documented evidence to show the fluid restriction of 1500 ml per day was met. In addition, the intake and output weekly summaries to address the adequacy of the fluids and accuracy of documentation was not documented. On 9/16/25 at 1040 hours, an interview for Resident 2 was conducted with CNA 1. CNA 1 verified Resident 2 was on fluid restriction per instruction from the charge nurse. CNA 1 stated he measured the fluid intake from the meal tray of the resident on each meal and recorded the amount on the fluid intake log in the computer. CNA 1 verified he only recorded the fluids consumed from the meal tray of the resident. On 9/16/25 at 1050 hours, an interview and medical record review for Resident 2 was conducted with LVN 4. LVN 4 verified Resident 2's physician's order for the fluid restriction of 1500 ml per day. LVN 4 stated the CNAs recorded the fluid intake of the resident consumed from the meal tray. LVN 4 verified the fluid intake of Resident 2 was not properly monitored and documented. On 9/22/25 at 0818 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was in bed, awake and watching television. There was no water pitcher observed on the side of the bed for the resident. Resident 2 stated he was informed by the licensed nurses he needed to limit his fluid intake due to his condition. Resident 2 stated he did not have water, only had milk and some juice when he ate. On 9/22/25 0904 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 verified Resident 2's physician's order for the fluid restriction. RN 1 stated the CNAs were responsible for recording the fluid intake of the resident and recorded the amount on the task documentation for the fluid restriction. RN 1 was asked for the accurate documentation for the fluid intake of Resident 2. RN 1 showed the Fluid Intake Task (recorded log) for the resident and stated the recorded log was combined with the dietary and nursing departments' intake. RN 1 verified the fluid intake monitoring for Resident 2 was not accurate as per the physician's order. RN 1 verified there was no documented weekly summary for the intake and output for Resident. On 9/22/25 at 0940 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for one final sampled Resident (Resident 2) and one nonsampled Resident (Resident19) reviewed for respiratory care. * The facility failed to ensure Resident 2's CPAP's (Continuous Positive Airway Pressure) machine was cleaned as per the manufacturer's user cleaning guidelines. * The facility failed to ensure Resident 19's oxygen tubing storage bag was routinely changed. These failures had the potential to adversely affect the health and well-being for the residents and posed the risk for infection.Findings: 1. Review of the facility's P&P titled Oxygen Therapy dated 11/2017 showed for oxygen - storage, maintenance, and handling: - Oxygen tubing, mask, and cannulas will be changed no more than every seven days and as needed. The supplies will be dated each time they are changed. Medical record review for Resident 19 was initiated on 9/15/25. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Order Summary Report dated 9/16/25, showed the following physician's orders: - dated 4/11/25, to administer oxygen at two liters per minute via nasal cannula to keep the oxygen saturation at or above 92%. - dated 8/6/25, to change the oxygen tubing every night shift on a Sunday. On 09/15/25 at 0922 hours, during the initial tour of the facility, Resident 19 was observed in the bathroom with her oxygen on at two liters per minute via nasal cannula. Resident 19's oxygen tubing was dated 9/15/25, however, the clear oxygen storage bag where half of the oxygen tubing was stored was dated 9/7/25. On 09/15/25 at 0940 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 was informed regarding Resident 19's oxygen storage bag dated 9/7/25. When asked, LVN 5 stated the oxygen tubing and oxygen tubing storage bags for the residents with prescribed oxygen treatment were routinely changed every night shift on Sundays. LVN 5 verified Resident 19's oxygen storage bag was dated 9/7/25 and stated the oxygen storage bag should have been changed. LVN 5 stated Resident 19's oxygen tubing storage bag should be changed for infection control and prevention. On 09/17/25 at 1058 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Review of the facility's P&P titled BiPAP (Bilevel Positive Airway Pressure) and CPAP dated 9/10/20, showed the specific cleaning instruction guidelines of the CPAP device. The components of the machine such as masks, nasal pillows, tubing and headgear should be cleaned with warm soapy water daily and allow to airdry. Replace the head gear (straps) weekly or as needed. On 9/16/25 at 0911 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed in bed and Resident 2's bedside table was noted to have a CPAP (ResMed AirSence 10) machine. The CPAP machine was turned off with the tubing and the mask inside the clear plastic bag. Resident 2 was asked if he was using the CPAP machine regularly, Resident 2 stated yes. Resident 2 stated when he used the CPAP machine at home, he cleaned the mask and tubing once in a while per the suggestion from the CPAP machine's manual. Resident 2 was asked if the facility staff cleaned the CPAP machine per the CPAP machine's manual. Resident 2 stated he never saw the facility staff clean the CPAP machine ever since he was admitted to the facility. Resident 2 added he might ask the staff to clean the machine. Review of the ResMed AirSence 10 (CPAP machine) user guide (undated) showed under the caring for the device section, to regularly clean the tubing assembly, water tub, and mask to prevent the growth of the germs that can adversely affect the health. Medical record review for Resident 2 was initiated on 9/16/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 was cognitively intact. Under Section O of the assessment, showed Resident 2 was coded for the use of a non-invasive machine. Review of Resident 2's Order Summary Report dated 9/16/25, showed a physician's order dated 8/25/25, for the following care of the CPAP machine: - to clean the mask with soap and water daily and as needed when soiled, and - to clean the filter every week and change as needed when heavily soiled or per manufacturer's recommendation. On 9/16/25 at 1040 hours, an interview for Resident 2 was conducted with CNA 1. CNA 1 stated Resident 2 was able to remove the CPAP mask. CNA 1 was asked who was responsible for cleaning the CPAP machine and equipment. CNA 1 stated the licensed nurses were responsible for cleaning the CPAP machine and equipment. When asked if he had seen the licensed nurses cleaning the CPAP machine, CNA 1 stated he had not seen the licensed nurses cleaning the CPAP machine because he did not stay long in the room. CNA 1 stated he just placed the mask in the clear plastic bag after Resident 2 had use it and when he was asked to put the mask away by the resident. On 9/16/25 at 1050 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 4. LVN 4 stated the licensed nurses were responsible for taking off the CPAP machine and putting the mask in the clear plastic bag. When asked who was responsible for cleaning the mask and the machine, LVN 4 stated all the licensed nurses were responsible for cleaning the machine. LVN 4 verified the physician's order for the CPAP machine's care. LVN 4 was asked if she cleaned the CPAP machine. LVN 4 verified and acknowledged she did not clean the mask of the CPAP machine as ordered. LVN 4 stated the resident could have infection if the mask and the machine were not clean. LVN 4 was asked for a copy of the CPAP machine user guide/manual. LVN 4 verified there was no copy of the CPAP machine manual. On 9/22/25 at 0904 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 verified Resident 2's physician order for the CPAP machine use. RN 1 stated the licensed nurses were responsible for cleaning the CPAP machine and equipment after each use. RN 1 was asked about the cleaning of the CPAP machine and if the licensed nurses followed the manufacturer's recommendation for cleaning the CPAP mask, tubing, and machine. RN 1 verified the CPAP manual was not available and RN 1 was not aware about the cleaning recommendation of the CPAP machine per manufacturer's manual. On 9/22/2025 at 0940 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, and medical record review, the facility failed to provide the appropriate care and services for the use of the GT for one of one final sampled resident (Resident 3) reviewed for GT feeding. * The facility failed to ensure the enteral water flush was programmed on Resident 3's enteral feeding pump as ordered by the physician. This failure posed the risk for developing dehydration complications for Resident 3.Findings: On 9/19/25 at 1425 hours, Resident 3 was observed lying on the bed with the GT feeding infusing at 55 ml/hr. A water bag was observed hanging and dated 9/19/25. However, the water flush (ml/hr) was not programmed into the GT pump to show how much water flush the resident was receiving. Medical record review for Resident 3 was initiated on 9/19/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had a diagnosis of dysphagia (difficulty swallowing) and had a GT. Review of Resident 3's Order Summary Report showed the following physician's orders:- dated 7/18/25, to administer Jevity 1.2 (type of enteral feeding) at 55 ml/hr via pump for 20 hours, turn on at 1400 hours.- dated 8/28/25, to administer the water flush at 70 ml per hour for 20 hours, for a total of 1400 ml via GT pump. Review of Resident 3's plan of care showed a care plan problem revised 9/16/25, addressing Resident 3's dependence on the GT feeding for hydration and nourishment. The interventions included to follow the current MD feeding orders. Review of Resident 3's Nutritional Risk Assessment V-8 dated 8/25/25, showed Resident 3 had an elevated blood urea nitrogen (BUN - a test to assess kidney function) on 7/24/25, possibly due to medications or dehydration. The nutritional intervention was to adjust the water flush to 70 ml per hour via GT pump. On 9/19/25 at 1456 hours, an observation, interview, and concurrent medical record review for Resident 3 was conducted with LVN 3 in Resident 3's room. Resident 3's GT feeding was on. The GT pump showed the enteral feeding was set at 55 ml per hour. LVN 3 was unable to show Resident 3's water flush was programmed into the GT pump. LVN 3 verified Resident 3's physician's order to administer the water flush at 70 ml per hour for 20 hours via GT pump. LVN 3 stated Resident 3 received water flushes via GT pump to prevent the GT from clogging and to hydrate Resident 3. LVN 3 was then observed programming Resident 3's GT pump to set the water flush at 70 ml per hour. On 9/22/25 at 1315 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and P&P review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of two final sampled residents (Resident 7) when: * A significant unplanned weight loss of 21.8 lbs., 10.2% in six months was not assessed by the Registered Dietitian (RD). * The Interdisciplinary Team (IDT) did not evaluate the significant unplanned weight loss of 21.8 lbs., 10.2% in a timely manner. These failures resulted in Resident 7's compromised nutritional status not monitored and addressed timely, which had the potential to lead to further medical complications.Findings: a. Review of the facility's P&P titled Evaluation of Weight and Nutritional Status effective 2/20/25, showed: 1. The facility will maintain an acceptable nutritional status for resident per professional standards by: a. Assessing the resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status. b. Analyzing the assessment information to identify the medical conditions, causes and/or problems related to the resident's condition and needs. c. Implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice. d. Developing interventions involving the resident and/or the resident representative to ensure the resident's needs, preferences and goals are accommodated. e. Monitoring and evaluating the resident's response, or the last of response to interventions. f. Revising or discontinuing the approaches as appropriate or justifying the continuation of current approaches.Purpose: To ensure that residents maintain acceptable parameters of nutritional status through evaluation of weight and diet.Process: 1. Definitions: b. Weight loss- unplanned weight loss in a resident. Significant weight loss (5% and/or 5 pounds in one month, 7.5% in three months, or 10% in six months). 