Every finding on record at Montello Care Center

Based on observation, interview, and record review, the facility did not ensure that residents admitted without a pressure injury (PI) did not develop pressure injuries and did not ensure residents are provided cares and services consistent with professional standards of practice to prevent the development or worsening of PI for 1 of 3 residents (R3) reviewed for pressure injuries.R3 was admitted to the facility with an open area. The facility failed to complete skin assessments, wound assessments, and obtain treatment orders; R3 developed a stage 3 pressure injury.Evidenced by:The American Medical Directors Association (AMDA) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PIs in the following categories: Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location.The facility's policy titled Pressure Injury Prevention and Management no date, states in part .c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented.5. Monitoring: a. The RN (Registered Nurse) Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record.The facility's policy titled Skin Assessment no date, states in part .1. A full body, or head to toe, skin assessment will be conducted by a licensed nurse upon admission/re-admission, daily for three days, and weekly thereafter.7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document any identified wound(s), as discovered, to include type of wound, wound measurements, color, type of tissue in wound bed, drainage, odor, pain, etc.R3 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, type 2 diabetes mellitus, generalized anxiety disorder, and chronic pain syndrome.R3's most recent Minimum Data Set (MDS) dated [DATE] states that R3 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R3 is cognitively intact.R3's admission Body Check Form dated 6/4/26 states in part .chronic OA (open area) R (right) poserrior [sic] thigh- tx (treatment) in place. The form also includes a diagram of a body with a circle drawn around an X labeled OA near the left gluteal fold.It is important to note that Surveyor requested R3's admission wound assessment documentation and physician's order for treatment, and none was provided. Additionally, Surveyor requested R3's weekly skin checks that correspond with their shower, the facility was unable to provide R3's weekly skin checks.Wound Management Detail Report states in part: Observation: Date/Time Observed Pressure Ulcer: 6/19/26 11:18Length - head to toe direction (centimeters): 4.5Width- side to side direction (centimeters): 8Can depth be measured?: YesDepth (measure deepest part of visible wound (centimeters): 0.3Exudate Amount: ModerateExudate color and consistency: Serosanguineous (pale red to pink, thin and watery)Wound odor present?: NoStage: Stage 3Undermining present?: NoSinus tract/tunneling present: NoTissue type: Granulation tissuePercent of wound covered by granulation tissue: 100Wound edges/margins: Irregular wound edges; Well defined wound edgesSkin surrounding wound: Assess within 4cm (centimeters) of wound edge: Erythema (redness)/blanchableIs wound vac present?: NoComments: Initial evaluation. 100% pale-beefy red granulation tissue. No slough.Physician Assistant (PA)) order dated 6/19/26 states Wound care: Pressure injury of right gluteal cleft: Cleanse with soap and water, pat dry, apply oil emulsion cut to fit open area, f/b (followed by) calcium alginate cut to fit, secure with bordered foam. Change three times a week and as needed for soilage or rolling. [DX (Diagnosis): Pressure ulcer of right buttock, stage 3] .Of note, R3 went 15 days without a comprehensive wound assessment with measurements or treatment being ordered.On 8/5/26 at 9:58 AM, Surveyor interviewed LPN C (Licensed Practical Nurse). Surveyor asked LPN C what the process is for weekly skin checks, LPN C stated that they have body audit forms at the nurse's station and after the resident finishes their shower, the nurse will go in and observe their skin. Surveyor asked LPN C if they observed R3's skin yesterday (scheduled shower day and shift), LPN C stated that they didn't think R3 gets a shower on day shift.On 8/5/26 at 10:36 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when they were made aware of R3's pressure injury, DON B stated 6/19/26. Surveyor asked DON B if there was any additional documentation of R3's open area on admission, DON B stated no. Surveyor asked DON B what the process is when a resident is admitted to the facility with an open area/wound, DON B stated they would get measurements, it goes into the wound manager and to make sure there is a treatment in place. DON B stated they would also expect an in-depth description of the wound. Surveyor asked DON B what the expectation for weekly skin checks are if a resident refuses their shower, DON B stated that the skin check should still be completed.The facility failed to ensure that a resident that was admitted with an open area received care in conjunction with the standards of practice.

Based on interview and record review, the facility did not ensure that residents' total program of care to include all physician visit notes were completed for 4 of 4 residents (R2, R3, R4, and R5) reviewed.R2's medical record does not include the required physician visit notes.R3's medical record does not include the required physician visit notes.R4's medical record does not include the required physician visit notes.R5's medical record does not include the required physician visit notes.Evidenced by:The facility policy, Physician Visits and Physician Delegation, dated, 2025, states, in part;.It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents.The physician should:.Date, write and sign a progress note for each visit.The Medical Director should: a. Visit residents who are not seen by their attending physician or alternate physician according to schedule.Document a progress note and orders for care as needed.Example 1:R2 was admitted to the facility on [DATE].On 8/4/26 at 2:22 PM, Surveyor interviewed R2. Surveyor asked R2 if their MD (Medical Doctor) comes to the facility to visit them, R2 stated that they used to, but they haven't come in a while. Surveyor asked R2 if their MD is the facility's Medical Director, R2 stated yes.It is important to note R2's medical record does not include the routine MD visits. Surveyor requested documentation and facility did not provide documentation.Example 2R3 was admitted to the facility on [DATE].On 8/4/26 at 2:30 PM, Surveyor interviewed R3. Surveyor asked R3 if their MD comes to the facility to see them, R3 stated no. Surveyor asked R3 if they know their MD's name, R3 stated that when they were admitted , the facility told them they have doctors that come to the building.It is important to note R2's medical record does not include the routine MD visits. Surveyor requested documentation and facility did not provide documentation.Example 3R4 was admitted to the facility on [DATE]. It is important to note R4's medical record does not include the routine MD visits. Surveyor requested documentation and facility did not provide documentation.Example 4:R5 was admitted to the facility on [DATE]. It is important to note R5's medical record does not include the routine MD visits. Surveyor requested documentation. Facility provided the initial 30-day MD visit, but no other MD visits were provided.On 8/5/26 at 3:40 PM, Director of Nursing (DON) B, indicated she would expect the MD visits to be documented in the resident progress notes. DON B indicated typically the MD notes will pull over to the facility system and if the documentation and visit occurred it would be under resident progress notes. DON B indicated DON B typically looks at the Physician Assistant notes in the resident progress notes, but she has never looked for the MD visit notes. DON B indicated understanding of the above concerns.The facility failed to ensure all residents MD visit notes were in the resident medical record.

Based on interview and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal, and oral hygiene for 1 of 3 Residents (R3) out of a sample of 5 residents.R3 reported to Surveyor that they are not receiving scheduled showers.Evidenced by:The facility's policy titled Activities of Daily Living (ADLs) no date, states in part .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care.3. A resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, and personal hygiene.R3 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, type 2 diabetes mellitus, generalized anxiety disorder, and chronic pain syndrome.R3's most recent Minimum Data Set (MDS) dated [DATE] states that R3 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R3 is cognitively intact. R3's care plan dated 6/4/26 states in part .Problem: Category: ADLs Functional.My ability to dress and toilet without assistance is limited d/t (due to) weakness and need for staff assistance.Approach: x1 staff assistance with dressing and personal hygiene.Per the facility's Weekly Shower/Bath Schedule R3 is scheduled to have their shower on Tuesday and Saturday AM (day) shift.R3's shower documentation is as follows:6/6/26: refused6/9/26: refused6/13/26: no documentation6/16/26: received shower6/20/26: no documentation6/23/26: wants [CNAs name] to do shower- no documentation that shower was given.6/27/26: wants [CNAs name] to do shower- no documentation that shower was given.6/30/26: no documentation7/4/26: no documentation7/7/26: prefers [CNAs name] to do shower- Refused7/11/26: no documentation7/14/26: received shower7/18/26: no documentation7/21/26: no documentation7/25/26: no documentation7/28/26: no documentation8/1/26: no documentation8/4/26: no documentationIt is important to note that out of 18 opportunities, R3 has refused a shower 3 times and has been showered 2 times.On 8/5/26 at 9:12 AM, Surveyor interviewed R3. Surveyor asked R3 if they had been receiving their showers as scheduled, R3 stated no and they haven't gotten a shower in a while.On 8/5/26 at 10:36 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how they track to ensure that showers are being completed, DON B stated that they go by the body check sheets. Surveyor asked DON B if there is any follow up if a resident refuses or is not provided with a shower, DON B states that another shower should be offered, but they are not tracking showers.The facility did not ensure that residents were receiving showers as scheduled.

Based on observation, interview, and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (R1) reviewed.R1 was admitted to the facility with wounds on their bilateral lower extremities. R1 missed their appointment with the wound care clinic, and the facility does not have documentation that wound care was completed with current wound care orders.Evidenced by:The facility's policy titled Wound Treatment Management no date, states in part .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.7. Treatments will be documented on the Treatment Administration Record or in the electronic health record.R1 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, depression, type 2 diabetes mellitus with foot ulcer, and unspecified protein-calorie malnutrition.R1's wound care order dated 6/1/26 states: Wound care per podiatry: apply xeroform, ABD (abdominal pad) to left heel and secure with webril and tape; cleanse right lateral lower leg with saline and pat dry, apply skin prep to peri wound, apply calcium alginate to wound base and cover with bordered foam; treatment to be done 3 times weekly.On 6/4/26, R1 saw the podiatrist. Documentation states: R (right) 2,3 gangrenous changes. Stage 4 DTI (Deep Tissue Injury) L (left) heel, not acutely infected. QOD (every other day) dressing chx (change) B/L LE (lower extremities). Urgent vascular sx (symptoms) follow up. [City name] Wound Clinic f/u (follow up).On 6/11/26, R1 went to the wound clinic. Wound care notes state in part .L (Left) heel: 4.0 cm (centimeters) x 2 cm x 0.2 cm. L calf: 7.0 cm x 3.3 cm x 0.1 cm. R lateral shin: 1.0 cm x 0.9 cm x 0.1 cm. R 3 (third) digit: circumferential black/purple.Dressings: .R aquacel extra small x2 on both sides of the 3rd digit between the toes, Alevyn 4x4 to the lateral shin, loosely applied roll gauze and coban to secure dressings. L Allevyn 4x4 x2 to heel and calf, loosely applied gauze roll and coban to secure dressings.I did encourage him to keep dressings in place until his next appointment on Monday. He can have nursing staff redress the wounds if they are following[sic] off or draining through.Wound clinic orders dated 6/11/26 state in part: . Next appt (appointment) 6/15/26 8:30 AM. Recommendation / follow-up: Keep the dressings on place [sic] and dry. Can change dressing if draining through but keep in place until next visit if not draining.It is important to note that the facility did not obtain the provider's notes until 6/15/26 at 12:46 PM and did not implement the changes in the orders or get clarification on the orders/ dressings used at the wound care visit.On 8/4/26, Surveyor reviewed R1's nurses notes and Medication Administration Record/ Treatment Administration Record (MAR/TAR). There was no documentation on 6/15/26 indicating that R1's dressings were changed due to their missed appointment with the wound clinic. R1's MAR/TAR wound care documentation for 6/15/26 states in part .Not administered: On hold Comment: per wound clinic.On 8/4/26 at 3:55 PM, Surveyor interviewed DON B (Director of Nursing). DON B reported that R1 had missed their appointment with the wound clinic on 6/15/26 due to a mix up with the transportation company and R1's appointment time. Surveyor asked DON B if R1's wound care was provided, DON B stated yes and that the LPN (Licensed Practical Nurse) had completed wound care that afternoon. Surveyor asked DON B why the MAR/TAR states that wound care was not completed, DON B stated that it was done but was not documented.On 8/5/26 at 1:29 PM, Surveyor interviewed LPN D. Surveyor asked LPN D about R1's wound care appointment on 6/15/26, LPN D stated that there was a mix up with their transportation, so R1 missed the appointment. Surveyor asked LPN D if they provided wound care to R1 after the missed appointment, LPN D stated that initially they had marked R1's MAR/TAR that wound care was not done due to their appointment, but after the appointment was missed, LPN D stated that they were instructed to perform R1's wound care. Surveyor asked LPN D if they documented the wound care provided, LPN D stated they couldn't remember.On 8/5/26 at 3:00 PM, Surveyor interviewed DON B. Surveyor asked DON B if wound care is provided, should staff be documenting it, DON B stated yes.The facility did not ensure that residents that require wound care, have wound care provided as ordered.