2. Clinical Evaluation: a. In connection with the assessments mentioned above, IDT will further assess nutritional needs and goals of the resident within the context of his/her overall condition including the following: .v. Nutrition prescription/macronutrients. Medical record review for Resident 7 was initiated on 9/15/25. Resident 7 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), protein calorie malnutrition (a condition where a person does not consume enough protein and calories to meet their body's needs) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 7's Weights and Vitals Summary dated 6/5/25, showed Resident 7's weight of 191.4 lbs. (21.8 lbs. or 10.2% significant weight loss in six months, comparison to the resident's weight of 213.2 lbs. on 1/7/25). Review of Resident 7's MDS assessment dated [DATE], showed under Section K, Resident 7 weighed 191 lbs. Resident 7 had experienced 10% or more unplanned weight loss in the past six months and was not on a physician prescribed weight loss regime. Review of Resident 7's Order Summary Report dated 9/18/25, showed a physician's order dated 5/5/22, for a No Added Salt diet with regular texture, regular/thin consistency, chopped meat, and thin liquids. On 9/16/25 at 1430 hours, an interview and concurrent medical record review for Resident 7 was conducted with the RD. The RD stated he had worked at the facility for two months. When asked to explain the facility's protocol when a resident experienced a significant weight loss, the RD stated the RD should complete a nutritional assessment, the IDT should meet to discuss the appropriate interventions and the resident centered plan of care should be updated. The RD verified Resident 7 had experienced a significant unplanned weight loss of 21.8 lbs., 10.2% weight loss in six months between January and June 2025. The RD verified there was no nutritional assessment completed to address Resident 7's significant weight loss of 21.8 lbs., 10.2% significant weight loss in six months for the month of June 2025. The RD further verified there was no nutritional assessment completed for Resident 7 between June and September of 2025. When asked about a physician's order for a planned weight loss, the RD verified there was no order for a physician prescribed weight loss regime nor was there a resident centered plan of care reflecting a planned weight loss regime. b. Review of the facility's P&P titled Evaluation of Weight and Nutritional Status effective 2/20/25, showed: 2. Clinical Evaluation (a.) In connection with the assessments mentioned above, the IDT will further assess nutritional needs and goals of the resident within the context of his/her overall condition.(b.) Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days, 10% in 180 days.will be evaluated by the IDT to determine the cause of the weight loss/gain and the interventions required. On 9/18/25 at 1027 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 7 experienced a significant unplanned weight loss of 21.8 lbs., 10.2% in six months from January to June 2025. The DON verified the RD did not complete a nutritional assessment in June 2025 to address Resident 7's significant weight loss. The DON reviewed Resident 7's quarterly MDS assessment, Section K dated 6/9/25. The DON verified the resident's MDS reflected a significant weight loss of 10% or more in the past six months and Resident 7 was not on a physician prescribed weight loss regime nor was there a physician order for such. The DON verified there was no RD assessment or interventions to address the unplanned weight loss until September 2025. When asked who attended the IDT weight variance meetings, the DON stated herself, the RD, DSS, and Speech Therapist. The DON verified the IDT did not meet in June 2025 to discuss Resident 7's significant unplanned weight loss. The DON stated the IDT met on 7/9/25, to discuss Resident 7's significant weight loss but should have met to address Resident 7's unplanned significant weight loss in June 2025.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to implement the infection control practices in the facility designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to maintain an accurate and complete infection control surveillance program for June, July, and August 2025. This failure posed the risk for not identifying the residents' infections and preventing the implementation of the interventions to control the potential transmission of communicable diseases to other residents in the facility. * The facility staff failed to perform hand hygiene between changing of the gloves during the medication administration. This failure posed the risk for the transmission of infection to the resident.Findings: 1. Review of the facility's P&P titled Infection Control Surveillance dated 3/1/14, showed the Infection Preventionist conducts ongoing surveillance for HAIs and epidemiologically significant infections that have substantial impact on potential resident outcome, and that require transmission based or an if precautions and other preventative interventions. The section for The Surveillance of Infections showed the criteria for identifying HAIs are based on the current standard definition of infections according to the McGeer Criteria and Centers for Disease Control and Prevention (CDC) and the licensed nursing staff monitors the residents for sign and symptoms that suggest infection, according to the current criteria and definition of infections, and document and reports suspected infections to the Charge Nurse as soon as possible. Under the section for Gathering Surveillance Data, showed the infection Preventionist will review the Infection Control Surveillance Form and Surveillance Data Collection Form initiated by the Licensed Nurse and determine if the infection is HAI or CAI. The Infection Preventionist will document accordingly on Section B of IC-05-Form -O – Infection Surveillance as well as Section B of the appropriate Surveillance Data Collection Form (IC-05-Form A-M). On 9/19/25 at 0830 hours, review of the facility's Antibiotic Stewardship Record Log for June, July, and August 2025 was conducted. The review of the log failed to show whether the following residents had HAI, CAI, or did not meet the McGeer Criteria: - for Resident 26, the onset of symptoms was on 6/17/25; - for Resident 10, the onset of symptoms was on 6/20/25; - for Resident 47, the onset of symptoms was on 7/3/25; - for Resident 28, the onset of symptoms was on 7/11/25; - for Resident 1, the onset of symptoms was on 7/29/25; - for Resident 65, the onset of symptoms was on 8/30/25; - for Resident 23, the onset of symptoms was on 8/31/25; and - for Resident 72, date of onset of symptoms on 8/31/25. On 09/19/2025 at 1322 hours, an interview and concurrent facility document review was conducted with the IP. The IP verified she missed to complete the documentation by placing a checkmark on a box to indicate whether the residents had HAI or CAI or did not meet the McGeer Criteria. On 9/22/25 at 1126 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. 2. Review of the facility's P&P titled Hand Hygiene revised 9/2020 showed hand hygiene should be performed before and after removing the personal protective equipment (PPE). Medical record review for Resident 11 was initiated on 9/16/25. Resident 11 was admitted to the facility on [DATE], and readmitted on [DATE]. On 9/16/25 at 0802 hours, a medication administration observation was conducted with LVN 2 for Resident 11. LVN 2 was observed preparing the following medications: - one bottle of alcaftadine (to treat allergic conjunctivitis) eyedrop; - one bottle of artificial tears eyedrop (used to treat dry eyes); - one tablet of aspirin (antiplatelet medication) 81 mg; - one tablet of baclofen (muscle relaxant medication) 10 mg; - two tablets of cholecalciferol (supplement) 1000 IU; - one tablet of cranberry (supplement) 450 mg; - one capsule of gabapentin (anti-convulsant medication) 300 mg; - one tablet of linagliptin (diabetic medication) 5 mg; - one tablet of metformin (diabetic medication) 1 grams; - one tablet of multivitamin with minerals (supplement); and - 17 grams of polyethylene glycol (laxative medication). LVN 6 was observed performing hand hygiene and donning gloves when he entered Resident 11's room to administer the medications. After administering Resident 11's oral medications, LVN 2 was observed removing his gloves and donning a new pair of gloves. LVN 2 was not observed performing hand hygiene prior to donning the new pair of gloves. LVN 2 then administered Resident 11's eye drop into both of the resident's eyes. On 9/16/25 at 0833 hours, an interview was conducted with LVN 2. LVN 2 was asked regarding hand hygiene when changing into a new pair of gloves. LVN 2 stated it was important to perform hand hygiene prior to donning a new pair of gloves for infection control. LVN 2 verified he did not perform hand hygiene between the glove use during the medication administration observation. On 9/22/25 at 1315 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 19 final sampled resident (Resident 18) and two nonsampled residents (Residents 30 and 68) reviewed for accident hazards remained free from accident hazards. * The facility failed to ensure Resident 18's neuro check assessments were conducted after a fall on 1/2/25. * The facility failed to monitor Residents 30 and 68's Wander Guard for functionality. These failures had the potential to place the residents at risk for serious injuries and posed the risk for not having accurate information documented to prevent further accidents and or injuries to the residents. Findings: 1. Review of the facility's P&P titled Signaling Device dated 10/26/23, showed checking the placement and functionality of the signaling device should be verified every shift and daily. The licensed nurses will document the placement and functionality in the resident's medical record. According to Accutech Healthcare Security Solutions (Wander Guard) tag and band maintenance guide, the tags should be tested on a weekly basis for maximum protection of residents. a. On 9/17/25 at 1002 hours, Resident 30 was observed sitting in his wheelchair and a Wander Guard device was observed on his left wrist. Medical record review for Resident 30 was initiated on 9/17/25. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's Order Summary Report showed a physician's order dated 10/5/23, to apply the Wander Guard on the left wrist of the resident and to check the placement of Wander Guard every shift. However, there was no documented evidence a physician's order was obtained to check for the functionality of the Wander Guard. Review of Resident 30's plan of care showed a care plan problem dated 10/5/23, addressing the resident's risk for injury related for elopement. The interventions included for the placement of the Wander Guard. However, there was no documented evidence to show the monitoring of the placement and functionality of the the device was included in the care plan interventions. Review of Resident 30's H&P examination dated 4/28/25, showed Resident 30 had no capacity to understand and make decisions. On 9/17/25 at 1116 hours, an interview for Resident 30 was conducted with CNA 1. CNA 1 stated Resident 30 preferred to sit near the door and had episodes of wanting to get out of the facility. CNA 1 stated Resident 30 had a Wander Guard on his left wrist. b. On 9/17/25 at 1012 hours, Resident 68 was observed in his bed and a Wander Guard device was observed on his left wrist. Medical record review for Resident 68 was initiated on 9/17/25. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68's plan of care showed a care plan problem dated 4/5/24, addressing the resident's risk for injury related for elopement. The interventions included for the placement of Wander Guard and to monitor the placement every shift. However, there was no documented evidence to show the monitoring of the functionality of the the device was included in the care plan interventions. Review of Resident 68's Order Summary Report showed a physician's order dated 10/26/24, to apply the Wander Guard on the left wrist of the resident and to check the placement of the Wander Guard every shift. However, there was no documented evidence a physician's order was obtained to check for the functionality of the Wander Guard. Review of Resident 68's H&P examination dated 10/27/24, showed Resident 68 had no capacity to understand and make decisions. Review of Resident 68's Elopement Evaluation dated 7/25/25, showed Resident 68 was evaluated as a high risk of elopement On 9/17/25 at 1112 hours, an interview for Resident 68 was conducted with CNA 6. CNA 6 stated Resident 68 liked to wander around the facility and wanted to go home. CNA 6 verified Resident 68 had a Wander Guard on his left wrist. On 9/17/25 at 1514 hours, an interview for Residents 30 and 68 was conducted with LVN 3. LVN 3 stated Resident 30 wanted to leave the facility but could easily be redirected. LVN 3 verified Resident 30 have a Wander Guard device. LVN 3 stated Resident 68 had a behavior of wanting to go outside of the facility. LVN 3 verified Resident 68 had a Wander Guard device. LVN 3 stated the facility staff checked the placement of the Wander Guard every shift. LVN 3 stated the maintenance staff were responsible for checking the functionality of the Wander Guard device every day. On 9/18/25 at 1034 hours, an interview and concurrent facility document review for Resident 30 and 68 was conducted with the Director of Maintenance. The Director of Maintenance verified he was responsible for checking the Wander Guard alarms of the residents. The Director of Maintenance stated he checked the functionality of the Wander Guard device once a month, after it was activated and applied to the residents. The Director of Maintenance was asked for the log for documenting for checking of the Wander Guard device. The Director of Maintenance was able to show the log when he placed the Wander Guard device on the resident. However, the Director of Maintenance was not able to show documented evidence for the monitoring of the functionality of the Wander Guard device once a month. The Director of Maintenance verified and acknowledged there was no monthly documentation in the log for the checking of the Wander Guard device. On 9/18/25 at 1049 hours, an interview and concurrent medical record review for Residents 30 and 68 was conducted with LVN 4. LVN 4 verified and acknowledged Residents 30 and 68 had Wander Guard devices. LVN 4 verified there was no physician's order for the checking of the functionality of the Wander Guard for Residents 30 and 68. LVN 4 stated a physician's order should have been obtained because the Wander Guard device was considered as a restraint. On 9/18/25 at 1100 hours, an interview and concurrent medical record review for Residents 30 and 68 was conducted with RN 1. RN 1 stated the licensed nurses were responsible for checking the placement of the Wander Guard of the residents every shift. RN 1 stated the maintenance staff was responsible for applying and checking of the functionality of the Wander Guard device. RN 1 was informed of the above findings. RN 1 verified there was no documentation to show the facility staff were checking the functionality of the Wander Guard device for Residents 30 and 68. On 9/22/25 at 0940 hours, an interview and concurrent medical record review for Residents 30 and 68 was conducted with the DON. The DON was informed and verified the above findings. 2. Review of the facility's P&P titled Fall Management Program dated 3/13/21, showed the facility will implement a fall management program that supports providing an environment free from fall hazards. For Post Fall Response: - Following every resident fall, the licensed nurse will perform a post fall evaluation and update, initiate or revise the Resident's care plan as necessary. - For an unwitnessed fall or a witnessed fall with suspected or known head injury, the licensed nurse will complete neurological checks at the ordered frequency or as listed below equaling 72 hours: a. Every 15 minutes x 1 hour, then b. Every 30 minutes x 1 hour, then c. Every hour x 4 hours, then d. Every 4 hours x 66 hours or until the physician states it is no longer necessary or after 72 hours if the Resident's condition is stable and not showing signs or symptoms of neurological injury. Medical record review for Resident 18 was initiated on 9/15/25. Resident 18 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review Resident 18's Change in Condition form dated 1/2/25, showed at 2345 hours, Resident 18 fell from the wheelchair and sustained a laceration on the left forehead. Review of Resident 18's care plan for fall related to poor balance, psychoactive drug use and unsteady gait dated 1/3/25, showed interventions including a neurological assessment. Review of Resident 18's Discharge Summary Notes dated 1/3/25, showed at 0005 hours, Resident 18 was transferred to the acute care hospital for further evaluation. The resident's primary physician and resident representatives were made aware. Review of Resident 18's admission summary dated [DATE], showed at 1517 hours, Resident 18 was readmitted from the acute care hospital. Review of Resident 18's medical records failed to show a neurological assessment was completed on the following dates and times: - no neurological assessment 15 minutes after fall incident 1/2/25 at 2345 hours (Resident 18 was discharged to the acute care hospital on 1/3/25 at 0005 hours) - no neurological assessments after the resident was admitted back to the facility on 1/4/25, a total of 72 hours per the facility's policy. On 9/17/25 at 1032 hours, a medical record review for Resident 18 and concurrent interview was conducted with RN 1. RN 1 stated for fall incidents, neurological check assessments should be done by licensed nurses for 72 hours after the incident of fall. RN 1 verified Resident 18's neurological assessments were not completed equal to 72 hours of monitoring and acknowledged it should have been done. On 9/17/25 at 1058 hours, an interview was conducted with the DON. The DON acknowledged the above findings and verified the neurological checks after Resident 18's fall incident should have been performed.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 7) remained free from an accident/hazards due to the use of the side rails/ grab bars. * The facility failed to ensure the informed consent was obtained and completed for Resident 7's bilateral U grab bars. This failure had the potential to put the resident at risk for entrapment and serious injuries. Findings: According to FDA.gov, deaths and serious injuries related to side rail entrapment have occurred with the use of side rails. The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Review of the facility's P&P titled Bed Rails revised on 5/30/24, showed the ordering physician will obtain informed consent from the resident/ resident representative prior to the use of bed rails. On 9/15/25 at 0943 hours, during the initial tour of the facility, Resident 7 was observed lying in bed awake and verbally responsive. Resident 7's bed was observed with the bilateral U grab bars elevated. On 9/17/25 at 0951 hours, a follow up observation was conducted with Resident 7. Resident 7 was observed lying in bed awake and verbally responsive. Resident 7's bed was observed with the bilateral U grab bars elevated. Medical record review for Resident 7 was initiated on 9/15/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 7/24/25, showed Resident 7 was unable to make her own medical decisions. Review of Resident 7's Quarterly MDS assessment dated [DATE], showed Resident 7 had a BIMS of 9, indicating moderate impaired cognition. Review of Resident 7's Order Summary Report for 9/2025 showed a physician's order dated 7/28/22, for the bilateral grab bars for the ADL care changes, mobility, positioning, and as an enabler. Further review of Resident 7's medical record failed to show the informed consent was obtained for the use of the bilateral U grab bars. On 9/17/25 at 1059 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 7 used the bilateral U grab bars for turning and repositioning while in bed. On 9/18/25 at 1026 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 7 currently used the bilateral U grab bars for turning in bed. LVN 1 verified the above findings and stated the informed consent should be obtained for safety measures and updated when the physician's order changed. On 9/22/25 at 1313 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 12) was free from unnecessary psychotropic medications. * The facility failed to ensure the targeted behaviors for the use of Ativan (antianxiety medication) were documented prior to administering the medication to Resident 12. This failure had the potential for the resident to experience adverse effects from the psychotropic medication and unnecessary use of the psychotropic medication. Findings: Review of the facility's P&P titled Behavior/Psychoactive Medication Management revised 4/2025 showed any order for psychoactive medication must include a specific behavior manifestation and the residents have the right to be free from chemical restraints. Review of the facility's P&P titled Medication - Administration revised 6/2025 showed the facility shall ensure the residents received the correct medications in a safe and documented manner and a licensed nurse will document the reason for the use of PRN medications. Medical record review for Resident 12 was initiated on 9/17/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 9/26/24, showed Resident 12 had no capacity to understand and make decisions. Review of Resident 12's plan of care showed a care plan problem revised 12/18/24, addressing Resident 12's use of the Ativan medication related to her anxiety disorder. The interventions included to monitor, record, and document the occurrences of the target behavior symptoms for the use of the Ativan medication. Review of Resident 12's Order Summary Report showed the following physician's orders:- dated 8/20/25, to administer Ativan 0.5 mg one tablet by mouth every six hours as needed for anxiety manifested by agitation as evidence by attempting to hit the staff.