Based on interview and record review, the facility did not ensure residents were seen by a physician every 30 days for the first 90 days after admission and at least every 60 days thereafter for 3 of 4 residents (R2, R3, and R5) reviewed for physician visits out of a total sample of 5 residents.R2 did not see an MD every 30 days for the first 90 days after admission.R3 did not see an MD every 30 days for the first 90 days after admission.R5 did not see an MD every 30 days for the first 90 days after admission.Evidenced by:The facility policy, Physician Visits and Physician Delegation, dated 2025, states, in part;.It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents.The physician should: See resident within 30 days of initial admission to the facility.The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State law.Example 1:R2 was admitted to the facility on [DATE].On 8/4/26 at 2:22 PM, Surveyor interviewed R2. Surveyor asked R2 if their MD (Medical Doctor) comes to the facility to visit them, R2 stated that they used to, but they haven't come in a while. Surveyor asked R2 if their MD is the facility's Medical Director, R2 stated yes.Example 2:R3 was admitted to the facility on [DATE].On 8/4/26 at 2:30 PM, Surveyor interviewed R3. Surveyor asked R3 if their MD comes to the facility to see them, R3 stated no. Surveyor asked R3 if they know their MD's name, R3 stated that when they were admitted , the facility told them they have doctors that come to the building.Example 3:R5 was admitted to the facility on [DATE]. It is important to note R5's medical record does not include the routine MD visits. Surveyor requested documentation. Facility provided the initial 30-day MD visit, but no other MD visits were provided.On 8/5/26 at 3:40 PM, Director of Nursing (DON) B, indicated she would expect residents to see MD for the first 30, 60, and 90 days, and every 60 days thereafter. DON B and Surveyor reviewed facility policy and DON B indicated understanding. DON B indicated DON B typically looks at the Physician Assistant notes in the resident progress notes but has never looked for the MD visit notes. DON B indicated understanding of the above concerns.The facility did not ensure residents were seen by a physician every 30 days for the first 90 days after admission and at least every 60 days thereafter.

Based on interview and record review, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 4 of 4 (R1, R2, R3, and R4) residents reviewed. The facility did not obtain podiatry visit notes for R1. The facility did not obtain timely wound care visit notes for R1. The medical records for R2, R3, and R4 do not include any MD routine visit notes. Evidenced by: The facility did not provide a medical records policy. Example 1: R1 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, depression, type 2 diabetes mellitus with foot ulcer, and unspecified protein-calorie malnutrition. On 6/4/26, R1 saw the podiatrist. The facility has not obtained the podiatry visit notes. On 6/11/26, R1 went to the wound clinic. The facility did not obtain the provider's notes until 6/15/26 at 12:46 PM and did not implement the changes in the orders or get clarification on the orders/ dressings used at the wound care visit. Example 2: R2 was admitted to the facility on [DATE]. On 8/5/26 Surveyor requested R2's MD routine visit notes. The facility did not provide the routine MD visit notes. The facility sent additional documentation on 8/8/26, the additional information did not include R2's routine MD visit notes. Example 3: R3 was admitted to the facility on [DATE]. On 8/5/26 Surveyor requested R3's MD routine visit notes. The facility did not provide the routine MD visit notes. The facility sent additional documentation on 8/8/26, the additional documentation did not include R3's routine MD visit notes. Example 4: R4 was admitted to the facility on [DATE]. On 8/5/26 Surveyor requested R4's MD routine visit notes. The facility did not provide the routine MD visit notes. The facility sent additional documentation on 8/8/26, the additional documentation did not include R4's routine MD visit notes. On 8/5/26 at 3:40 PM, Director of Nursing (DON) B indicated she would expect the MD visits to be documented in the resident progress notes. DON B indicated typically the MD notes will pull over to the facility system and if the documentation and visit occurred it would be under resident progress notes. DON B indicated DON B typically looks at the Physician Assistant notes in the resident progress notes, but she has never looked for the MD visit notes. DON B indicated understanding of the above concerns. The facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized.

Based on interview and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 3 residents (R2 & R3) reviewed for medication errors. R3 did not receive her ordered morphine tablet on 5/28/26 (PM), 5/29/26 (AM), 5/29/26 (PM), and 5/30/26 (AM). The morphine was not given as ordered due to the medication being unavailable in the facility. R2 has not received his Trelegy since his admission on [DATE]. This is evidenced by: The facility policy, titled Medication Administration, dated 1/1/26, states in part: .Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation.12. Compare medication source.with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route and time.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. The facility policy, titled Medication Reordering, undated, states in part: Policy: It is the policy of the facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident.Policy Explanation and Compliance Guidelines: 1. The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting.5. In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician. Example 1 R3 was admitted to the facility on [DATE] with diagnoses that include, in part: fibromyalgia (a neurological disorder that causes widespread body pain and fatigue), sciatica – left side (nerve pain that radiates from the back down the left leg), and lumbago with sciatica – right side (lower back pain with nerve pain that radiates down the right leg). R3's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/6/26, indicates her BIMS (Brief Interview for Mental Status) score is 14 out of 15, indicating she is cognitively intact. On 6/8/26 at 12:03 PM, Surveyor spoke with R3. R3 indicated the facility had recently run out of her morphine and she had missed four or five doses of it. Surveyor reviewed R3's MAR from 5/1/26 to 6/8/26 and noted the following: Order: Morphine – Schedule II tablet extended release; 15 mg; Amount to Administer: 1 tablet; oral. Frequency: twice a day. Diagnoses: Fibromyalgia. Start date: 10/9/25. Administration times: Morning (6:00 AM – 10:00 AM) and Evening (7:00 PM – 9:00 PM). -5/28/26 at 7:10 PM: Not Administered: Drug / Item Unavailable -5/29/26 at 9:49 AM: Not Administered: Drug / Item Unavailable -5/29/26 at 7:27 PM: Not Administered: Drug / Item Unavailable -5/30/26 at 8:49 AM: Not Administered: Drug / Item Unavailable Survey reviewed R3's progress notes and did not see any notes pertaining to the morphine being out of stock or reordered. On 6/8/26 at 2:20 PM, Surveyor interviewed RN E (Registered Nurse) regarding reordering medications for residents. RN E indicated staff peels the label off of a medication card and puts it on a sheet that is faxed to the pharmacy. New medications are supposed to come in every night and on the weekends. The facility does not keep a record of the faxes that have been sent. On 6/8/26 at 2:45 PM, Surveyor interviewed MT F (Med Tech) regarding reordering medications for residents. MT F indicated a label is faxed to the pharmacy for narcotic refills and they are delivered to the facility nightly. Surveyor asked MT F about R3's missing morphine doses and MT F referred Surveyor to the ADON (Assistant Director of Nursing) or DON (Director of Nursing). On 6/8/26 at 2:57 PM, Surveyor spoke with ADON C and asked her about R3's missing morphine administrations. ADON C reviewed R3's chart and was unable to find any notes or communication with the doctor regarding the missing doses. ADON C indicated staff should be reordering medications when there are five tablets remaining. ADON C indicated staff could have gotten in touch with the on-call doctor who is available 24/7. ADON C indicated she would have expected that R3 should not have missed four doses of morphine in a row. On 6/8/26 at 3:04 PM, Surveyor spoke with DON B about R3's missing morphine administrations. DON B indicated either staff didn't reorder the medication timely or the prescription was up and the pharmacy didn't notify the facility. DON B indicated she would look into this issue. On 6/8/26 at 3:53 PM, DON B indicated she spoke with the pharmacy and they had no record of notifying the facility that R3's morphine prescription was about to expire with zero refills remaining. As of mid-May, the pharmacy sends lists to the facility with narcotic prescriptions that are expiring soon to ensure they aren't missed. On 6/8/26 at 5:00 PM, Surveyor spoke with DON B. DON B indicated the floor nurse is responsible for reordering medications and the DON or ADON should be contacted if a medication hasn't arrived by the next morning. Surveyor asked if it is the responsibility of the pharmacy or the facility to reorder a medication that has an expiring prescription before it runs out. DON B indicated if the pharmacy notices, they may contact the prescriber, but said she would have expected the facility to follow up and reorder the morphine before R3 ran out of it. Example 2 R2 was admitted to the facility on [DATE] and has diagnoses that include Chronic Systolic Heart Failure (your heart muscle has weakened and lost its ability to squeeze forcefully,) and Chronic Obstructive Pulmonary Disease (long term lung condition that causes permanent damage, making it hard to breathe.) R2's Minimum Data Set (MDS) assessment dated [DATE], indicated that resident has a BIMS (Brief Interview for Mental Status) of 15. This indicates R2 is cognitively intact. R2's Physician orders read: Trelegy Ellipta (fluticasone-umeclidin-vilanter) blister with device; 200-62.5 mcg (microgram); amt (amount): 1 puff; inhalation. Special Instructions: RInse mouth after use with water. Do not swallow. [DX: Chronic obstructive pulmonary disease, unspecified] Once a Day; Morning 0600-1000. Start Date: 5/29/26-6/8/26. (D/C Date) R2's MAR states: 5/30/26-6/8/26; Reason/Comments: Not administered: Drug/Item Unavailable On 6/8/26 at 12:15 PM, Surveyor interviewed RN E, who stated if we don't have a medication in the cart we will check with the ADON (Assistant Director of Nursing) or DON (Director of Nursing) to see if they have any information. I would also call the pharmacy to see if they are sending it. On 6/8/26 at 12:20 PM, Surveyor interviewed ADON C. Surveyor asked ADON C why R2 was not receiving his Trelegy that was ordered. ADON C stated not sure what is going on with Trelegy. It tends to be because of cost and if insurance will pay for it. Surveyor asked ADON C about the note at the bottom of Pharmacy Fill Status sheet saying Pharmacy dispensed drug on 6/2/26 at 12:08. DO NOT SEND PER (DON B's NAME), DON. ADON C indicated to Surveyor, you would have to ask DON B. On 6/8/26 at 12:25 PM, Surveyor interviewed DON B. Surveyor asked DON B, if she can you tell surveyor what is happening with R2's Trelegy order, as it states it is not available. DON B stated I am not sure because I was not here last week. Sometimes this will happen with inhalers, pharmacy will give substitutes and will be on the substitute clipboard, I will have to look and get back to you. On 6/8/26 at 4:03 PM, Surveyor interviewed DON B. Surveyor asked when a medication is not available who is responsible for the follow up. DON B stated the initial follow up if it doesn't come from the pharmacy is the floor nurses. The next day if it is not there then it would be the ADON or myself. Surveyor asked DON B who is responsible for reviewing the MAR and seeing what is happening with the medication. DON stated the ADON or myself (DON B). Surveyor asked DON B in reading this note from the pharmacy it looks like the Trelegy was supposed to be sent out on 6/2/26, can you help me understand why it was not sent out. DON B stated it was either not available or not cost-effective. Surveyor asked DON B would you expect that this medication should have been followed up on with pharmacy when it was not received. DON B stated absolutely.

Based on interview and record review, the facility did not ensure Residents are free of any significant medication errors for 1 of 3 residents (R3) reviewed for medication errors.R3 did not receive her time-sensitive medication during the scheduled administration window 38 times between the dates of 5/1/26 and 6/8/26.This is evidenced by:The facility policy, titled Medication Administration, dated 1/1/26, states in part: .Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation.12. Compare medication source.with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route and time.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.According to the National Institutes of Health National Library of Medicine (www.nih.gov), patients with Parkinson's disease require strict adherence to an individualized, timed medication regimen . Dosing intervals are specific to each individual patient because of the complexity of the disease. When medications are not administered on time and according to the patient's unique schedule, patients may experience an immediate increase in symptoms. Delaying medications . can cause patients with Parkinson's disease to experience worsening tremors, increased rigidity, loss of balance, confusion, agitation, and difficulty communicating. R3 was admitted to the facility on [DATE] with diagnoses that include, in part: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).R3's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/6/26, indicates her BIMS (Brief Interview for Mental Status) score is 14 out of 15, indicating she is cognitively intact.On 6/8/26 at 12:03 PM, Surveyor spoke with R3. R3 indicated she does not always get her medications when they are scheduled.Surveyor reviewed R3's MAR from 5/1/26 to 6/8/26 and noted the following:Order: Carbidopa-Levodopa (medication for managing Parkinson's disease) tablet; 25-100 mg (milligrams); Amount to administer: 2 tablets; oral. Frequency: Four times a day. Administration times: Morning (6:00 AM - 7:00 AM), Noon (11:00 AM - 12:00 PM), Evening (4:00 PM - 5:00 PM), Bedtime (9:00 PM - 10:00 PM). Diagnosis: Parkinson's disease. Start date: 10/9/25.The following Carbidopa-Levodopa administrations for R3 were given late:-5/1/26: 6:00 AM - 7:00 AM dose was administered at 9:28 AM-5/3/26: 9:00 PM - 10:00 PM dose was administered at 12:04 AM on 5/4/26 with the comment: Late Administration: Other / Comment: previous shift.-5/4/26: 6:00 AM - 7:00 AM dose was administered at 9:27 AM-5/4/26: 11:00 AM - 12:00 PM dose was administered at 1:53 PM-5/5/26: 6:00 AM - 7:00 AM dose was administered at 9:57 AM-5/6/26: 6:00 AM - 7:00 AM dose was administered at 8:59 AM-5/7/26: 6:00 AM - 7:00 AM dose was administered at 9:14 AM-5/8/26: 6:00 AM - 7:00 AM dose was administered at 9:13 AM-5/9/26: 6:00 AM - 7:00 AM dose was administered at 8:17 AM-5/9/26: 4:00 PM - 5:00 PM dose was administered at 5:59 PM-5/11/26: 6:00 AM - 7:00 AM dose was administered at 9:10 AM-5/12/26: 6:00 AM - 7:00 AM dose was administered at 9:13 AM-5/13/26: 6:00 AM - 7:00 AM dose was administered at 9:10 AM-5/14/26: 6:00 AM - 7:00 AM dose was administered at 9:29 AM-5/15/26: 6:00 AM - 7:00 AM dose was administered at 8:46 AM-5/19/26: 6:00 AM - 7:00 AM dose was administered at 10:05 AM-5/20/26: 6:00 AM - 7:00 AM dose was administered at 9:01 AM-5/21/26: 6:00 AM - 7:00 AM dose was administered at 9:35 AM-5/22/26: 6:00 AM - 7:00 AM dose was administered at 9:47 AM-5/23/26: 6:00 AM - 7:00 AM dose was administered at 9:32 AM-5/24/26: 6:00 AM - 7:00 AM dose was administered at 8:48 AM-5/25/26: 6:00 AM - 7:00 AM dose was administered at 9:14 AM-5/26/26: 6:00 AM - 7:00 AM dose was administered at 9:29 AM-5/27/26: 6:00 AM - 7:00 AM dose was administered at 9:17 AM-5/28/26: 6:00 AM - 7:00 AM dose was administered at 8:57 AM-5/29/26: 6:00 AM - 7:00 AM dose was administered at 9:49 AM-5/30/26: 6:00 AM - 7:00 AM dose was administered at 8:50 AM-5/31/26: 6:00 AM - 7:00 AM dose was administered at 9:55 AM-6/1/26: 6:00 AM - 7:00 AM dose was administered at 8:27 AM-6/2/26: 6:00 AM - 7:00 AM dose was administered at 9:44 AM-6/4/26: 6:00 AM - 7:00 AM dose was administered at 9:54 AM-6/4/26: 4:00 PM - 5:00 PM dose was administered at 7:16 PM-6/5/26: 6:00 AM - 7:00 AM dose was administered at 9:25 AM-6/6/26: 6:00 AM - 7:00 AM dose was administered at 8:56 AM-6/6/26: 11:00 AM - 12:00 PM dose was administered at 1:34 PM-6/6/26: 4:00 PM - 5:00 PM dose was administered at 6:58 PM-6/7/26: 6:00 AM - 7:00 AM dose was administered at 8:50 AM-6/8/26: 6:00 AM - 7:00 AM dose was administered at 8:49 AM On 6/8/26 at 4:00 PM, Surveyor spoke with LPN D (Licensed Practical Nurse) via telephone, as R3's MAR indicated LPN D had been responsible for 26 of the 38 late Carbidopa-Levodopa administration times. Surveyor asked LPN D about her process for administering medications to residents and charting the administration times. LPN D indicated she prepares the medications and checks given immediately after they are administered. Surveyor asked LPN D if the charting reflects that a medication scheduled from 6:00 AM - 7:00 AM is given at 9:28 AM, is that when it was given? LPN D said yes.On 6/8/26 at 5:08 PM, Surveyor spoke with DON B (Director of Nursing). DON B reviewed the late administration times for R3's Carbidopa-Levodopa. DON B indicated she would expect staff to prioritize giving this medication so it is within the scheduled window. DON B indicated she would work on educating staff about this.