- dated 8/18/25, to monitor the target behaviors for the use of the Ativan medication due to anxiety manifested by agitation as evidence by attempting to hit the staff and to record the number of behavior occurrences. Review of Resident 12's MAR for 8/2025 and 9/2025 showed the dates and times Resident 12 had received the Ativan medication without documented evidence Resident 12 displayed the targeted behaviors for the use of the Ativan medication:- on 8/2/25 at 1305 hours;- on 8/11, 8/25, and 9/16/25 at 1800 hours;- on 8/12 and 9/9/25 at 1700 hours;- on 9/1/25 at 1600 hours; and- on 9/2/25 at 0720 hours. Further review of Resident 12's medical record failed to show documented evidence Resident 12 displayed the targeted behaviors for the use of the Ativan medication prior to administering the psychotropic medication. On 9/16/25 at 1013 hours, 9/17/25 at 0902 hours, 9/18/25 at 0836 hours, and 9/19/25 at 0834 hours, Resident 12 was observed sleeping in her bed. On 9/18/25 at 1411 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 1. LVN 1 stated Resident 12 had occurrences where Resident 12 would try to scratch or grab the facility staff. LVN 1 stated Resident 12 received the Ativan medication as needed for anxiety manifested by agitation as evidence by hitting the facility staff. LVN 1 further stated if Resident 12 did not display the targeted behaviors for the use of the Ativan medication, then the licensed staff should not administer the medication because Resident 12 did not need the psychotropic medication and it could alter Resident 12's behavior. LVN 1 verified the above findings. On 9/18/25 at 1442 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON stated if Resident 12 did not display the targeted behaviors for the use of Ativan medication, it was expected that Resident 12 would not receive the PRN psychotropic medication. The DON verified the above findings. On 9/22/25 at 1315 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 19 final sampled residents (Resident 11) maintained good grooming and personal hygiene. * The facility failed to ensure Resident 11's long fingernails were trimmed. This failure posed the risk of the resident to experience physical discomfort and health complications. Findings: Review of the facility's P&P titled Grooming Care of the Fingernails and Toenails dated 10/21/21, showed nail care is given to clean nail bed and keep nails trimmed. Fingernails are trimmed by Certified Nursing Assistants (CNAs), except for Residents with diabetes or circulatory impairments, this includes toenails except for high-risk residents. Note: A Licensed Nurse will trim those Residents' nails. High risk Residents and Residents with hypertrophic, myotic and keratotic toenails are referred to a podiatrist. Medical record review for Resident 11 was initiated on 9/15/25. Resident 11 was admitted to the facility on [DATE], and readmitted on [DATE]. On 9/16/25 at 1125 hours, during the Resident Council meeting, Resident 11 stated he kept requesting from the facility staff for his fingernails to be trimmed. However, Resident 11 stated he was told the facility staff did not trim the residents' fingernails. Resident 11 added the facility had not done anything about his long fingernails. On 9/16/25 at 1448 hours, an observation of Resident 11's fingernails and concurrent interview was conducted with Resident 11. Resident 11's fingernails (10 fingernails) on the left and right hand were observed long with brown colored stains on the back of the fingernails. When asked, Resident 11 stated he requested for his fingernails to be trimmed three weeks ago. However, Resident 11 repeatedly stated the facility staff had not done anything about his fingernails. On 9/16/25 at 1450 hours, an observation of Resident 11's fingernails and concurrent interview was conducted with CNA 2. CNA 2 was informed of Resident 11's long fingernails. CNA 2 verified Resident 11's fingernails were long and should have been trimmed. CNA 2 further stated she would ask the charge nurse first if Resident 11's fingernails should be trimmed by a licensed staff or if she would be allowed to trim the resident's fingernails. On 9/16/25 at 1455 hours, an observation of Resident 11's fingernails and concurrent interview was conducted with LVN 2. LVN 2 was informed of Resident 11's long fingernails. LVN 2 assessed Resident 11's fingernails and verified Resident 11's fingernails should have been trimmed, and stated the CNAs could trim the residents' fingernails. LVN 2 further stated he would follow up with CNA 2 to ensure Resident 11's fingernails were carefully trimmed. On 9/17/25 at 1058 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing Facility Assessment;2. A resources necessary to care for residents including weekends;3. A plan to maximize recruitment and retention of direct care staff; and4. A contingency plan for staffing needs. These failures had the potential to not meet the residents care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation dated 8/8/24, the CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also, a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan. Review of the Facility's assessment dated [DATE], did not show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the Facility Assessment, a resources necessary to care for residents including weekends, a plan to maximize recruitment and retention of the direct care staff, and a contingency plan for the staffing needs. On 9/18/25 at 1032 hours, an interview and concurrent facility document review of the Facility Assessment was conducted with Administrator. The Administrator verified the Facility Assessment was dated 2/6/25, and acknowledged he was not aware of the new update of the Facility Assessment from the CMS. The Administrator verified there were no direct care staff, direct care representatives, residents, resident representatives, and family members actively involved in developing the Facility Assessment. The Administrator further verified there were no plan to maximize recruitment and retention of the direct care staff, a resources necessary to care for residents including weekends, and a contingency plan for the staffing needs. The Administrator verified and acknowledged the Facility Assessment was not updated based on the latest update from the CMS.

Based on interview, medical record review, and facility document review, the facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 for one of three residents (Resident 15) reviewed for beneficiary notification. The NOMNC and SNFABN forms are used to inform the residents of their potential financial liability, appeal rights, and protection should they wish to receive care and services that may not be covered by Medicare. * The facility failed to ensure followed up was made with Resident 15's responsible party to have him review and sign the NOMNC and SNF ABN forms. This failure had the potential of not allowing Resident 15 and/or their representative to make an informed decision regarding their Medicare servicesFindings: Medical record review for Resident 15 was initiated on 9/17/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 2/25/25, showed the resident had no capacity to understand and make medical decisions. Review of Resident 15's NOMNC (undated) showed the effective date coverage of Resident 15's skilled nursing service would end on 3/24/25. The section for the signature of the resident or representative was blank. The document also showed the Business Office manager (BOM) called Resident 15's responsible party on 3/21/25, notifying the responsible party of the Medicare Covered Part A stay was ending on 3/24/25. Review of Resident 15's SNF ABN showed Medicare doesn't pay for everything even some care that you and your health care provider think you need. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage or its utilization review committee believes that the care listed below does not meet the Medicare coverage requirement. Beginning 3/25/25, you may have to pay out of pocket for this care if you do not have insurance that may cover those costs. Further review of the document did not show the signature of Resident 15 and/or the resident's authorized representative. Review of Resident 15's Optional Form to Document Alternate Delivery for the NOMNC showed Resident 15's responsible party was contacted via telephone call on 3/21/25, and via email on 3/24/25. In addition, the Confirmation of Refusal to Sign section was blank. On 9/17/25 at 0906 hours, an interview and concurrent medical record review was conducted with the BOM (Business Office Manager). The BOM stated Resident 15's responsible party requested the NOMNC and SNF ABN forms be sent to his email address. The BOM reviewed Resident 15's medical record and verified the above findings. The BOM stated she did not have any documentation to show she followed up with Resident 15's responsible party to have him review and sign the NOMNC and SNF ABN forms. On 9/22/25 at 1300 hours, an interview was conducted with the Administrator, DON, Nursing Consultant, and Chief Business Officer. The Administrator, DON, Nursing Consultant, and Chief Business Officer were notified and acknowledged the above findings.

Based on interview, medical record review, and the facility P&P review, the facility failed to ensure the medical record for one out of 19 final sampled residents (Resident 28) was complete and accurate. * The facility failed to ensure the MAR documentation on 9/1/25, for Resident 28's oxygen saturation rate during a day shift was accurate. In addition, the MAR was incomplete for Resident 28's meal intake percentage for the dinner entry on 8/22/25. These failures had the potential for the resident's care needs not being met as their medical information was incomplete and inaccurate. Findings: Review of the facility's P&P titled Medical Records, Completion and Correction dated 1/1/12, showed to ensure that medical records are complete and accurate:- The facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation.- Entries will be complete, legible descriptive and accurate. Review of the facility's P&P titled Pulse Oximetry dated 1/2/25, showed to provide the standards for performing pulse oximetry to monitor and trend a resident's oxygen saturation in the subacute unit:- All licensed caregivers performing pulse oximetry on the residents shall be in-serviced on the standards of its use and the performance of the procedure. Medical record review for Resident 28 was initiated on 9/15/25. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28's Order Summary Report dated 9/16/25, showed the following physician's orders:- dated 7/3/25, to check the oxygen saturation rate every shift.- dated 6/2/25, to monitor the meal percentage with meals. Review of Resident 28's MAR for August 2025 showed the missing entry on 8/22/25, for the resident's dinner meal percentage. Review of Resident 28's MAR for September 2025 showed the resident's oxygen saturation rate was 137% on 9/1/25, during the day shift. On 09/17/25 at 1020 hours, an interview and concurrent medical record review for Resident 28 was conducted with RN 1. RN 1 verified the documented oxygen saturation rate of 137% for the resident on 9/1/25, was a typographical error. In addition, RN 1 verified and acknowledged the missed documentation for the resident's dinner meal percentage on 8/22/25. RN 1 stated the resident's MAR should have been completed. On 09/17/25 at 1058 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the copy of the advance directive (a legal document stating a person's wishes about receiving medical care if the person is no longer able to make medical decisions) was maintained in the resident's medical record for one of 19 final sampled residents (Resident 33). * The facility failed to maintain a copy of Resident 33's advance directive in the resident's medical record. This failure had the potential for the facility to provide treatment and services against the resident's wishes. Findings: Review of the facility's P&P titled Advance Directive revised date [DATE], showed upon admission, the Admissions Staff or Designee will provide written information to the resident concerning his or her right to make decisions concerning medical care; including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. During the Social Service Assessment process, the Director of Social Services or Designee will also ask the resident if they have a written advance directive. If the resident has an Advance Directive, the facility shall request a copy of the document from the resident or the resident's representative. It is the resident's or resident representative's responsibility to provide the facility with a copy of any Advance Healthcare Directive (AHCD) document (living will, health care proxy, or medical power of attorney), or other document that could affect their care. If a copy is provided by the resident or resident representative, it will be placed in the medical record. Review of Resident 33's medical record was initiated on [DATE]. Resident 33 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 33's Advance Healthcare Directive Acknowledgment form dated [DATE], showed Resident 33 had no advance directive and did not want information at the time. Review of Resident 33's Order Summary Report showed a physician's order dated [DATE], for a full code (healthcare directive that all life-saving measures should be used if a resident's heart stops or they stop breathing) and CPR will be given. Review of the Resident 33's H&P examination dated [DATE], showed Resident 33 had no mental capacity to make decisions. Review of Resident 33's Quarterly Social Service Progress Note dated [DATE], showed the information on how to execute an advance directive was provided and Resident 33 had an advance directive on file. However, there was no copy of the advance directive in Resident 33's medical record. On [DATE] at 0847 hours, an interview and concurrent medical record review was conducted with the Case Manager/SSD. The Case Manager/SSD verified the above findings and stated a copy of the advance directive should be in the resident's medical record and uploaded in the resident's electronic medical record. The Case Manager/SSD further stated in the event when the resident had a change of condition, unable to verbalize their needs, or incapacitated, the facility would be able to reach the resident's next of kin. On [DATE] at 1313 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for nine of nine sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9). * The facility failed to ensure safe smoking practices were followed for eight of nine residents who smoked in the facility. Residents 1, 2, 3, 4, 5, 7, 8, and 9 were not thoroughly assessed to determine if they required supervision while smoking. * The facility failed to ensure nine of nine residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) had individualized care plan problems developed to address safe storage and use of smoking materials. These failures posed the risk of fire and serious injury to all the residents. On 2/11/2020 at 1502 hours, the Administrator was informed an IJ situation was identified regarding the following deficient practices: * The facility failed to follow their P&P for the residents who smoked by not thoroughly assessing eight of nine sampled residents who smoked in the facility for their ability to smoke with or without supervision. * The facility failed to develop individualized care plan problems addressing safe storage and use of smoking materials for nine of nine sampled residents. * The facility failed to ensure the safety measures were followed by allowing eight of nine sampled residents to smoke without supervision. On 2/12/2020 at 1700 hours, the IJ was abated after the facility submitted a plan of corrective action: * Conducted thorough assessments for all residents who smoked in the facility. * Developed and revised all nine residents' plans of care to include safe storage, use of the smoking materials, and supervision. * Implemented a smoking schedule and assigned a staff member to supervise the residents while smoking. * In-serviced all staff on the facility's P&P and safety measures related to smoking. The facility provided documentation which showed staff, including the nursing staff, department managers, maintenance, and housekeeping staff had all been in-serviced on the facility's smoking P&P, new smoking schedule, and safe smoking practices. Findings: According to the facility's P&P titled Smoking by Residents revised 1/2017, smoking, whether it is traditional tobacco or herbs smoked in cigarettes, pipes, cigars, or electronic cigarettes, are governed by this policy. Using the Resident Smoking Assessment, the licensed nurse will assess residents who express a desire to smoke upon admission, quarterly, annually, and upon significant change of condition identification, and present it to the IDT for review. The IDT will review the resident assessment for safety at minimum at the following intervals: upon admission, quarterly, annually, and upon significant change of condition identification. As identified by the Smoking Assessment, residents who require assistance and/or monitoring for smoking safety are not allowed to smoke unaccompanied. Residents who use electronic smoking devices must be able to independently demonstrate: a. Ability to fill the vapor chamber with the solution without spillage. b. Ability to change the atomizer at least weekly and as needed. c. Ability to change the battery daily or as needed. d. Ability to cleanse the mouthpiece. The IDT will develop an individualized plan for use of smoking materials, safe storage, assistance, and required supervision, if necessary, for residents who smoke. The resident and/or their responsible party will be educated regarding the risks of smoking and safe smoking measures developed by the IDT. This will be documented in the resident's clinical record. Review of the list of smokers provided by the facility dated 2/11/2020, showed there were seven smokers in the facility (Residents 1, 2, 3, 4, 5, 6, and 7). RN 1 stated all the residents smoked without supervision and without a smoking schedule. 1. According to a complaint allegation received on 2/11/2020, Resident 1 was observed smoking an electronic cigarette in a room with oxygen in use. According to an article titled E-cigarette Explosion in a Patient Room published April 2019 by the Agency for Healthcare Research and Quality (psnet.ahrq.gov), the use of any ignition source in the presence of oxygen is potentially hazardous. This issue was addressed specifically by the British Compressed Gases Association, which showed, Electronic cigarettes are . a potential ignition source and, in the context of oxygen-rich environments, have the same fire risks as traditional cigarettes. On 2/11/2020 at 0909 hours, Resident 1's roommate (Resident A) was observed lying in bed receiving oxygen at two liters per minute via a nasal cannula (thin flexible tube with small prongs inserted into the nostrils). Medical record review for Resident 1 was initiated on 2/11/2020. Resident 1 was admitted to the facility on [DATE]. Review of the Physician order [REDACTED]. Another order dated 11/19/19, showed Resident 1 was to use a [MEDICAL CONDITION] machine at bedtime for sleep apnea. Review of Resident 1's ADL flowsheet showed an entry dated 2/3/2020, by a CNA who worked on the 1500 to 2300 hours shift. The CNA documentation showed Resident 1 was smoking in his room all the time. The supervisor was aware and spoke with the resident. On 2/11/2020 at 1004 hours, an interview was conducted with Resident 1. Resident 1 stated he used to smoke in the facility but stopped two days ago. When asked if he smoked inside his room, Resident 1 stated yes, he was caught smoking in the room by staff two days ago. When asked where he kept his smoking materials, Resident 1 stated the staff.put it away. Review of the medical record failed to show a smoking assessment was completed for Resident 1. Review of the plan of care failed to show a care plan problem was developed to address Resident 1's smoking. On 2/11/2020 at 1102 hours, an interview was conducted with RN 1. RN 1 stated Resident 1 smoked an electronic cigarette and he kept his smoking materials with him. RN 1 was unable to show documentation a smoking assessment was completed nor documentation Resident 1 was assessed for his ability to use the electronic smoking device. On 2/11/2020 at 1143 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated the activities staff reported seeing Resident 1 smoke inside the room, so he (LVN 1) went and reminded Resident 1 not to do it again. LVN 1 stated he could not remember when the incident happened. LVN 1 was unable to show documentation the incident was reported to the Administrator, DON, nor any member of the IDT. On 2/11/2020 at 1213 hours, an interview was conducted with the Activities Director. The Activities Director stated on 2/8/2020 (she could not remember the time), she went to deliver Resident 1's mail in his room when she saw Resident 1 inhaling something from a black thing in his mouth, which the Activities Director described as vaping. The Activities Director stated she reported the incident right away to LVN 1. The Activities Director stated they did not supervise the residents who smoked in the smoking patio. The facility staff pushed the door open for the residents so they could go out and smoke. 2. On 2/11/2020 at 1301 hours, Resident 2 was observed smoking without supervision on the smoking patio. Medical record review for Resident 2 was initiated on 2/11/2020. Resident 2 was admitted to the facility on [DATE]. Review of the Safe Smoking assessment dated [DATE], showed the assessment had not been completed. Under the section for other comments, the assessment showed Resident 2 was a smoker. Review of Resident 2's plan of care showed a care plan problem with a creation date of 2/4/2020, to address the risk for smoking related injury or conditions. However, the care plan did not address safe storage and use of Resident 2's smoking materials. On 2/11/2020 at 1510 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed smoking on the smoking patio. There was no staff member present. Resident 2 stated he kept his cigarettes and lighter in his pocket. 3. On 2/11/2020 at 1126 hours, an interview was conducted with Resident 3. Resident 3 stated he smoked without supervision. Resident 3 stated he kept his cigarettes and lighter with him but could not locate where they were at the time of this interview. Medical record review for Resident 3 was initiated on 2/11/2020. Resident 3 was admitted to the facility on [DATE]. Review of the medical record failed to show a smoking assessment was completed for Resident 3. Review of the plan of care showed a care plan problem with a creation date of 12/24/19, to address the risk for smoking related injury or conditions. However, the care plan did not address safe storage and use of Resident 3's smoking materials. 4. On 2/11/2020 at 1121 hours, an interview was conducted with Resident 4. Resident 4 stated he smoked without supervision. When asked where he kept his smoking materials, Resident 4 stated he kept his cigarettes and lighter inside his bedside drawer in his room. Medical record review for Resident 4 was initiated on 2/11/2020. Resident 4 was admitted to the facility on [DATE]. Review of the Safe Smoking assessment dated [DATE], failed to show the IDT had met to determine if Resident 4 needed supervision while smoking. Review of the plan of care showed a care plan problem with a creation date of 2/6/2020, to address the risk for smoking related injury or conditions. However, the care plan did not address safe storage and use of Resident 4's smoking materials. 