Based on interview and record review the facility failed to ensure therapeutic diets prescribed by the attending physician are entered and followed for 1 of 3 residents reviewed (R1). R1 did not have therapeutic diet entered as ordered. This is evidenced by: The Facilities Policy and Procedure entitled Therapeutic Diet Orders dated 1/1/26 documents in part; The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician .Therapeutic Diet is a diet ordered by a physician .as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease or increase specific nutrients in the diet. Examples include low salt, diabetic, or low cholesterol diets . R1 was a short-term admission to the facility and was admitted on [DATE]. R1 has the following diagnoses: metabolic encephalopathy (altered brain function or structure caused by systemic chemical imbalances, organ failure, or toxins), chronic obstructive pulmonary disease (long-term lung condition), systolic (congestive) heart failure (heart's left ventricle weakens and can't contract forcefully enough to pump adequate, oxygen-rich blood to the body), persistent atrial fibrillation (continuous irregular heart rhythm), essential (primary) hypertension (chronic blood pressure), coronary atherosclerosis due to lipid rich plaque (fatty, cholesterol-filled deposits have built up in the heart's arteries), hyperlipidemia (high cholesterol and triglyceride levels), type 2 diabetes mellitus with neuropathy, morbid (severe) obesity due to excess calories (chronic condition where the body stores more calories as fat than it burns during daily energy expenditure), and primary pulmonary hypertension (rare, progressive lung disorder characterized by high blood pressure in the pulmonary arteries). R1's After Visit Summary, dated 4/19/26-4/27/26 has a section on page two that documents, in part: Read these attachment, Carbohydrate Counting for Diabetes Mellitus Adult (ENGLISH), Fluid Restriction (ENGLISH) . R1's Hospital Discharge summary dated [DATE] has R1's diet listed as Diet: cardiac. R1's physician orders at the facility dated 4/27/26 documents .Diet: Controlled Carbohydrate Diet . (Of note this order does not match R1's hospital discharge paperwork, no documentation was provided regarding a provider changing R1's diet from cardiac to controlled carbohydrate.) On 6/8/26 at 4:43 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B What diet order R1 has documented in the discharge summary, DON B said cardiac. Surveyor asked DON B where the order for the controlled carbohydrate diet came from, DON B replied she would need to look into that. On 6/8/26 at 5:08 PM, Surveyor interviewed DON B. Surveyor asked DON B what she found out about the diet that was entered in for R1, DON B explained that she thinks the staff read the After Visit Summary document where on page 2 it has Carbohydrate Counting for Diabetes Mellitus. Surveyor asked DON B if R1 should have had cardiac diet entered based on his discharge summary, DON B stated yes.

Based on staff interview and record review, the facility did not provide adequate supervision for 1 resident (R) (R7) of 3 sampled residents who expressed suicidal ideation and threats of self-harm. On 4/19/26, R7 expressed suicidal ideation and was placed on 15-minute checks for 72 hours which the facility failed to complete in full. On 4/22/26, R7 pulled the call light out of the wall and threatened to wrap the cord around R7's neck. The facility failed to implement increased supervision for R7 despite the threats of self-harm. On 4/23/26, R7 was found with the call light cord wrapped around R7's neck. The facility's failure to provide adequate supervision after R7 expressed suicidal ideation and self-harm created a finding of immediate jeopardy that began on 4/22/26. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 5/4/26 at 4:35 PM. The immediate jeopardy was removed on 5/11/26; however, the deficient practice continues at a scope/severity level D (Potential for Harm/Isolated) as the facility continues to implement its action plan.Findings include:The facility's Suicide Prevention policy, dated 1/1/2026, indicates: It is the policy of the facility to act quickly and appropriately if a resident expresses thoughts of suicide. Compliance guidelines indicate: 1. All staff members will immediately report any suicidal ideation to the resident's charge nurse and the Social Worker. 2. Immediately notify the resident's physician if the resident presents with suicidal ideation, even if they are not specific about a plan/intent. 3. If applicable, notify the resident's responsible party of the resident's suicidal ideation. 4. The resident will not be left alone. One-on-one care will be provided after an attempt is made until they receive emergency psychiatric care or until a physician determines the risk of suicide is no longer present. 5. Objectively document the resident's mood and behaviors as well as all actions taken in the medical record.R7 was admitted to the facility on [DATE] with diagnoses to include type II diabetes, neuropathy, depression, and chronic pain. R7's most recent Minimum Data Set (MDS) assessment, dated 4/6/26, stated R7's Brief Interview for Mental Status (BIMS) score was 9 out of 15, indicating moderate cognitive impairment. R7's Power of Attorney for Healthcare (POAHC) was activated during this admission.A care plan, initiated 4/2/26, contained a goal for R7 to adjust comfortably to the facility. The care plan contained interventions to check in with R7 to see how R7 was adjusting, describe the layout of the facility, and accompany R7 to meals/therapy/bathroom/activities/etc., as needed.A hospital Discharge summary, dated [DATE], indicated R7 had a diagnosis of depression and was prescribed sertraline 25 milligrams (mg) daily.A progress note, dated 4/6/26, indicated R7 experienced confusion and hallucinations and called out frequently. A urinalysis was negative for a urinary tract infection (UTI). A progress note, dated 4/8/26, indicated R7 was confused and calling out.A progress note, dated 4/19/26, indicated R7 was screaming, rude, argumentative, and disturbing other residents.A progress note, dated 4/19/26 at 3:13 PM, indicated R7 expressed suicidal ideation and stated R7 was going to kill themself. R7 was placed under close observation and monitored for safety and changes in behavior.A progress note, dated 4/20/26 at 1:16 AM, indicated R7 had episodes of screaming at night, wanting to know R7's whereabouts, wanting to go home, and using foul/argumentative language. R7 remained on 15-minute checks. A progress note, dated 4/20/26 at 8:30 AM, stated R7 felt down and wished R7 was dead. R7 was moved to a room closer to the nurses' station for monitoring and was placed on 15-minute checks for 72 hours. R7 expressed frustration with changes, including the inability to walk independently and not be home. (Of note: Surveyor reviewed documentation of R7's 15-minute checks. Documentation began on 4/19/26 at 2:00 PM and was completed on 4/21/26 at 10:00 PM which was 56 hours instead of 72 hours.)A physician visit note, dated 4/20/26 and written by Primary Care Provider (PCP)-I, indicated R7's urine culture was negative for a UTI. R7 had a recent increase in behaviors which occurred more in the evening. R7 became more aggressive and exhibited suicidal ideation after R7's spouse (POAHC-K) left the facility in the evening. The note indicated R7's behavior could be more in line with anxiety or another Diagnostic and Statistical Manual (DSM)-V (the principal authority for psychiatric diagnoses) diagnosis psychosis. The note indicated R7 had suicidal ideation on the evening of 4/19/26 and the possibility of cognitive behavioral therapy (CBT) would be explored via consult. (Of note: The recommendation for CBT was not explored.)R7's care plan was updated on 4/22/26 to include behavior symptoms. The care plan indicated R7 made accusations of self harm or of a negative nature triggered by POAHC-K leaving the facility. The care plan contained interventions to notify R7's PCP if R7 mentions suicidal thoughts, offer 1:1 conversation following negative statements, and figure out when R7 is upset and offer activities of liking when POAHC-K leaves to help distract from negative thoughts. (Of note: R7's care plan did include threats of self-harm or behaviors due to R7's spouse leaving in the evening prior to the update on 4/22/26. R7 also did not have a care plan related to depression or antidepressant medication.)On 5/4/26 at 1:45 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C regarding R7's suicidal ideation and behavior. CNA-C verified CNA-C observed R7 yelling in R7's room at approximately 10:00 PM on 4/22/26. R7 pulled the call light out of the wall, attempted to hit CNA-C with it, and stated R7 wanted to kill themself and was going to wrap the call light cord around R7's neck. CNA-C reported the incident to agency Licensed Practical Nurse (LPN)-J. CNA-C stated R7 was not on increased supervision or 15-minute checks at that time.On 5/4/26 at 1:07 PM and 4:12 PM and on 5/5/26 at 9:02 AM, Surveyor attempted to call LPN-J and left voicemails. The calls were not returned as of this writing. A physician visit note, dated 4/22/26, indicated PCP-I would continue sertraline 25 mg for R7; however, if R7's behaviors continued to increase after POAHC-K left at night, PCP-I would consider the use of quetiapine 50 mg at night for a behavioral component (not purely dementia-related).On 5/4/26 at 11:12 AM, Surveyor interviewed CNA-D regarding R7's suicidal ideation. CNA-D verified CNA-D found R7 on the morning of 4/23/26 at approximately 7:00 AM with the call light cord wrapped twice around R7's neck. R7 was screaming that R7 wanted to kill themself. CNA-D stated Director of Nursing (DON)-B was notified and staff contacted Emergency Medical Services (EMS). CNA-D was told during report at the start of the 4/23/26 AM shift that R7 yelled that R7 wanted to kill themself and hit staff with the call light on the 4/22/26 PM shift. CNA-D verified R7's behavior and suicidal ideation increased when POAHC-K left the facility in the evening. CNA-D did not think R7 was on increased supervision after expressing suicidal ideation on the evening of 4/22/26. (Of note: R7's medical record did not contain progress notes related to the incidents on 4/22/26 or 4/23/26.)On 5/4/26 at 3:20 PM, Surveyor interviewed LPN-H regarding R7's suicidal ideation and behavior. LPN-H verified LPN-H worked the NOC shift from 4/22/26 to 4/23/26. LPN-H indicated R7 was upset on 4/22/26 at the beginning of LPN-H's shift and confirmed LPN-H had to replace R7's call light because R7 ripped it out of the wall. LPN-H verified R7 was not on 15-minute checks/increased supervision during the shift. On 5/4/26 at 3:01 PM, Surveyor interviewed DON-B regarding R7's suicidal ideation and behavior. DON-B verified staff discovered R7 screaming with the call light cord wrapped around R7's neck on the morning of 4/23/26. EMS was notified and R7 was hospitalized . DON-B was not aware of any other instances (other than 4/19/26) in which R7 made suicidal comments. DON-B verified R7 should have been on 15-minute checks from 4/19/26 through 4/22/26 (72 hours) and could not provide documentation for the missing 16 hours.On 5/4/26 at 10:58 AM, Surveyor interviewed NHA-A regarding R7's suicidal ideation. NHA-A verified CNA-D found R7 on 4/23/26 at approximately 7:00 AM with the call light cord wrapped around R7's neck. NHA-A stated R7 made suicidal comments on 4/19/26, however, NHA-A was not aware R7 made any other threats of self-harm. NHA-A verified R7 was sent to the hospital on 4/23/26 because NHA-A thought R7 was actively suicidal, and the facility could not meet R7's mental health needs.The failure to provide adequate supervision for a resident who expressed suicidal ideation created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on 5/11/26 when it completed the following:1. Reviewed all residents with a history/diagnosis of depression and suicidal ideation and implemented/reviewed/revised care plans.2. Implemented Suicide Prevention and Suicide Assessment policies and reviewed them with the Medical Director.3. Completed staff education, including suicide assessment and prevention basics, shift-to-shift report, security checks, notification, care plan updates, and increased supervision/1:1 monitoring.4. Initiated 24-hour report board audits 5 times per week for behavioral changes in condition and/or comments that could be interpreted as suicidal ideation or increasing depression.