5. On 2/11/2020 at 1116 hours, an interview was conducted with Resident 5. Resident 5 stated she smoked without supervision. When asked where she kept her smoking materials, Resident 5 stated she kept them in her back pack and in the closet in her room. Medical record review for Resident 5 was initiated on 2/11/2020. Resident 5 was readmitted to the facility on [DATE]. Review of the medical record failed to show a smoking assessment was completed for Resident 5. Review of the plan of care failed to show a care plan problem was developed to address Resident 5's smoking. On 2/11/2020 at 1705 hours, Resident 4 was observed smoking on the smoking patio. 6. On 2/11/2020 at 1114 hours, an interview was conducted with Resident 6. Resident 6 stated she smoked without supervision. When asked where she kept her smoking materials, Resident 6 stated she kept them in her purse. Medical record review for Resident 6 was initiated on 2/11/2020. Resident 6 was readmitted to the facility on [DATE]. Review of the Safe Smoking assessment dated [DATE], showed Resident 6 was able to smoke independently. However, the Safe Smoking Assessment was not completed for Resident 6 on a quarterly basis as per the facility's policy. Review of the plan of care failed to show a care plan problem was developed to address Resident 6's smoking. 7. On 2/11/2020 at 1102 hours, an interview was conducted with Resident 7. Resident 7 stated he smoked independently. When asked where he kept his smoking materials, Resident 7 stated he had his cigarettes and lighter with him. Medical record review for Resident 7 was initiated on 2/11/2020. Resident 7 was readmitted to the facility on [DATE]. Review of the medical record failed to show a smoking assessment was completed for Resident 7. Review of the plan of care failed to show a care plan problem was developed to address Resident 7's smoking. On 2/11/2020 at 1446 hours, a follow-up interview and concurrent review of medical records was conducted with RN 1. RN 1 stated she was in charge of the facility today as the Administrator was at another facility. RN 1 reviewed the medical records of Residents 1, 2, 3, 4, 5, 6, and 7 and verified the above findings. 8. On 2/11/2020 at 1301 hours, Residents 8 was observed smoking without supervision on the smoking patio. Medical record review for Resident 8 was initiated on 2/11/2020. Resident 8 was admitted to the facility on [DATE]. Review of the Safe Smoking assessment dated [DATE], failed to show the IDT had met to determine if Resident 8 needed supervision while smoking. Review of the plan of care failed to show a care plan problem was developed to address Resident 8's smoking. On 2/11/2020 at 1628 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed the medical record and verified the above findings. RN 1 stated Resident 7 kept her smoking materials. 9. Medical record review for Resident 9 was initiated on 2/11/2020. Resident 9 was admitted to the facility on [DATE]. On 2/11/2020 at 1511 hours, Resident 9 was observed smoking without supervision on the facility's smoking patio. On 2/11/2020 at 1612 hours, an interview was conducted with Resident 9. Resident 9 stated he smoked without supervision. When asked where he kept his smoking materials, Resident 9 stated he did not have any, he would ask for cigarettes and borrow a lighter from another resident when he needed to smoke. Review of the medical record failed to show a smoking assessment was completed for Resident 9. Review of the plan of care failed to show a care plan problem was developed to address Resident 9's smoking. On 2/11/2020 at 1615 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed the medical record and verified the above findings. RN 1 stated she was not aware Resident 9 was a smoker. On 2/11/2020 at 1700 hours, the Administrator was informed of Residents 8 and 9 who were not included in the list of smokers provided by the facility. However, Residents 8 and 9 were observed smoking without supervision on the smoking patio. The Administrator acknowledged the findings.

Based on interview, clinical record review and facility document review, the facility failed to thoroughly implement their abuse P&P and to fully investigate reported allegations of resident-to-resident abuse for 13 of 16 sampled residents (Residents 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 14, 15, and 16). On 7/15/15, the facility reported allegations of resident-to-resident abuse which occurred in July and August 2014 for Residents 2, 3, 4, and 5. On 8/3/15, the facility reported an allegation of resident-to-resident abuse between Residents 9 and 16. On 8/4/15, the facility reported an allegation of resident-to-resident abuse between Residents 8 and 16. On 8/21/15, the facility reported three separate allegations of resident-to-resident abuse between Residents 10 and 16, between Residents 5 and 11, and between Residents 8 and 16. * On 8/10/15, the facility reported an injury of unknown origin for Resident 7. The facility failed to thoroughly implement their abuse P&P to fully investigate the resident's injury of unknown origin. * The facility failed to thoroughly implement their abuse P&P for four of 16 sampled residents (Residents 8, 9, 5, and 16). The residents were identified by the facility to have been involved in resident-to-resident abuse allegations during the past year. * The facility failed to ensure a thorough investigation was conducted and reported to the appropriate authorities when the facility became aware Resident 1 had been involved in four resident-to-resident allegations of abuse where he was identified to be the alleged abuser. * Resident 2 reported she awoke and found Resident 1's hand near her vaginal area. A CNA witnessed Resident 1's hand under Resident 2's covers. The facility failed to conduct an investigation and failed to report the allegation of abuse to the appropriate authorities. * Resident 3 reported she awoke and found Resident 1's hand on her thigh, moving his hand up her leg. The facility failed to conduct a thorough investigation and failed to report any investigative findings to the Department. * Resident 4 reported he awoke and found Resident 1 placing his finger in his (Resident 4's) anus. The facility failed to ensure a thorough investigation was conducted, failed to report the allegation of abuse to the appropriate authorities, and failed to provide investigative findings to the Department within 5 days. * Resident 5 reported Resident 1 touched her inappropriately. The facility failed to ensure a thorough investigation was conducted for the allegation of resident-to-resident abuse for Resident 5 and failed to report the allegation of abuse to the appropriate regulatory agencies. * Resident 7 reported someone squeezed her hand. The resident's right hand was assessed to be swollen and bruised. An x-ray showed Resident 7 sustained a [MEDICAL CONDITION] finger on her right hand. The facility failed to ensure a thorough investigation was conducted for Resident 7's injury and failed to report the investigation findings to the Department within 5 days. * Resident 8 reported she was sitting in her wheelchair with her right elbow on the arm of the wheelchair, lower arm and hand flexed upwards when Resident 16 came from behind her and hit her between the thumb and first finger of her right hand. The facility failed to ensure a thorough investigation was conducted and failed to report a written investigative summary to the Department within 5 days. * On 8/21/15, the facility reported another resident-to-resident abuse allegation between Residents 8 and 16. The facility reported Resident 16 used her fist to strike Resident 8 from behind and hit Resident 8's left shoulder blade. The facility failed to conduct a thorough investigation and failed to report the investigation findings to the Department within 5 days. * Resident 9 reported Resident 16 slapped her on the face when she attempted to pass Resident 16 in the hallway. The facility failed to ensure a thorough investigation was conducted and failed to ensure Resident 9 had been clinically assessed when the allegation of abuse was reported. * Resident 10 reported a nurse had struck her with papers on 3/9/15, and caused an injury to her eye. Resident 10 was sent to the acute hospital on [DATE], after a fall and reported to the hospital staff that a facility nurse had struck her in the eye with papers. The facility failed to ensure a thorough investigation was conducted to address the allegation of abuse. * Resident 11 reported on 4/26/15, her roommate stated, maybe I should just kill you and your boyfriend. The facility failed to ensure a thorough investigation was conducted. * Resident 14 was reported to have struck Resident 15 on her right arm. The facility failed to ensure a thorough investigation was conducted and reported timely to the Department. * Resident 15 reported Resident 14 struck her on the right arm. The facility failed to ensure a thorough investigation was conducted and failed to report the investigation findings to the Department within 5 days. * The facility reported Resident 16 had been involved in several alleged physical resident-to-resident abuse allegations where Resident 16 had been identified as the aggressor. The facility failed to ensure thorough investigations were conducted and failed to ensure a safe environment for other residents. Failure to follow the facility's P&P and thoroughly investigate allegations of abuse and injuries of unknown origin placed residents at risk for further abuse and a negative impact on their physical, emotional, and/or mental health status condition. Findings: Review of the facility's P&P titled Abuse Prevention/Suspicious Criminal Activity Program dated 3/2013 showed the following: - If an alleged abuse/suspicious criminal activity occurs between one resident and another resident and the resident who perpetrated the alleged abuse/suspicious criminal activity has demonstrated behaviors that place others at risk, other measures will be put in place to protect all other residents. - Employees or others who have information about an alleged or suspected abuse/suspicious criminal activity and who do not come forward with this information, either before or during an investigation, are considered as culpable as the person(s) committing the alleged or suspected abuse/suspicious criminal activity. - The role of the Abuse/Suspicious Criminal Activity Coordinator includes monitoring and coordinating the program, investigating alleged or suspected abuse/suspicious criminal activity, and reporting alleged, suspected or substantiated abuse/suspicious criminal activity to the appropriate regulatory or law enforcement agency within the timeframes stipulated by law or regulation. - Verbal reports/statements by residents, families or staff that allege abuse/suspicious criminal activity will be considered an allegation of abuse/suspicious criminal activity until an investigation substantiates or fails to substantiate the allegation. Allegations will be immediately reported (24 hours a day, 7 days a week) to the RN Supervisor or any Department Manager in the facility and/or the Abuse/Suspicious Criminal Activity Coordinator. - The facility will complete a thorough and extensive investigation. Injuries of unknown origin will be reported to the DON for further investigation. Incidents of unknown origin that involve suspicious injury will be treated as possible abuse/suspicious criminal activity and investigated as such. - The facility investigation will include a description of the initial allegation, a summary of findings, notes on facts utilized to substantiate or unsubstantiate the allegation, a list of people interviewed and a conclusion. - A licensed nurse will conduct a