Based on staff interview and record review, the facility did not ensure resident-to-resident altercations and a potential allegation of abuse were thoroughly investigated for 6 residents (R) (R3, R4, R1, R2, R5, and R6) of 6 sampled residents. On 2/16/26, R3 and R4 were involved in a resident-to-resident altercation. The facility did not thoroughly investigate the altercation. On 2/24/26, R1 and R2 were involed in a resident-to-resident altercation. The facility did not thoroghly investigate the altercation. In addition, the facility's investigation indicated R2 would be on 1:1 supervison. The facility did not have documentation that 1:1 supervision was provided for R2. On 4/22/26, R5 and R3 were involved in a resident-to-resident altercation. The facility did not thoroughly investigate the altercation. On 2/21/26, R6 reported a staff member was aggressive during peri-care. The facility did not thoroughly investigate the potential allegation of abuse. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 1/2026, indicates: .V. Investigation of Alleged Abuse, Neglect, and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. B. Written procedures for investigations include: .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations . 1. On 5/4/26, Surveyor reviewed R3's medical record. R3 had diagnoses including dementia, mild cognitive impairment, unspecified mood disorder, insomnia, anxiety, and emotional liability and mood disorder. R3's Minimum Data Set (MDS) assessment, dated 4/20/26, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R3 had severe cognitive impairment. R3 had an activated Power of Attorney for Healthcare (POAHC). On 5/4/26, Surveyor reviewed R4's medical record. R4 had diagnoses including dementia, anxiety, major depressive disorder, and unspecified psychosis. R4's MDS assessment, dated 2/23/26, had a BIMS score of 2 out of 15 which indicated R4 had severe cognitive impairment. R4 had an activated POAHC. On 5/4/26, Surveyor reviewed a facility-reported incident (FRI) submitted to the State Agency (SA) that indicated on 2/16/26 at approximately 4:30 PM, R3 self-propelled a wheelchair toward the lobby and bumped into R4's wheelchair. A staff who witnessed the incident was not sure if R3 grabbed the back of R4's wheelchair or if R3 accidentally bumped R4's shoulder. R3 told R4 to get out of the way. R4 turned and swatted at R3. Initially, it was reported that R4 swatted at R3's head; however, further investigation determined R4 swatted at R3's forearm. The investigation included interviews with R3 and R4, but did not include interviews with other residents who may have witnessed the incident or experienced a similar occurrence. (See interview under example 4.) 2. On 5/4/26, Surveyor reviewed R1's medical record. R1 had diagnoses including anoxic brain damage, depression, and anxiety. R1's MDS assessment, dated 3/16/26, had a BIMS score of 5 out of 15 which indicated R1 had severe cognitive impairment. R1 had an activated POAHC. On 5/4/26, Surveyor reviewed R2's medical record. R2 had diagnoses including neurocognitive disorder with Lewy Body, anxiety, unspecified psychosis, and insomnia. R2's MDS assessment, dated 1/26/26, had a BIMS score of 00 of 15 which indicated there was an inability to assess R2 due to cognitive impairment. R2 had an activated POAHC. On 5/4/26, Surveyor reviewed a FRI submitted to the SA that indicated on 2/24/26 at 4:26 PM, R1 and R2 were in a lounge where residents congregate while waiting for meals. R2 backed up R2's wheelchair to move around other residents and accidently backed into R1 who yelled move it. Staff attempted to deescalate the situation. R1 moved R1's hand in a grabbing motion toward R2. When R1 touched R2, R2 moved R2's arms in a swinging motion. Staff attempted to separate R1 and R2 and were not sure if the swinging motion resulted in contact. R2 was agitated upon separation and after a cool down period. R2 was placed on 1:1 supervision until a review was completed and R2's behaviors decreased. The 24-hour report board indicated to monitor R1 and R2. Overstimulation of R2 was determined to be the root cause. The facility could not determine if an actual physical altercation occurred. The investigation included interviews with R1 and R2, but did not include interviews with other residents who may have witnessed the incident or experienced a similar occurrence. In adddition, the facility did not have documentation of R2's 1:1 supervision. (See interview under example 4.) 3. On 5/4/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had a diagnosis of wedge compression fracture of the first lumbar vertebra. R5's MDS assessment, dated 4/17/26, had a BIMS score of 13 out of 15 which indicated R5 had intact cognition. On 5/4/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbance, mild cognitive impairment, and emotional lability mood disturbance, insomnia, anxiety, and depression. R3's MDS assessment, dated 4/20/26, had a BIMS score of 5 out of 15 which indicated R3 had severely impaired cognition. R3 had an activated POAHC. On 4/22/26 at approximately 3:30 PM, staff reported an altercation between R3 and R5 (R3's roommate). Staff overheard R5 yell at R3 to get out of R5's bed. R3 grabbed R5's sheet and started pulling. While pulling the sheet, R3 hit/punched R5 in the knee/leg. R5 reported to staff that R5 did not feel it was intentional, but was due to R3 struggling to pull the sheet. The facility interviewed R3 and R5 but did not interview other residents who may have witnessed the incident or experienced a similar occurrence. (See interview under example 4.) 4. On 5/4/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including acute chronic respiratory failure with hypoxia, bipolar disorder, and anxiety. R6's MDS assessment, dated 3/24/26, had a BIMS score of 11 out of 15 which indicated R6 had moderate cognitive impairment. R6 had a Guardian. On 5/4/26, Surveyor reviewed a FRI submitted to the SA that indicated in the late afternoon/early evening on 2/21/26, R6 reported that a male Certified Nursing Assistant (CNA) entered R6's room, closed the door, and washed R6's vagina and buttocks roughly and aggressively with a washcloth. R6 stated R6 tried to scream for help, but no one came. The investigation included an interview with R6 and a police investigation. R6 was sent to the hospital for a Sexual Assault Nurse Examiner (SANE) examination which was negative. The investigation did not include resident interviews to see if other residents had similar concerns or staff interviews to see if staff witnessed something similar or received similar complaints from residents. On 5/4/26 at 11:26 AM and 12:48 PM, Surveyor interviewed NHA-A who indicated staff and resident interviews should be completed whenever there is an allegation of abuse. NHA-A verified the facility did not have resident and/or staff interviews for the 4 FRIs noted above. NHA-A stated Former Director of Nursing (FDON)-L left employment on 2/27/26 and may have destroyed the documents.

Based on staff interview and record review, the facility did not ensure an appropriate discharge process for 1 resident (R) (R7) of 1 sampled resident.On 4/23/26, the facility called Emergency Medical Services (EMS) after R7 made suicidal statements and had a call light cord wrapped around R7's neck. Crisis was notified and developed a plan to keep R7 safe in the facility. Nursing Home Administrator (NHA)-A told Power of Attorney (POAHC)-K the facility could not meet R7's needs and R7 could not return to the facility. POAHC-K did not receive a written transfer notice. R7's medical record did not contain a bed hold or transfer notice, discharge summary, or recapitulation of stay. Findings include:The facility's Transfer, Emergency Acute Care policy, dated March 2025, indicates: Residents transferred to an acute care setting for emergency treatment are provided with a notice of transfer and permitted to return to the facility .2. When a resident is temporarily transferred to an acute care facility, a notice of transfer is provided to the resident and resident representative as soon as practicable before the transfer.On 5/4/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including depression and chronic pain. R7's Minimum Data Set (MDS) assessment, dated 4/6/26, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R7 had moderate cognitive impairment. R7 had an activated Power of Attorney for Healthcaer (POAHC-K). R7's medical record contained a Discharge MDS assessment, dated 4/23/26, that indicated R7's return was not anticipated. R7's medical record did not contain a bed hold or transfer notice, discharge summary, or recapitulation of stay. On 5/4/26 at 10:56 AM, Surveyor interviewed NHA-A regarding R7's transfer to the hospital. NHA-A verified R7 was found with a call light cord wrapped around R7's neck on the morning of 4/23/26. R7's Primary Care Provider ((PCP)-I) was notified. NHA-A stated EMS arrived and talked with R7, POAHC-K, and a crisis team (via telephone) and determined R7 did not need to go to the hospital. R7 and POAHC-K declined transfer to the hospital at that time. NHA-A stated the facility could not meet the needs of the safety plan that was developed by the crisis team, including the removal of cords from R7's room and increased supervision. NHA-A stated after a lengthy discussion with EMS management and POAHC-K, it was decided to send R7 to the hospital for evaluation. NHA-A informed POAHC-K and EMS staff that R7 could not return to the facility because the facility could not meet R7's mental health needs.On 5/4/26 at 11:12 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D regarding R7's hospital transfer. CNA-D verified CNA-D found R7 with a call light cord wrapped around R7's neck on 4/23/26 and EMS was notified. CNA-D stated POAHC-K was emotional about the situation and the statement by NHA-A that R7 could not return to the facility. On 5/4/26 at 12:02 PM, Surveyor interviewed Family Member (FM)-F regarding R7's discharge. FM-F stated R7 and POAHC-K were told R7 had to leave the facility because R7 was suicidal despite the fact a crisis team stated R7 was safe to remain in the facility.On 5/4/26 at 1:57 PM, Surveyor interviewed Hospital Case Manager (HCM)-G regarding R7's readmission to the facility. HCM-G stated R7, POAHC-K, and R1's family were refusing to allow R7 to be readmitted to the facility due to the events that led to R7's transfer to the hospital.

Based on observation, staff interview, and record review, the facility did not ensure food was stored, prepared, and served in a sanitary manner. This practice had the potential to affect all 29 residents residing in the facility.Staff did not consistently monitor and document food holding and cooking temperatures.Staff did not adhere to temperature requirements when testing parts per million (PPM) of the sanitizing solution.The temperatures of kitchen and unit coolers and freezers were not consistently monitored or documented.The dish machine temperatures and chlorine test strips were not consistently monitored or documented.Findings include:During an initial tour of the kitchen on 12/1/25 at 10:03 AM, Dietary Manager (DM)-D stated the facility follows the Wisconsin Food Code as their standard of practice.Holding/Cooking Temperatures:The Wisconsin Food Code documents at 3-401.11 Raw Animal Foods: .Raw animal foods such as eggs, fish, meat, poultry, and foods containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked. The Wisconsin Food Code documents at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding: (A) .Time/temperature control for safety food shall be maintained: (1) 135 degrees Fahrenheit (F) or above, except that roasts cooked to a temperature and for a time specified in paragraph 3-401.11 (B) or reheated as specified in paragraph 3-403.11 (E) may be held at a temperature of 130 degrees F or above; or (2) At 41 degrees F or less.The Wisconsin Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that: .(G) employees are properly cooking time/temperature control for safety food, being particularly careful in cooking those foods known to cause severe foodborne illness and death, such as eggs and comminuted meats, through daily oversight of the employees' routine monitoring of the cooking temperatures using appropriate temperature measuring devices properly scaled and calibrated .From 12/2/25 to 12/3/25, Surveyor reviewed the facility's food holding and cooking temperature logs for October and November 2025 and identified the following deficiencies in maintaining required documentation for all perishable foods across all three daily meals:~ For the month of October, 12 of 93 meals did not contain cooking and holding temperature entries.~ For the month of November, 13 of 90 meals did not contain cooking and holding temperature entries.~ For the month of November, 30 of 90 meals did not contain holding temperatures. ~ For the month of November, 14 of 90 meals did not contain cooking temperatures.On 12/3/25 at 10:36 AM, Surveyor interviewed DM-D who confirmed the missing temperature entries and verified cooking and holding logs should be consistently completed. DM-D stated facility-wide kitchen improvements have been in progress since DM-D started in October. DM-D acknowledged that staff have not been recording holding temperatures for cold items and noted beverages remain out of the cooler during meal service which can extend up to two hours.Sanitizing Solution:The Wisconsin Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the Environmental Protection Agency (EPA)-registered label use instructions.The Wisconsin Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other deviceThe Wisconsin Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that.(L) employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing, and chemical concentration, pH, temperature, and exposure time for chemical sanitizing. During an initial kitchen tour that began at 10:03 AM on 12/1/25, Surveyor and DM-D observed sanitizing buckets and a quaternary (quat) sanitizer testing log at the three-compartment sink. The log required twice daily (AM/PM) concentration readings of 200 PPM but did not include a designated column to record the temperature of the sanitizing solution. DM-D stated the facility uses Hydrion QT-40 sanitizer test strips. The manufacturer's instructions on the dispenser indicate for accurate results, the solution must be between 65 F and 75 F and the strip must be submerged for 10 seconds. DM-D confirmed the facility does not verify or document the temperature of the solution prior to testing.On 12/2/25 at 12:28 PM, Surveyor observed [NAME] (CK)-E fill the 3-compartment sink with water and a sanitizing chemical. CK-E then submerged a sanitizing test strip in the sink for approximately 10 seconds which resulted in a reading between 150 and 200 PPM. CK-E did not verify the temperature of the sanitizing solution before testing. CK-E confirmed that checking the temperature of the sanitizing solution is not part of the facility's standard procedure.Surveyor's reviewed the facility's sanitizer test strip logs and noted 26 missing entries over a two month period: 15 omissions in October and 11 omissions in November.On 12/3/25 at 10:36 AM, Surveyor interviewed DM-D who acknowledged the missing entries and confirmed kitchen logs should be consistently completed. DM-D stated DM-D has been working to implement various departmental changes since starting in October.Cooler and Freezer Temperatures:The 2022 Wisconsin Food Code documents at 3-202.11 Temperature: .Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illnesses. Refrigerators should be set below 41 F (5 Celsius (C)) and freezers at or below 0 F (-18 C).The Wisconsin Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that .(F) employees are verifying that foods delivered to the food establishment during non-operating hours are from approved sources and are placed into appropriate storage locations such that they are maintained at the required temperatures, protected from contamination, unadulterated, and accurately presented.From 12/2/25 to 12/3/25, Surveyor reviewed temperature logs for the main kitchen cooler and freezer and a snack refrigerator on the unit. The facility required three daily temperature checks for the main kitchen units. Surveyor identified 14 missing entries in October and 4 in November. The facility required twice daily temperature checks for the snack refrigerator. Surveyor identified 17 missing entries in October and 20 in November.On 12/3/25 at 10:36 AM, Surveyor interviewed DM-D who acknowledged the missing entries for the kitchen and snack refrigerator logs and confirmed temperature checks should be consistently documented. DM-D stated DM-D was working to implement departmental improvements to address the documentation gaps.Dishwashing Temperatures/Chemical Logs:The Wisconsin Food Code documents at 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature: .(B) The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120 degrees F. The Wisconsin Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.The Wisconsin Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that .(L) employees are properly sanitizing cleaned multi-use equipment and utensils before they are reused through routine monitoring of solution temperature and exposure time for hot water sanitizing and chemical concentration, pH, temperature, and exposure time for chemical sanitizing. During an initial tour of the kitchen on 12/1/25 at 10:03 AM, DM-D stated the facility operates a low-temperature chemical dish machine. Surveyor observed the machine's data plate which specified a minimum wash and rinse temperature of 120 F and a chlorine rinse concentration of 50 PPM. DM-D stated the facility used Hydrion chlorine test strips and required staff to verify water temperatures three times daily (prior to the start of dishwashing) and to test chlorine levels twice daily. From 12/2/25 to 12/3/25, Surveyor reviewed the facility's chlorine test strip log which indicated staff should submerge the test strip for one second with a PPM reading of 50. Surveyor noted in October, 6 of 62 entries were incomplete and 21 entries measured 100 PPM or higher. In November, 11 of 60 entries were incomplete and 30 entries measured or exceeded 100 PPM.Surveyor also reviewed the facility's dishwasher temperature log and noted 11 of 93 incomplete entries in October, and 30 of 90 incomplete entries in November. On 12/3/25 at 10:36 AM, Surveyor interviewed DM-D who acknowledged the missing dishwasher temperature and chlorine test strip log entries. DM-D stated DM-D has been implementing kitchen improvements since October and confirmed all log entries should be consistently completed.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R10) of 4 sampled residents received a written transfer and bed-hold notice, including their right to return to the facility. In addition, the facility did not notify the Office of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges. This practice had the potential to affect more than 4 of the 29 residents residing in the facility.R10 was transferred to the hospital on 9/22/25, 10/10/25, and 11/18/25. The facility did not provide a written transfer notice to R10 for the hospital transfers. In addition, the facility did not provide bed-hold information for R10's 9/22/25 and 10/10/25 hospitalizations.The facility did not ensure the Office of the State LTC Ombudsman was notified of all transfers and discharges for 4 consecutive months. Findings include:The facility's Bed-Hold and Return policy, dated October 2022, indicates: All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payor source, are provided written notice about these policies at least twice: a. Well in advance of any transfer (e.g., in admission packet); and b. At the time of the transfer (or, if the transfer is an emergency, within 24 hours).The facility's Transfer, Emergency Acute Care policy, dated March 2025, indicates: Residents transferred to an acute care setting for emergency treatment are provided with a notice of transfer and permitted to return to the facility .2. When a resident is temporarily transferred to an acute care facility, a notice of transfer is provided to the resident and resident representative as soon as practicable before the transfer. 3. Copies of notices for emergency transfers are also sent to the representative of the Office of the State Long-Term Care Ombudsman.1. From 12/1/25 to 12/4/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including local infection due to central venous catheter. R10's Minimum Data Set (MDS) assessment, dated 11/26/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R10 had intact cognition. R10 was responsible for R10's healthcare decisions.R10's medical record indicated R10 was transferred to the hospital on 9/22/25, 10/10/25, and 11/18/25. R10's medical record did not include documentation that R10 was provided a written transfer notice on 9/22/25, 10/10/25, or 11/18/25 or bed-hold information for R10's 9/22/25 and 10/10/25 hospitalizations.On 12/3/25 at 2:11 PM, Surveyor interviewed Regional Nurse Consultant (RNC)-C who stated a verbal bed-hold was obtained for R10's 11/18/25 hospitalization but nothing was provided in writing. RNC-C also verified that R10 was not provided written transfer notices for any of R10's hospital transfers. RNC-C stated Social Worker (SW)-I was responsible for issuing transfer/discharge and bed-hold notices.On 12/4/25 at 12:21 PM, Surveyor interviewed SW-I who confirmed R10 was not provided with written transfer or bed-hold notices. SW-I confirmed a verbal bed-hold authorization was documented for R10's 11/18/25 hospitalization. SW-I stated SW-I was aware transfer and bed-hold notices should have been issued.2. On 12/3/25 at 2:11 PM, Surveyor interviewed RNC-C and requested documentation of transfer/discharge notifications to the State LTC Ombudsman. RNC-C stated SW-I was responsible for Ombudsman notification; however, RNC-C did not believe it had been done since SW-I was hired.On 12/4/25 at 12:21 PM, Surveyor interviewed SW-I who stated SW-I began working at the facility on 7/28/25. SW-I was not aware of SW-I's responsibility to notify the State LTC Ombudsman of transfers and discharges and had not done so since SW-I started at the facility.

Based on observation, staff interview, and record review, the facility did not ensure essential equipment was maintained in safe operating condition. This practice had the potential to affect more than 4 of the 29 residents and staff residing or working in the facility.The kitchen oven door was not in working condition.Findings include:The Vulcan VG260 is a heavy-duty, 60-inch wide gas restaurant range featuring two standard ovens, each 26 inches wide with thermostats adjustable from 150 Fahrenheit (F) to 500 F, one rack, and two rack positions.During a follow-up visit to the kitchen on 12/2/25 at 12:42 PM, Surveyor observed a black bungee cord tied around the oven door handle and secured around the leg of a side table next to the oven.On 12/2/25 at 12:42 PM, Surveyor interviewed [NAME] (CK)-E who stated the cord is used to keep the oven door shut. CK-E stated the oven door will not stay closed and will slam open if the bungee cord is not secured. CK-E stated the oven door had been broken for 3 years. CK-E stated CK-E was injured when the door fell open and had a burn on CK-E's lower leg as a result.On 12/2/25 at 12:42 PM, Surveyor asked CK-E to remove the bungee cord from the oven door. When CK-E removed the cord, the oven door fell open without resistance. Surveyor noted the kitchen is next to the resident dining room with an adjoining open door.On 12/2/25 at 12:46 PM, Surveyor interviewed Dietary Manager (DM)-D who verified the oven door was broken and did not remain closed unless secured with a bungee cord. DM-D stated the door had been broken for several years. DM-D indicated Nursing Home Administrator (NHA)-A submitted a purchase request to the corporate office for a new oven; however, the corporate office put a hold on all large purchase items. DM-D confirmed CK-E was injured when the oven door fell open and burned CK-E's leg. DM-D stated the door to the kitchen is left open during dining hours and when staff are in the kitchen. DM-D witnessed residents enter the kitchen through the door. DM-D stated residents can get within a few feet of the kitchen door before staff are able to assist them. DM-D stated when the kitchen is not in operation, the door to the dining room is locked.On 12/2/25 at 4:09 PM, Surveyor completed a follow-up observation in the kitchen. Surveyor noted the oven was in use and the bungee cord was removed from door. During the observation, DM-D attempted to remove a panel from the oven and the oven door fell open. DM-D caught the door before being hit.On 12/2/25 at 1:01 PM, Surveyor interviewed NHA-A who was aware the oven door was broken and held shut by a bungee cord. NHA-A stated the door had been broken since NHA-A started in October. NHA-A stated the goal was to get a new oven. NHA-A sent a purchase request to the corporate office for approval but was not aware of its status. NHA-A acknowledged the broken oven door was a potential safety risk.

Based on observation, staff interview, and record review, the facility did not ensure a call light was within reach for 2 residents (R) (R8 and R12) of 15 sampled residents.R8 and R12 were observed without access to a call light or a means to notify staff if assistance was needed.Findings include:The facility's Answering the Call Light policy, revised September 2022, indicates: The purpose of this procedure is to ensure timely responses to residents' requests and needs .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. 1.From 12/1/25 to 12/4/25, Surveyor reviewed R8's medical record. R8 was most recently admitted to the facility on [DATE] and had diagnoses including dementia, affective mood disorder, anxiety, stroke, convulsions, psychosis, and insomnia. R8's Minimum Data Set (MDS) assessment, dated 9/26/25, indicated R8 was rarely/never understood. R8 had a Guardian for healthcare decisions.On 12/1/25 at 10:51 AM, Surveyor observed R8 in a wheelchair by a window in R8's room. R8's call light was on the bed and not within reach. On 12/3/25 at 10:15 AM, Surveyor observed R8 in a wheelchair by a window in R8's room. R8's call light was on the floor at the foot of the bed and not within reach.(See interviews under example 2.)2. From 12/1/25 to 12/4/25, Surveyor reviewed R12's medical record. R12 was most recently admitted to the facility on [DATE] and had diagnoses including dementia, epilepsy, respiratory failure, cognitive communication deficit, anxiety, depression, and stroke. R12's MDS assessment, dated 10/7/25, had a Brief Interview for Mental Status (BIMS) score of 99 which indicated R12 could not complete the assessment. R12 had a Guardian for healthcare decisions. On 12/1/25 at 12:17 PM, Surveyor observed R12 in a Broda chair next to R12's bed. R12's call light was on the bed and not within reach.On 12/3/25 at 10:15 AM, Surveyor observed R12 in a Broda chair in R12's room. R12's call light was on the bed attached to a pillow behind the Broda chair and not within reach. On 12/3/25 at 10:17 AM, Surveyor activated R12's call light and verified the call light was working.On 12/3/25 at 10:29 AM, Surveyor observed Certified Nursing Assistant (CNA)-Q enter R12's room and assist R12 to Bingo. CNA-Q verified the call light should have been within R12's reach.On 12/3/25 at 10:45 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-M who verified a resident's call light should always be within reach.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R27 and R38) of 3 sampled residents signed and received copies of a Notice of Medicare Non-Coverage (NOMNC) form which is used to inform residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility), and standard claim appeal rights and instructions.The facility did not provide a NOMNC form to R27 or R38 at least two calendar days before their Medicare Part A services ended.Findings include:The facility's undated Advance Beneficiary Notices policy indicates: It is the policy of the facility to provide timely notices regarding Medicare eligibility and coverage .4. The current Centers for Medicare & Medicaid Services (CMS)-approved versions of the forms shall be used at the time of issuance to the beneficiary. Contents of the form shall comply with related instructions and regulations regarding the use of the form .c. A Notice of Medicare Non-Coverage (NOMNC), form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if the resident is leaving the facility or remaining in the facility .7. To ensure the resident or their representative has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare-covered Part A stay .8. The Business Office Manager, or designee is responsible for issuing notices .10. Delivery Requirements: a. The notice shall be written legibly in a language and/or format that the resident/representative understands .b. The notice shall be hand-delivered if possible to obtain the beneficiary or representative signature .c. The notice shall be prepared with an original and at least two copies. The facility shall retain the original and give a copy to the resident/representative.CMS form CMS-10123 indicates a NOMNC form must be delivered at least two calendar days before Medicare-covered services end or the second to last day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48 hour requirement .The provider must ensure the beneficiary or representative signs and dates the NOMNC form to demonstrate the beneficiary or representative received the notice and understands the termination decision can be disputed.1. From 12/1/25 to 12/4/25, Surveyor reviewed R27's medical record. R27's Medicare Part A stay began on 11/19/25. R27's last covered day of Part A services was 11/28/25. The facility did not provide R27 or R27's representative with a NOMNC form or provide evidence that R27 or R27's representative were aware of appeal rights. R27 discharged home from the facility on 11/28/25.On 12/2/25 at 4:08 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified a NOMNC form was not issued to R27. NHA-A indicated it is Social Worker (SW)-I's responsibility to issue the NOMNC form. NHA-A acknowledged that R27 should have received a NOMNC form.On 12/2/25 at 4:17 PM, Surveyor interviewed SW-I who verified SW-I did not issue a NOMNC form to R27 or notify R27 of appeal rights.2. From 12/1/25 to 12/4/25, Surveyor reviewed R38's medical record. R38's Medicare Part A stay began on 8/20/25. R38's last covered day of Part A services was 9/3/25. The facility did not provide R38 or R38's representative with a NOMNC form or provide evidence that R38 or R38's representative were aware of appeal rights. R38 discharged home from the facility on 9/3/25.On 12/2/25 at 4:08 PM, Surveyor interviewed NHA-A who verified a NOMNC form was not issued to R38. NHA-A indicated it is SW-I's responsibility to issue the NOMNC form. NHA-A acknowledged that R38 should have received a NOMNC form.On 12/2/25 at 4:17 PM, Surveyor interviewed SW-I who verified SW-I did not issue a NOMNC form to R38 or notify R38 of appeal rights.