physical exam for any resident who reports alleged physical abuse/suspicious criminal activity. - The facility will report all alleged and substantiated abuse/suspicious criminal activity to the appropriate enforcement agencies as required and take appropriate actions to minimize further occurrences. Mandated reporters will send a written report within 24 hours (2 hours for suspected abuse resulting in serious bodily injury) to the local Ombudsman, local law enforcement agency (if required), and CDPH. The form titled SOC 341 will be used for initial reporting to appropriate agencies. According to the facility's P&P titled Unexplained Injuries-Investigations dated 8/1/14, unexplained injuries are promptly and thoroughly investigated by the DON, Services and/or other staff person appointed by the Administrator. Documentation must include information relevant to risk factors and conditions that cause or predispose someone to similar signs and symptoms. Any descriptions in the clinical record must be sufficiently detailed and should not speculate about cause. Review of the facility's Recertification Survey completed on 4/1/15, showed the facility was cited at F226 for failure to conduct an investigation into an allegation of resident-to-resident abuse. The facility's plan of correction showed The Abuse Coordinator will monitor for compliance by reviewing all reports of alleged abuse and confirming that a written investigation of the incident was completed according to the facility's Abuse Prevention P&P. 1. Resident 1 was alleged to have been involved in resident-to-resident abuse with Residents 2, 3, 4, and 5 during July and August of 2014. Clinical record review was initiated for Resident 1 on 7/29/15 at 0910 hours. Resident 1 was admitted on [DATE], and discharged on [DATE]. According to the H&P dated 5/23/14, Resident 1 had fluctuating capacity to understand and make decisions. Review of physician's orders [REDACTED]. On 7/29/15 beginning at 0910 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator confirmed he was the facility's Abuse Coordinator. When asked to provide documentation regarding the investigations for alleged abuse regarding Residents 1, 2, 3, 4, and 5, he stated everything was handled through the IDT and anything they had would be in the DON and IDT's notes. The Administrator was asked if he conducted an investigation for the allegation of abuse between Residents 1 and 4. He stated he sent a letter to CDPH, but no other investigation had been done. When asked if he conducted an investigation for the allegation of abuse between Residents 1 and 5, and for the allegation of abuse between Residents 1 and 3, he deferred to the DON. On 7/29/15 at 1015 hours, the DON joined the interview and concurrent facility document and clinical record review with the Administrator. The Administrator informed the DON of the documents needed and the DON left the room to obtain them. Upon her return, she provided an internal document showing the allegation made by Resident 5. The Administrator stated all of the allegations were handled through the IDT process and he did not do his own investigations. The Administrator stated the investigations between Resident s 2, 3, and 4 were all handled the same way. The facility's Abuse P&P was reviewed with the Administrator, which showed the Abuse Coordinator will coordinate/conduct an investigation and listed steps to take with an investigation. The Administrator verified the P&P outlined his role and responsibilities. Review of a Nurse's Record dated 7/8/14 at 0600 hours, showed Resident 1 was found in a female resident's room and was touching her leg while she was sleeping. The note showed will monitor behavior closely. Review of an IDT note dated 7/18/14 at 1000 hours, showed Resident 1 was observed/reported to have caressed/touched another resident (Resident 2) on the upper extremity and thigh and had also gone into another resident's room. The IDT's recommendations included continued observation of Resident 1's behaviors. According to a physician's evaluation dated 7/27/14, Resident 1 had been wandering into other residents' rooms and had touched these residents on the arms and legs. Review of a Physician's Progress Note dated 8/11/14, showed Resident 1 touched another resident in her vaginal area. The note also showed Resident 1 had a history of [REDACTED]. Review of another facility internal document dated 8/22/14, showed Resident 1 allegedly touched another resident's anus (Resident 4) while Resident 4 was in bed asleep. During an interview with the Administrator on 7/29/15 at 1430 hours, the Administrator stated he had not done an investigation for Resident 1's involvement with allegations of abuse. He stated Resident 1's behaviors were addressed by the IDT and the IDT would have documented their findings. On 8/25/15 at 0825 hours, a telephone interview was conducted with the Ombudsman assigned to the facility. The Ombudsman stated their office did a thorough search and did not find any documentation to show the facility notified them about the allegations of abuse involving Resident 1. The Ombudsman stated she did not receive any reports from the facility regarding the allegations of abuse during July and August 2014 or any reports for resident-to-resident abuse allegations between Resident 1 and Residents 2, 3, or 4. a. On 7/29/15 at 0910 hours, a concurrent interview and facility document review was conducted with the Administrator. He was asked to provide all documents showing the facility conducted an investigation into Resident 2's allegation of abuse. The Administrator provided an internal document dated 8/1/14, showing Resident 2 reported she woke up and found Resident 1's hand touching her vaginal area. The document showed a CNA observed Resident 1's hand under Resident 2's covers at 0630 hours; however, there was no documentation to show the CNA was interviewed. The Administrator confirmed he did not notify the appropriate authorities of Resident 2's allegation of abuse. He stated he did not complete an SOC 341 or conduct other interviews. The Administrator stated he did not conduct an investigation. On 7/29/15 at 1430 hours, an interview was conducted with the DON. She was asked to locate an IDT note to show Resident 2's allegation of abuse was addressed. The DON provided a xeroxed copy of her note, showing the IDT met on 8/12/14, regarding the alleged abuse. It did not show the resident's physician was notified of the incident. Review of the facility's internal document dated 8/1/14 at 0630 hours, showed a CNA witnessed the alleged abuse and a medication nurse saw Resident 1 in Resident 2's room at 0630 hours and told him to go back to his room. When the DON was asked if she interviewed these staff members, she stated, I don't know. I'll need to check my notes. The DON located a nurse's note (undated) at 0720 hours, which showed Resident 1 was observed to have his hand under Resident 2's covers by a CNA. There was no documentation to show Resident 2's physician had been contacted about the incident. b. Clinical record review was initiated for Resident 3 on 7/29/15. Resident 3 was admitted to the facility on [DATE], and re-admitted on [DATE]. Resident 3 reported on 7/8/14, she woke up and found a male resident (Resident 1) in a wheelchair at her bedside. He was touching her thigh and moving his hand up her leg. Resident 3 shouted at him and told him to get out. On 7/29/15 at 1130 hours, an interview was conducted with the Administrator. The Administrator confirmed he had not taken the steps outlined under Investigation, and handled it through the IDT. Review of the Social Work Progress Notes showed a late entry dated 8/21/14 (untimed) that Resident 3 alleged she woke up at approximately 0530 hours on 7/8/14, and found a man (Resident 1) in a wheelchair at her bedside, touching her thigh, and progressively working his hand up her leg. Resident 3 yelled at Resident 1 to get out and Resident 1 started to wheel himself toward the door of the room. Resident 3 called the nurse and Resident 1 was escorted away from the door. The note did not show if a staff member reported the allegation of abuse (as recalled by the resident to have happened on 7/8/14) to the administrative staff. On 7/29/15 at 1530 hours, an interview was conducted with the Administrator. He confirmed he did not conduct an investigation regarding Resident 3's allegation of abuse. He stated it was handled through the IDT. On 8/11/15 at 0950 hours, an interview was conducted with Resident 3. Resident 3 stated she recalled the incident and stated she suddenly awoke and was startled to find a male resident in her room, touching her thigh. On 7/29/15 at 1445 hours, a concurrent interview and clinical record review was conducted with the DON. She was asked to locate any documentation showing the IDT addressed the allegation of abuse and evaluated Resident 3; however, she was unable to do so. The DON was asked to locate documentation to show Resident 3 had a nursing assessment conducted when she reported the allegation of abuse. The DON located nursing documentation which described the incident; however, the documentation did not show a clinical assessment of Resident 3 had been conducted. In addition, there was no documentation to show the physician and responsible party had been notified. The Administrator was asked to provide all documentation to show an investigation was conducted for Resident 3's allegation of resident-to-resident abuse. The Administrator provided an internal facility document dated 8/22/14. The section for date of incident and time of incident was left blank. The sections to document information about witnesses and staff observations were marked N/A. There was no documentation to show the nurse who escorted the resident out of Resident 3's room was interviewed for this investigation. The Administrator was asked to provide documents to show the abuse allegation had been investigated. The Administrator stated the allegation of abuse was handled through the IDT process and he did not conduct his own investigation. The Administrator stated he reported the resident-to-resident abuse to the Ombudsman. When the Administrator was asked if the Ombudsman responded to his report, he stated he did not know. The Administrator stated the police never responded and he thought it was odd the Department never came out about this. The Administrator was informed the Department did not receive his report. c. Review of an SOC 341 form Report of Suspected Dependent Adult/Elder Abuse dated 8/22/15, provided by the Administrator on 7/29/15, showed the facility was notified on 8/21/14, by another resident that Resident 4 stated Resident 1 placed his finger in Resident 4's anus while he was sleeping. The report showed Resident 4 was interviewed and stated the other resident did not poke him in the anus, rather, the other resident had his finger in the crack of his (Resident 4's) buttock while he was sleeping. On 7/29/15 at 0910 hours, a concurrent interview, clinical record review for Resident 4, and facility document review was conducted with the Administrator. He was asked to provide documentation to show he investigated Resident 4's allegation of abuse. The Administrator stated he dealt with this issue through the IDT and there was no other formal investigation. The Administrator also provided a copy of a letter addressed to the Department dated 8/29/14, which showed a copy of the above Confidential Report was also faxed to the Ombudsman and Police Department. However, the letter showed neither agency had responded. The Administrator stated he sent a letter to the Department; however, he was advised the letter was not received by the Department. On 7/29/15 at 1015 hours, the DON joined the interview and concurrent facility document review was conducted. The DON was asked to locate documentation in Resident 4's clinical record to show a clinical assessment had been conducted when the abuse allegation was reported to the facility, but she was unable to do so. The DON referred to a brief note, written on a Post-Fall Assessment form dated 8/22/14. The note did not show the physician or responsible party had been notified and did not address the allegation of abuse. d. Clinical record review was initiated for Resident 5 on 7/29/15. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 5 reported on 8/21/14, she was sitting in her wheelchair when Resident 1 rolled up next to her in his wheelchair and touched the inside of her thigh and tried to move his hand upward toward her groin. The facility failed to ensure a thorough investigation was conducted for the allegation of resident-to-resident abuse for Resident 5 and failed to report the allegation of abuse to the appropriate regulatory agencies. Review of the clinical record for Resident 5 showed a Social Work Progress Note dated 8/21/14, as a late entry for 8/5/14, which showed Resident 5 had confided in her friend regarding the allegation of abuse. The SSD documented she interviewed Resident 5 and Resident 5 repeated the same allegation as above. Further review of Resident 5's clinical record showed no documented evidence of a clinical assessment and no documentation by the IDT to show the allegation of abuse was addressed and investigated. An interview was conducted with the Administrator on 7/29/15 at 0910 hours. The Administrator was asked if an investigation had been completed for Resident 5. The Administrator deferred to the DON. During an interview with the Administrator on 7/29/14 at 1125 hours, the Administrator stated everything was handled through the IDT and anything they had would be in the DON and IDT's notes. Review of Resident 5's Incident Report showed the date of the allegation of abuse was 8/21/14, and the time of the alleged incident was mid-morning. The Incident Report had a section titled Review Findings which showed Resident 5 had a psychological consult completed on 7/23/14. On 7/29/15 at 1220 hours, an interview and concurrent clinical record review for Resident 5 was conducted with the DON. The DON was asked to locate the IDT notes which addressed Resident 5's allegation of abuse and the IDT's recommendations. The DON was asked if a clinical assessment had been conducted by nursing and if the physician and responsible party had been notified. The DON was unable to find the requested documentation in Resident 5's clinical record. e. The facility reported a resident-to-resident allegation of abuse for Resident 5 on 4/27/15. The Investigation Summary dated 5/1/15, showed the facility was unable to substantiate the allegation. The allegation showed Resident 5 verbally threatened Resident 11 by saying I should just kill you and your boyfriend. The Administrator was unable to provide any other documented evidence to show the allegation was thoroughly investigated. Review of Resident 5's clinical record did not show the IDT addressed the allegation of abuse or show any interventions or recommendations. An interview was conducted with the DON on 8/11/15 at 1400 hours. The DON was asked to locate the information regarding the resident-to-resident allegation of abuse. The DON was unable to provide any other information. The DON stated the Administrator had conducted the investigation. 2.a. Review of an SOC 341 dated 8/2/15, showed a resident-to-resident allegation of abuse between Resident 16 and Resident 9, which occurred on 8/1/15. The facility reported Resident 9 alleged she was slapped in the face by Resident 16 when she asked to pass by her in the hallway. Review of the facility's investigation summary regarding the incident with Resident 9 on 8/1/15, dated 8/9/15, showed it was not completed timely. Review of a Post-Fall assessment dated [DATE], did not show the details of the incident and what steps were taken on the resident's behalf. b. Review of an SOC 341 dated 8/4/15, showed on 8/3/15, Resident 8 was hit by Resident 16 on her right arm/hand. Review of the facility's Investigation Summary dated 8/10/15, showed Resident 8 was visiting with another resident in the doorway of the other resident's room when she felt a slap on her right hand. Review of a Post-Fall Assessment form dated 8/4/15, showed the IDT addressed the incident and recommended Resident 16 be monitored as a 1:1 (one to one) until the resident was assisted to bed at bedtime. The Administrator confirmed he did not conduct any interviews regarding the allegation of abuse between Resident 16 and 8 on 8/4/15. The Administrator stated that was the second time in two days Resident 16 had struck another resident. On 8/21/15 at 1214 hours, the facility reported a second resident-to-resident abuse allegation between Residents 16 and 8 and the resident-to-resident abuse allegations between Residents 16 and 10 and between Residents 16 and 13. c. The facility reported Resident 16 was being wheeled by a caregiver in the hallway on 8/20/15. When Resident 16 was being wheeled past Resident 8, Resident 16 struck Resident 8 on the left shoulder with her fist. Review of the investigation documents provided by the facility showed page two of a two-page document dated 8/21/15. The document contained information to show the authorities were notified of the resident-to-resident abuse allegation on 8/20/15. A short-term care plan problem dated 8/21/15, showed there were two incidents of resident-to-resident abuse from the previous week reported to the facility on [DATE]. The facility reported a resident-to-resident abuse allegation between Residents 8 and 16 on 8/21/15 at 1214 hours. The facility reported Resident 8 was walking in the hallway when a caretaker was pushing Resident 16 in her wheelchair from behind. Resident 8 reported Resident 16 struck Resident 8's left shoulder blade with her fist as she approached her. Review of an internal facility document dated 8/21/15, showed Resident 16's caregiver witnessed the allegation of abuse. On 8/27/15, the facility provided the second page of a two page document which showed the authorities were to be notified of the incident on 8/21/15. Contents of the missing first page were unknown. The narrative report showed Resident 16 was coming up the hallway behind Resident 8, being pushed by a caregiver. As the caregiver started to push Resident 16's wheelchair around Resident 8, Resident 16 struck Resident 8's left upper shoulder blade with her left fist. As of 9/1/15 (11 days after the facility reported the allegation of abuse to the Department), the Department had not received an investigation summary of findings as required by the regulatory requirement and facility's P&P. On 8/11/15 at 1525 hours, an interview was conducted with Resident 8. Resident 8 stated while she was across the hall visiting with another resident, Resident 16 went into her room and ate two of her bananas and the banana peels were on the floor. Resident 8 stated Resident 16 also ate her raisins, two chocolate bars, and two cups of miniature chocolates that she kept in the drawer of her bedside table. Resident 8 stated later on the same day, she was visiting another resident while sitting in her wheelchair which was located in the doorway to a resident's room. Resident 8 stated her elbow rested on the arm of the wheelchair and her lower right arm and hand were flexed upwards. Resident 16 came from behind and used the side of her hand by her little finger to whack my hand between the thumb and index finger. Resident 8 stated she spontaneously reacted by swinging her hand backwards and she thought she hit Resident 16. Resident 8 stated, I think she (Resident 16) was angry with me because I told staff about her eating my candy. The incident was witnessed by Resident A. On 8/17/15 at 1135 hours, an interview was conducted with Resident A. Resident A recalled the incident and confirmed what Resident 8 described above. Resident A stated Resident 16 was mean; she (Resident 16) also tried to hit her. Resident A was asked to describe what happened. Resident A stated Resident 16 held up her fist and shook it at her, but she (Resident 16) knew she could not get out of her wheelchair to hit her. Resident A stated Resident 16 had also gone into her room and ate the candy she had at her bedside. d. The facility reported Resident 16 struck Resident 10 on the upper left shoulder with her fist while she was talking to Resident 10 after playing bingo on 7/28/15. The facility was notified about the allegation of abuse on 8/20/15. Review of an SOC 341 dated 8/21/15, showed on 8/20/15, Resident 10 reported to the facility Resident 16 struck her on the left shoulder with her fist on 7/28/15. The facility reported the resident-to-resident abuse for Resident 10 on 8/21/15, and provided an Investigation Summary on 8/28/15. The facility failed to ensure the investigation was conducted within 5 days as per the regulatory requirements and facility's P&P. Review of the clinical record documents for Resident 10 showed on 8/20/15, Resident 10 reported to the facility staff that she was struck on the left shoulder by Resident 16 in the afternoon of 7/28/15. Resident 10 stated she was sitting near the nurses' station, talking to Resident 16 when Resident 16 struck her. The clinical record showed no documented evidence Resident 10's physician or responsible party were notified. 3. Clinical record review was initiated for Resident 10 on 8/11/15. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 10 reported a nurse had struck her with papers on 3/9/15, causing an injury to her eye. The facility reported the allegation of abuse on 3/26/15, and an Investigation Summary dated 4/1/15. The facility failed to ensure a thorough investigation was conducted. Review of Resident 10's clinical record showed no documented evidence of a clinical assessment, no IDT assessment or IDT recommendations, and no documentation the physician and responsible party were notified. An interview was conducted with the DON on 8/11/15 at 1425 hours. The DON was asked for the investigation for Resident 10's allegation of abuse, and the DON stated she was not familiar with Resident 10's investigation. The DON stated the Administrator did the investigation. An interview and concurrent clinical record review was conducted with the Administrator on 8/11/15 at 1515 hours. The Administrator stated Resident 10 had a fall on 3/12/15, and was sent to the hospital emergency department. Resident 10 informed the staff at the hospital that she was hit by a nurse at the facility. The Administrator stated the police came to the facility; however, there was no documented evidence of the date and time the police came to the facility. The Administrator stated the interviews were done and the findings were unsubstantiated. The Administrator was unable to provide documentation for the investigation findings which concluded the allegation of abuse was unsubstantiated. When asked for any other clinical documentation, the Administrator stated the DON handled that. The Administrator was unable to show documented evidence of the investigation findings. 4. Clinical record review was initiated for Resident 11 on 8/11/15. Resident 11 was admitted to the facility on [DATE]. Resident 11 had reported on 4/26/15, her roommate stated, maybe I should just kill you and your boyfriend. The facility reported the resident-to-resident allegation of abuse on 4/27/15, and the Investigation Summary dated 5/1/15. The Investigation Summary concluded the facility was unable to substantiate the allegation. When asked about the