Based on staff interview and record review, the facility did not ensure the effectiveness of psychotropic medication was assessed for 1 resident (R) (R25) of 5 sampled residents.R25 was prescribed trazodone (an antidepressant medication) for insomnia. The facility did not complete a sleep assessment for R25 to assess the effectiveness of the medication. In addition, R25 did not have a care plan for insomnia.Findings include:The facility's Sleep Disorders-Clinical Protocol, revised April 2018, indicates: .2. Nursing staff (especially night shift staff) will describe any sleep disturbance in detail; for example, patterns over time, associated behavior, daytime sleepiness, and factors that appear to improve or worsen the situation .Cause Identification: 1. The staff will consider various causes of sleep disturbance such as noise level, room temperature, lighting levels, bed comfort, roommate distractions, and staff intrusion .Treatment/Management: .2. The physician will order appropriate interventions to address sleep disturbances. A. If sleep medications are indicated, they should be prescribed judiciously, in the lowest possible doses for the shortest possible time. Intermittent or short-term use is preferable to continuous nightly use .Monitoring: 1. The physician and staff will monitor the resident's progress toward improving sleep and adjust interventions accordingly. The facility's Psychotropic Medication Use policy, revised February 2025, indicates: 1. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Medication in the following categories are considered psychotropic medications: antipsychotic, antidepressant, antianxiety, hypnotic/sedative medication .3. Psychotropic medication management is an interdisciplinary process .that includes: a. determining adequate indications for use .c. adequate monitoring for efficacy and adverse consequences .Assessment and Evaluation of the Resident: 1. When determining whether to initiate, modify, or discontinue medication therapy, the Interdisciplinary Team conducts and documents an evaluation of the resident.From 12/1/25 to 12/4/25, Surveyor reviewed R25's medical record. R25 was most recently admitted to the facility on [DATE] and had diagnoses including neurocognitive disorder with Lewy bodies, insomnia, anxiety, psychosis, and conduct disorder. R25 received Hospice care and had a Guardian for healthcare decisions.R25 had the following medication orders: ~ Trazodone 100 milligrams (mg) oral tablet at bedtime for insomnia (dated 8/8/25)Medical provider documentation from 8/24/25 at 2:45 PM indicated R25 had experienced increased insomnia and anxiety.R25's medical record did not contain a sleep assessment or a care plan for insomnia. On 12/3/25 at 12:45 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-M who verified R25 received trazodone but did not have a sleep assessment to monitor the effectiveness of the medication.

Based on staff interview and record review, the facility did not implement their abuse policy and procedure for 1 (Certified Nursing Assistant (CNA)-R) of 8 staff reviewed for caregiver background checks. CNA-R was hired through a staffing agency and worked shifts at the facility starting on 7/9/25. The facility did not ensure the staffing agency completed an out-of-state background check for CNA-R who resided outside of Wisconsin within 3 years of hire. Findings include: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, indicates: .4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. On 12/4/25, Surveyor reviewed a sample of caregiver background checks for 8 facility and contracted staff, including CNA-R. Surveyor noted CNA-R's Background Information Disclosure form, dated 4/24/23, contained a home address in Louisiana which indicated CNA-R lived outside of Wisconsin within 3 years of hire. On 12/4/25 at 12:00 PM, Surveyor asked Nursing Home Administrator (NHA)-A for CNA-R's out-of-state background check. NHA-A stated CNA-R's out-of-state background check was not available through the staffing agency's website when NHA-A obtained background check information that Surveyor had requested earlier. NHA-A stated NHA-A would contact the staffing agency to obtain the out-of-state background check. On 12/4/25 at 1:45 PM, NHA-A informed Surveyor that when NHA-A contacted the staffing agency and requested CNA-R's out-of-state background check, the staffing agency stated they would look for it and get back to NHA-A. On 12/4/25 at 2:17 PM, NHA-A informed Surveyor that NHA-A had not received CNA-R's out-of-state background check. NHA-A stated when a caregiver is hired through the staffing agency, the agency obtains all background check information. Once hired by the staffing agency, the caregiver may pick up shifts at the facility. NHA-A stated background checks should be available through the staffing agency's website, but are not always verified due to agency staff that pick up shifts at their convenience. NHA-A stated when staff are hired by the agency, the facility trusts the agency to complete a thorough background check prior to hire.

Based on staff and resident interview and record review, the facility did not ensure a potential allegation of abuse was thoroughly investigated for 1 resident (R) (R5) of 1 sampled resident.On [DATE], staff discovered R5 in R5's room between the wall and the bed. Staffs' statements were inconsistent regarding R5's injuries. The facility did not investigate the discrepancy regarding the injuries. Findings include: From [DATE] to [DATE], Surveyor reviewed R5's medical record. R5 was admitted to facility on [DATE] and had diagnoses including anoxic brain damage, epilepsy, palliative care, asthma, hemiplegia, encephalopathy, and thrombocytosis. R5's Minimum Data Set (MDS) assessment, dated [DATE], indicated R5 was dependent for cares, transfers, and mobility. R5 had a legal Guardian. From [DATE] to [DATE], Surveyor reviewed a facility-reported incident that indicated R5 had a swollen right eye and face and abrasions on the right shoulder and arm on [DATE]. Administration was notified and started an investigation. The proper notifications were made and X-rays were ordered. The facility's 5-day investigation was submitted to the State Agency (SA) on [DATE]. Staff interviews indicated Licensed Practical Nurse (LPN)-N discovered R5 in bed with R5's left upper body on the edge of the air mattress and right upper body leaning toward the wall. R5's lower extremities were in the bed. LPN-N put R5's upper body back in bed, ensured R5 was safely positioned, and asked Certified Nursing Assistant (CNA)-O to help reposition R5. After R5 was repositioned, CNA-O asked if CNA-O could return to the resident CNA-O was caring for prior to assisting with R5. LPN-N then cleaned R5's face and obtained vital signs which were within normal limits. The facility updated R5's care plan and educated staff on abuse/reporting. Resident interviews indicated they were happy with care at the facility and felt safe. It was determined that a seizure caused R5's injuries. On [DATE] at 11:26 AM, Surveyor interviewed CNA-O who indicated (LPN-N) asked CNA-O to assist in R5's room on [DATE]. When CNA-O entered R5's room, R5's face appeared swollen and bloodied. (LPN-N) was caring for R5 and CNA-O asked to go back and finish with the resident CNA-O had been caring for. When CNA-O returned to R5's room, R5's face was clean. Wash cloths next to R5 appeared bloody. CNA-O did not ask what was on the wash cloths or report anything because CNA-O thought (LPN-N) would do so. On [DATE] at 11:39 AM, Surveyor interviewed LPN-N who indicated LPN-N found R5 between the bed and the wall on [DATE]. LPN-N assisted R5 back into bed and asked CNA-O for assistance. CNA-O then went back to help another resident. LPN-N cleaned up sputum on R5's face and made sure R5 was positioned correctly. LPN-N stated R5 did not have any injuries or swelling and was not bleeding at all. LPN-N reported the information to the next shift and indicated to monitor R5. LPN-N did not document the findings in R5's medical record. On [DATE], Surveyor reviewed investigation statements from CNA-O and LPN-N which were consistent with Surveyor's interviews. On [DATE] at 11:59 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated LPN-N found R5 with R5's face against the wall. NHA-A verified LPN-N did not document the incident. NHA-A stated LPN-N's statement indicated there were no injuries and LPN-N wiped sputum off of R5's face. NHA-A vaguely remembered CNA-O's statement and was not aware of the discrepancy between the statements. NHA-A verified that NHA-A did not follow-up and investigate and the discrepancy between CNA-O and LPN-N's statements.

Based on staff interview and record review, the facility did not provide appropriate dementia care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 Resident (R) (R1) of 8 sampled residents.R1 was admitted to the facility on [DATE] for a 5-day respite stay. R1 had a history of elopement but no physically aggressive behavior. On the evening of 9/25/25, staff attempted to assist R1 to get R1 ready for bed. R1 resisted the care and stated only R1's wife does that. R1 became physically aggressive with staff and stated R1 wanted to leave the facility and go home. R1 attempted to exit multiple doors. Multiple staff pursued R1 through the facility, blocked exit doors from the inside and outside, and put hands on R1 to keep R1 from exiting which increased R1's agitation. Staff called law enforcement due to R1's heightened aggression. When law enforcement arrived, R1 indicated that R1 had been attacked by numerous individuals.Findings include:The facility's undated Communicating with an Agitated Resident Competency Skills: Behavioral Health training was provided to Surveyor on 10/13/25. The training indicates: Does the student: Approach resident from the front? Reassure resident using a calm voice throughout? Try to determine meaning behind resident's body language and gestures? Avoid arguing with resident? Monitor own body language and gestures? Maintain safe distance of approximately 6 feet away to the side of resident? Engage using the least restrictive measures first such as: allowing time and space to let outburst dissipate, redirect, or draw attention to something else?The facility's Identifying Involuntary Seclusion and Unauthorized Restraint policy, revised 9/2022, indicates: .2. Examples of involuntary seclusion include: a. Any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door .4. Behavioral issues that arise among residents are managed according to strategies documented in the care plan and approved by the behavioral team. 5. The negative physical and psychological impacts of physical restraint use may include: .g. Agitation, aggression, anxiety, or development of delirium.The facility's Wandering and Elopements (2001 Med-Pass, Inc.) policy indicates: .2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a courteous manner.On 10/13/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] for a 5-day respite stay and had diagnoses including Alzheimer's disease with early onset, dementia in other diseases without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety disorder, and encounter for palliative care. R1 had an activated Power of Attorney for Healthcare (POAHC) and received Hospice services. A behavioral symptom care plan, initiated 9/25/25, indicated R1 wandered (moved with no rational purpose, seemingly oblivious to needs or safety.) The care plan contained interventions, dated 9/25/25, to approach from the front and walk in step with (R1) first before redirecting; Avoid overstimulation (e.g., noise, crowding, other physically aggressive residents); If (R1) looks for family/significant other, reassure that others know where to find (R1); Maintain a calm environment and approach to (R1); When (R1) begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). A progress note, dated 9/25/25 at 10:00 AM, indicated the writer met with R1 and R1's POAHC to complete admission paperwork for a 5-day respite stay. The writer asked R1's POAHC for permission to put a WanderGuard on R1 for safety because R1 liked to wander.A progress note, dated 9/25/25 at 10:45 PM and written by Director of Nursing (DON)-B, indicated R1 became extremely agitated and combative at approximately 6:30 PM. R1 choked, punched, kicked, slammed, and threw multiple staff. The change in mood/behavior was likely a result of R1's first time respite status and unfamiliarity with staff and the environment. DON-B, NHA-A, Hospice staff, R1's POAHC, and law enforcement were notified. Law enforcement responded and contacted Adult Protective Services (APS) for further direction. APS and Hospice staff worked toward a resolution. R1's POAHC was out of state and two family friends picked up R1 at approximately 10:45 PM. Hospice staff followed them home to help get R1 situated.On 10/13/25 at 9:54 AM, Surveyor interviewed Hospice Case Manager (HCM)-D who indicated R1 had received Hospice services since 8/19/25. HCM-D indicated R1 did not have a history of violence and had always been cheerful with staff. R1 resided at home with R1's spouse and attended adult daycare on Mondays and Wednesdays with no known incidents. HCM-D indicated the respite stay was the first time R1 had stayed in a skilled nursing facility. On 10/13/25 at 11:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who worked with R1 on the evening of 9/25/25. CNA-E was told at shift change that R1 was easy going and not difficult to care for. CNA-E was assisting R1 with getting ready for bed when R1 became upset and stated R1 wanted to go home. CNA-E talked to R1 about staying in the facility for a few days. R1 became more agitated, and CNA-E backed off. R1 stomped on CNA-E's foot and CNA-E exited the room. R1 then exited the room and tried to leave the facility. R1 injured CNA-E who struggled to recall details because CNA-E was in shock and had not witnessed anything like that. CNA-E indicated staff held/blocked doors to prevent R1 from exiting the facility. CNA-E stated the facility provided education after the incident that staff should not block the door if a resident wants to leave. The education indicated staff should allow the resident to exit the facility and should follow the resident and contact authorities. On 10/13/25 at 11:22 AM, Surveyor interviewed CNA-F who indicated R1 stomped on CNA-E's foot when CNA-E got R1 ready for bed. CNA-F indicated R1 became increasingly agitated when R1 could not exit the facility and bolted from door to door, including on resident wings, in lounges, and in the dining room. CNA-E indicated staff tried to calm R1 and some tried to physically stop R1 from exiting or being aggressive. CNA-F exited the building during the incident and put a foot on the bottom of an exit door to prevent R1 from leaving. When R1 realized CNA-F was on the other side of the door, R1 ran to a different door. CNA-F ran to that door and stood outside the door to prevent R1 from leaving. R1 pounded on the delayed egress door but did not open the door. CNA-F stated [NAME] (CK)-J also stood in front of a door to stop R1 from leaving. R1 punched, kicked, and hit whoever R1 could see and a staff said to grab R1's pant leg to stop R1 from kicking. CNA-F indicated R1 injured several staff during the incident and some required emergency room (ER) treatment. CNA-F indicated CNA-G had received training from a previous job and instructed staff to stand back. CNA-F (who is no longer employed by the facility) did not receive education after the incident.On 10/13/25 at 11:37 AM, Surveyor interviewed agency CNA-G who worked the 9/25/25 PM shift. CNA-G was working on the other side of the building when Licensed Practical Nurse (LPN)-L sprinted down the hall and asked for help. CNA-G indicated R1 wanted to go home. CNA-G observed R1 hit CNA-E. When R1 saw staff approaching, R1 stopped hitting CNA-E and ran to an exit door. R1 sought out the fire exits but staff blocked the doors. CNA-G indicated one staff was outside of the doors that R1 tried to open. CNA-G asked CNA-F to hold the door shut in case R1 got out. R1 was swinging. Staff tried to stay out of R1's line of sight and moved residents into their rooms for protection. CNA-G had previous experience in similar situations and instructed staff to give R1 space. R1 stated R1 didn't know anyone and was trying to get to R1's spouse. R1 was calm when the police arrived. The police gathered statements, however, the facility did not. CNA-G worked 3 or 4 days after the incident but did not receive education post-incident or prior to working CNA-G's next shift.On 10/13/25 at 11:51 AM, Surveyor interviewed Medication Technician (MT)-H who indicated staff tried to ensure residents were safe during the incident. MT-H saw staff outside the building by the doors. MT-H stated R1 went from door to door and was flinging bodies along the way. MT-H is a long-term employee and received prior training on how to redirect residents from eloping and keep them safe in the building. MT-H received general dementia care training but was not trained on how to handle that level of agitation. Post-incident, MT-H received education on updated policies and proper procedures. MT-H stated staff should not block a door and indicated staff should open the door, let the resident out, and follow the resident for safety. On 10/14/25 at 3:05 PM, Surveyor interviewed [NAME] (CK)-J via phone who indicated CK-J heard yelling and saw R1 enter the dining room on 9/25/25. R1 yelled at the CNAs and was followed by 2 to 4 CNAs to ensure R1 did not elope. R1 attempted to elope out the dining room door; however, CK-J stood between R1 and the door. When R1 left the dining room, multiple CNAs followed R1 from door to door as R1 attempted to leave the facility. CK-J stated one CNA stood between R1 and the door to ensure R1 did not elope. R1 eventually sat in the lobby and CK-J stood behind R1. CK-J's hands were on the back of R1's chair as CK-J tried to calm R1 down. CK-J heard R1 kicked and swung at staff but did not witness it. When asked what R1 yelled when R1 entered the dining room, CK-J stated R1 yelled, I want to leave. Why won't you let me leave? CK-J stated R1 was half naked and it was dark. CK-J received training post-incident that if a resident wants to leave, staff should let the resident leave, follow them with a phone, and contact emergency medical services (EMS). CK-J was not asked to provide a statement about the incident and left when the police arrived. A police report, dated 9/25/25, indicated Sergeant (SGT)-I entered the facility and was directed to the main area near the nurses' station in the central part of the building on the north side. SGT-I observed numerous staff crying, out of breath, and disheveled. R1 was shirtless and seated in a chair. A person standing behind R1 appeared to be there to ensure R1 did not leave the chair. SGT-I was told by multiple staff that R1 had dementia and attempted to elope; however, staff stopped R1 from leaving. R1 struck, kicked, punched, and threw staff into door frames and walls. SGT-I attempted to talk to R1, however, R1 could not formulate sentences and appeared confused. At one point, R1 indicated to SGT-I that R1 was attacked by numerous individuals at the facility. On 10/13/25, Surveyor obtained county crisis documentation related to the incident. The documentation indicated SGT-I was called to the facility for a disorderly resident (R1) who had dementia. SGT-I reported that R1 became violent when staff would not let R1 leave the facility. SGT-I informed the writer that staff were holding R1 in a chair when SGT-I arrived citing safety concerns.On 10/13/25 at 3:41 PM, Surveyor interviewed SGT-I via phone. SGT-I was told staff put hands on R1 during the incident but were not holding R1 down when SGT-I arrived. SGT-I thought staff stated they had to block exits to prevent R1 from exiting the building. SGT-I indicated it was cool outside and R1 was not wearing a shirt. If R1 had eloped, SGT-I stated dogs or [NAME] may have been required to find R1. On 10/13/25 at 1:44 PM, Surveyor interviewed DON-B via phone. DON-B arrived at the facility after the police. DON-B indicated R1 was rocking in a chair in the lobby and appeared upset. R1 became upset when CNA-E attempted to change R1's clothing at bedtime and said only R1's spouse did that. CNA-E backed off, however, R1 wanted to go home. DON-B completed a skin check for R1's visible skin and observed no injuries. DON-B did not obtain staff statements since the facility had staff statements from the police investigation. DON-B heard multiple accounts of what occurred but was not aware that staff blocked doors and put hands on R1. DON-B stated staff should not have physically restrained R1 or held doors shut. DON-B stated staff education was provided on what to do for an unmanageable resident and thought most nursing staff were trained. On 10/13/25 at 3:51 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware that staff blocked doors or placed hands on R1. NHA-A indicated the facility had staff statements from the police investigation but initially thought DON-B had obtained statements. NHA-A had not received the police report and was not aware of the County Crisis Line (APSA) report. NHA-A confirmed staff were being trained on how to handle unmanageable residents and stated the facility was completing internal things; however, NHA-A was not finished with everything yet.

Based on staff interview and record review, the facility did not ensure the resident environment was free of abuse for 2 residents (R) (R1 and R2) of 9 sampled residents. R2 had a diagnosis of dementia and an activated Power of Attorney for Healthcare (POAHC). R2 had a history of sexually intimate encounters and sexual comments toward other residents and displayed verbally and physically aggressive behavior. On 1/10/25, 1/29/25, and 2/8/25, R2 made sexual comments, was verbally and physically aggressive toward other residents, and exhibited wandering behavior. The facility did not implement interventions to ensure the safety of R2 and other residents. On 3/18/25, a resident walked past R1's room and observed R2 touching R1's breasts underneath R1's shirt. R1 was cognitively impaired and had an activated POAHC. The facility's failure to prevent a cognitively impaired resident from being sexually abused by a resident with a history of inappropriate sexual behavior led to a finding of immediate jeopardy that began on 3/18/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 4/2/25 at 4:30 PM. The immediate jeopardy was removed on 4/9/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Resident-to-Resident Altercation policy, revised September 2022, indicates: All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the Nursing Supervisor, the Director of Nursing Services and the Administrator .2. Behaviors that may provoke a reaction by residents or others include: a. Verbally aggressive behavior such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating: b. Physically aggressive behavior such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; c. Sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing; d. Taking, touching, or rummaging through other's property; and e. Wandering into others' rooms/space .3. Occurrences of such incidences are promptly reported to the Nurse Supervisor, Director of Nursing Services, and Administrator .4. If two residents are involved in an altercation, staff: .d. Review the events with the Nursing Supervisor and Director of Nursing Services and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents; .f. Make any necessary changes in care plan approaches for any or all of the involved individuals; .i. Complete a report of incident/accident form and document the incident, findings, and any corrective measures taken in the resident's medical record. On 4/2/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had a diagnosis of dementia with psychosis. R2's Minimum Data Set (MDS) assessment, dated 3/5/25, had a Brief Interview for Mental (BIMS) score of 8 out of 15 which indicated R2 had moderate cognitive impairment. (A score of 7 out of 15 indicates severe cognitive impairment.) R2's 12/14/24 and 3/5/25 MDS assessments indicated R2 had verbal behavior directed toward others (threatening others, screaming at others, cursing at others) on 1 to 3 days during the observation period. R2's MDS assessment, dated 3/5/25, indicated R2 had wandering behavior on 1 to 3 days. R2 had an activated POAHC. A behavioral symptoms care plan (initiated 5/9/24) indicated R2 had socially inappropriate/disruptive behavioral symptoms as evidenced by sexually inappropriate behavior toward staff and other residents. The care plan contained interventions to observe and report socially inappropriate/disruptive behavior when around others (initiated 5/9/24), identify and report possible triggers for suggestive or sexual language or behavior including flirting and sexual jokes (initiated 5/9/24), assess R2 as needed using the sexuality and intimacy worksheet (initiated 5/9/24), redirect and remove when displaying negative forms of intimacy or sexual language (initiated 5/9/24), and provide supervision and/or escort to/from meals (initiated 7/9/24). A behavioral symptoms care plan (initiated 6/17/24 and revised 3/26/25) indicated R2 made statements regarding going home/leaving due to dementia and referenced placement of a WanderGuard. The care plan contained an intervention to remove R2 from other residents' rooms and unsafe situations (initiated 6/17/24). Surveyor reviewed previous facility-reported incidents (FRIs) submitted to the State Agency (SA) involving R2 and noted the following: ~ A FRI indicated R2 was involved in a resident-to-resident sexual interaction when R7 wandered into R2's room on 11/26/22. Staff discovered R2 rubbing R7's groin area. R7 was fully clothed. R2's medical record contained a sexual consent form, dated 7/9/24, that indicated R2 had no sexual intimacy or behaviors during the look back period or review with the Interdisciplinary Team (IDT). R2 had a WanderGuard due to a diagnosis of dementia. One-to-one supervision when outside of R2's room was discontinued. Fifteen minute checks were also discontinued. Staff were to provide supervision and/or escort R2 to and from meals. R2's POAHC was in agreement and R2's care plan was updated. A progress note in R2's medical record, written by Licensed Practical Nurse (LPN)-E and dated 1/10/25 at 6:25 PM, indicated R2 made inappropriate sexual comments and combative and angry comments toward other residents. LPN-E spoke with R2 which helped for a while, however, R2 later yelled in the dining room and tried to get other residents to leave the facility with R2. R2 was noted to have increased behaviors in the afternoon and evening. There were no care plan revisions for R2. A progress note, dated 1/29/25 at 3:05 AM, indicated R2 was verbally aggressive toward other residents. Staff kept an eye on R2 until R2 went to bed. Surveyor requested an incident report or more detail on what occurred, however, the facility was unable to provide the information. On 4/2/25 at 12:17 PM, Surveyor interviewed LPN-E who indicated R2 had a quick temper and little patience at times. LPN-E had not seen R2 strike anyone and indicated R2 was mostly verbally inappropriate. When asked about documentation on 1/10/25 regarding R2's sexual, combative, and angry comments toward other residents, LPN-E could not recall what R2 stated or who the comments were directed toward. LPN-E indicated R2's comments were blunt and often not directed at a specific person. LPN-E indicated incidents with R2 frequently occurred in the lobby which gets congested. LPN-E indicated female residents watch TV in the lobby which triggers R2 to make comments when R2 passes by. LPN-E indicated LPN-E's documentation should have been more specific regarding R2's comments and if they were directed at a specific resident. LPN-E indicated LPN-E reported all physical incidents and separated residents during physical and verbal incidents. LPN-E indicated incidents are documented in residents' progress notes and may be written on the 24-hour report board. LPN-E could not recall if LPN-E reported the incidents on 1/10/25 and 1/29/25 to administration. A progress note, dated 2/8/25 at 9:27 PM, indicated R2 wore (R8's) hat which angered (R8) who confronted R2. An argument was stopped by staff and the residents were separated. Staff were instructed to be sure R2 and R8 were kept apart. There were no care plan revisions for R2 following the incident. On 4/2/25 at 12:17 PM, Surveyor interviewed LPN-E who indicated R2 must have gone into R8's room and taken R8's hat. On 4/2/25 at 3:02 PM, Surveyor interviewed R8 who indicated R2 entered R8's room and took R8's hat. (R8's most recent MDS assessment, date 1/7/25, indicated R8 was not cognitively impaired.) ~ A FRI indicated R2 was in a wheelchair near the nurses' station on 2/21/25 when R6 who appeared emotional/tearful propelled around the nursing station in a wheelchair. R2 leaned forward to comfort R6 and put a hand on R6's thigh. R6 pushed R2's hand away which upset R2 who slapped R6's hand. Staff intervened and separated the residents. R6 was taken to R6's room and provided comfort. R2 remained in the common area near the nurses' station. Staff assessed R2 and R6 and noted no injuries. R2 and R6's physician and representatives were notified. LPN-E notified administration. The facility's investigation indicated R2 tried to console R6. A care plan initiated for R2 on 2/27/25 indicated R2 had a history of offering comfort to other residents via touch. The care plan contained interventions to encourage R2 to provide comfort through verbal communication and explain to R2 in a calm and respectful manner that R2's care and comfort is appreciated, however, not everyone likes to be touched. On 4/2/25 at 2:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who observed the interaction between R2 and R6 as CNA-F was coming up the hall and separated the residents. CNA-F indicated R6 was not tearful or upset prior to the incident but was an anxious person, had an anxious look on R6's face at times, and did not like to be touched. CNA-F indicated R6 was upset after the incident. On 4/2/25, Surveyor requested investigations and/or incident reports including care plan revisions for the progress notes that reference R2's behavior toward other residents. The facility was unable to provide the information. On 4/4/25, the facility provided care plans for R2 that included active and discontinued behavioral interventions. The care plans did not contain revisions following the incidents on 1/10/25, 1/29/25, or 2/8/25. On 4/2/25, Surveyor reviewed a FRI submitted to the SA. The FRI indicated on 3/18/25 at approximately 3:00 PM, R3 walked past R1's room and saw R2 feeling R1's breasts underneath R1's shirt. R3 told R2 to stop and notified staff who immediately responded and removed R2 from R1's room. Staff informed the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the NHA. R1 was assessed and R2 was placed on 1:1 supervision. Law enforcement was notified and an investigation was initiated. R1 and R2's representatives were notified and R2 was moved to a room on the opposite side of the facility. R2's care plan was revised. Interviews with residents and staff were completed. Staff followed-up with R1, R2, and R3 for psychosocial well-being. The investigation did not indicate staff education was completed following the incident. On 4/2/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and dementia. R1's MDS assessment, dated 3/19/25, indicated R1 had severe cognitive impairment. R1 had an activated POAHC. On 4/2/25 at 1:00 PM, Surveyor interviewed DON-B who indicated R2's behaviors were common knowledge. DON-B indicated there were interventions to redirect and remove R2 from the situation. DON-B indicated DON-B reviews progress notes and revises care plans if needed. DON-B was not aware of the 2/8/25 progress note that indicated a verbal altercation occurred when R2 took R8's hat. DON-B was aware of the 1/10/25 progress note that indicated R2 made sexually inappropriate comments and was physically and verbally aggressive toward other residents. DON-B was unable to provide further information regarding specific comments that were made and who the comments were directed toward or what type of aggressive behavior occurred and who it was directed toward. DON-B confirmed staff education was not completed post-event on 3/18/25 and indicated DON-B planned to provide staff education at a staff meeting next week. DON-B indicated staff were aware that R2 was on 1:1 supervision at all times when in R2's wheelchair. On 4/2/25 at 2:00 PM, Surveyor interviewed NHA-A who indicated NHA-A was not employed by the facility when the incident occurred on 1/10/25. NHA-A indicated NHA-A wanted to be informed of like-incidents in order to investigate and determine if care plan revisions were needed. NHA-A confirmed when incidents occur or when staff notice an increase in behaviors, NHA-A and DON-B should be notified so appropriate action can be taken. The failure to protect a resident from sexual abuse by a resident with a history of sexually inappropriate behavior created a reasonable likelihood for serious harm for that resident and other residents and led to a finding of immediate jeopardy. The facility removed the jeopardy on 4/9/25 when it completed the following: 1. Placed R2 on 1:1 supervision when awake. 2. Reviewed medical records and interviewed staff to identify other residents who may exhibit high-risk behavior. 3. Developed care plans for residents identified with the potential for high-risk behavior. 4. Reviewed the Abuse policy and playbook. 5. Completed staff education on resident rights, abuse, reporting responsibilities, and willful/intentional acts. 6. Initiated audits to ensure compliance. Surveyor observed R2 multiple times during the survey with 1:1 staff. R2 was noted to be in R2's room most of the day except for lunch. During lunch, R2 was seated at a table with like-gender residents. R2's 1:1 staff was observed seated beside R2.

Based on staff and family interview, and record review, the facility did not ensure an advance directive was followed for 1 Resident (R) (R1) of 3 residents reviewed for code status. R1 had a Do Not Resuscitate (DNR) order signed by R1 on [DATE] and signed by the physician on [DATE]. On [DATE], R1 was found unresponsive. Staff performed cardiopulmonary resuscitation (CPR). R1 sustained fractured ribs and was placed on a ventilator in the Intensive Care Unit (ICU). R1's family made the decision to withdraw life support on [DATE] and R1 passed away. The facility's failure to follow a resident's advance directive created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on [DATE] at 9:10 AM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at scope/severity level D as the facility continues to implement its action plan. Findings include: The facility's Advanced Directive Policy and Procedure, revised [DATE], contained the following information: Prior to or upon admission of a resident, Social Worker inquires of the resident, his/her family members, and/or his/her legal representative, about the existence of any written advance directives. a. Social Worker will review, obtain a copy and carry over any pre-established advance directives. b. Social Worker will provide nursing with a copy of the advance directives and nursing will place order into Electronic Medication Administration Record (EMAR) and dedicated binder for easy access. c. Nursing will call the medical director's office to let them know a fax will be coming over to the medical director for signature. Nursing to fax over and document in medical record. d. The above criteria will be done within the same shift of admittance to the facility. On [DATE], Surveyor reviewed R1's medical record, including admission documents and R1's advance directive. R1 was admitted to the facility on [DATE] with diagnoses to include a right humerus fracture, chronic obstructive pulmonary disease (COPD), hypertension, depression, and rheumatoid arthritis. R1's most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated R1 had intact cognition and required the assistance of one staff for activities of daily living (ADLs). R1's medical record contained a document titled Emergency Care Do Not Resuscitate Order (DNR), signed by R1 on [DATE] and signed by the physician on [DATE]. R1's medical record also contained a document titled [NAME] Care Center Critical Care Plan that indicated R1 chose to be a DNR. This was signed by R1 on [DATE] and by the physician on [DATE]. R1's medical record indicated R1's choice to be a DNR was updated on R1's face sheet on [DATE] at 9:10 AM (which was after R1 was found unresponsive on [DATE] and CPR was performed) A progress note, dated [DATE] at 11:31 AM, contained the following information: This morning (R1) requested to go outside at (6:45 AM) for a cigarette. Certified Nursing Assistant (CNA) assisted (R1) outside .Another resident went outside for a cigarette at (7:15 AM) and found (R1) slumped over in (R1's) wheelchair .Staff brought (R1) into (R1's) room and transferred (R1) onto the floor. Two CNAs started to perform CPR, chest compressions at (7:17 AM). Writer called 911. Night shift nurse gathered ambu bag (bag mask with valve to assist with breathing) and writer grabbed AED (automated external defibrillator) machine. Two sheriffs arrived at (7:20 AM) and assisted with CPR. Within approximately two minutes, ambulance and fire department arrived. (R1) left via ambulance at (8:10 AM) . On [DATE] at 10:30 AM, Surveyor interviewed R1's daughter who stated R1 was airlifted to another hospital and was in the ICU for three days before family withdrew life support measures. R1's daughter stated it was hard to have to make a decision they believed was already decided when R1 elected to be a DNR upon admission to the facility. On [DATE] at 10:57 AM, Surveyor interviewed Business Office Manager (BOM)-D regarding R1's advance directive and admission paperwork. BOM-D stated BOM-D was responsible for scanning signed DNR forms into the computer and for updating electronic medical records to reflect code status. BOM-D verified R1's DNR form was signed on [DATE] by a physician; however, BOM-D did not receive the form before BOM-D left for the day at approximately 3:30 PM. BOM-D scanned R1's DNR form and updated R1's face sheet on [DATE] at approximately 9:00 AM when BOM-D reported for work. On [DATE] at 1:15 PM, Surveyor interviewed CNA-F who did not work with R1 prior to [DATE]. CNA-F verified another resident caught CNA-F's attention and CNA-F ran outside to find R1 unresponsive and slumped over in R1's wheelchair. CNA-F performed a sternal rub and R1 did not respond. CNA-F brought R1 back to R1's room and Medication Technician (MT)-H told CNA-F that R1 was a full code. CNA-F and CNA-E lowered R1 to the ground and initiated CPR. On [DATE] at 1:22 PM, Surveyor interviewed CNA-E who assisted CNA-F with lowering R1 to the floor and providing CPR. CNA-E stated CNA-E was told by Licensed Practical Nurse (LPN)-I that R1 was a full code. CNA-E checked R1's medical record after R1 was sent to the hospital and verified the record indicated R1 was a full code. On [DATE] at 2:24 PM, Surveyor interviewed Social Worker (SW)-G who verified R1's DNR form was signed by R1 upon admission ([DATE]) and SW-G faxed the form to the physician that day. SW-G also stated SW-G called the physician's office to leave a message regarding the form and request for the physician's signature. SW-G added that, prior to R1's incident on [DATE], BOM-G was the only person who updated code status in medical records. On [DATE] at 10:45 AM, Surveyor interviewed Regional Clinical Nurse (RCN)-C who verified R1's DNR form was signed by a physician on [DATE] after BOM-D had left for the day. RCN-C added that it often takes several days for physicians to respond to signing DNR forms. On [DATE], Surveyor reviewed R1's hospital notes. R1 received a CT (computed tomography) scan of R1's chest. The results contained the following information: Anterior (near the front of the body) rib fractures are seen consistent with CPR. These involve the right second, third, fourth, fifth, sixth, seventh, eighth, ninth ribs .The left third, fourth, fifth, sixth, seventh, eighth, ninth ribs show anterior fractures as well. The report also indicated R1 had a right-sided pneumothorax (air trapped outside of the lung) and required a ventilator to breathe. R1 passed away at the hospital on [DATE]. According to a National Public Radio article, For many, a 'natural death' may be preferable to enduring CPR, Chest compressions are often physically, literally harmful. Fractured or cracked ribs are the most common complication, wrote the original Hopkins researchers, but the procedure can also cause pulmonary hemorrhage, liver lacerations, and broken sternums. If your heart is resuscitated, you must contend with the potential injuries. A rare but particularly awful effect of CPR is called CPR-induced consciousness: chest compressions circulate enough blood to the brain to awaken the patient during cardiac arrest, who may then experience ribs popping, needles entering their skin, a breathing tube passing through their larynx. The traumatic nature of CPR may be why as many as half of patients who survive wish they hadn't received it, even though they lived. It's not just a matter of life or death, if you survive, but quality of life. The injuries sustained from the resuscitation can sometimes mean a patient will never return to their previous selves. Two studies found that only ,d+[DATE]% of older patients who survive CPR were able to function independently; others found somewhat better rates of recovery. An even bigger quality of life problem is brain injury. When cardiac activity stops, the brain begins to die within minutes, while the rest of the body takes longer. Doctors are often able to restart a heart only to find that the brain has died . About 30% of survivors of in-hospital cardiac arrest will have significant neurologic disability. Again, older patients fare worse. Only 2% of those over 85 who suffer cardiac arrest survive without significant brain damage. https://www.npr.org/sections/health-shots/[DATE]/1177914622/a-natural-death-may-be-preferable-for-many-than-enduring-cpr The failure to follow a resident's advance directive and provide life saving measures against the resident's wishes led to serious harm for R1 which created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it completed the following: 1. Developed a root cause analysis and action plan and implemented appropriate process changes. 2. Educated staff, including the Medical Director, on the facility's code status policy and procedure on-site on [DATE] or prior to their next shift. 3. Completed an audit to ensure correct advance directives were in place for all residents.

Based on observation, staff interview and record review, the facility did not ensure residents were free from neglect or abuse as the facility failed to supervise their whereabouts to ensure they did not engage in sexual contact that went beyond hand holding and kissing for 2 Residents (R)(R1 and R2) of 5 sampled residents. The facility was aware that R1, who had a diagnosis of dementia and was assessed to be unable to consent, had a history of sexually intimate encounters. The facility neglected to implement appropriate interventions to supervise and prevent R1 from engaging in sexually intimate encounters with R2, who was also assessed as unable to consent to sexual encounters, and other residents. On 11/26/22, R1 was found in R2's room and R2 was touching R1 in the genital area. The facility concluded the investigation on 12/3/22 and substantiated sexual abuse. Using the reasonable person concept, since R1 and R2 were severely cognitively impaired and assessed as unable to consent to sexual contact, it is likely one or both would suffer harm as a result of the sexual contact. It is also likely that other residents would suffer harm if R1 and R1's cognitive impairment, sexual impulses, and lack of supervision led them to seek out other residents for sexual encounters. Facility failure to prevent sexual abuse from occurring, created a finding of immediate jeopardy that began on 11/26/22. Nursing Home Administrator (NHA) was notified of the immediate jeopardy on 12/08/22 at 4:05 PM. The immediate jeopardy was removed on 12/9/22, however the deficient practice continues at a scope/severity of D while the facility implements their plan of correction. Findings Include: Neglect is defined in Appendix PP State Operations Manual as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility policy titled Sexual and Intimacy Policy/Procedure, dated 8/8/22, states: The facility .acknowledges its responsibility to protect its' residents who may not be able to consent to sexual relationships. On 12/7/22, the Surveyor reviewed a Facility-Reported Incident (FRI), dated 11/26/22, that indicated R1 and R2 were the affected persons related to an occurrence in which R1 was found in R2's room with R2 rubbing on [R1's] groin/privates. The FRI indicated this occurred on 11/26/22. The final investigation and results were reported to the State Agency (SA) on 12/3/22 and sexual abuse was substantiated. R1 was admitted to the facility on [DATE] with diagnoses to include dementia with behaviors, mood disorder, anxiety, and hypertension (high blood pressure). R1's most recent Minimum Data Set (MDS) assessment, dated 9/23/22, shows R1's Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. R1's care plan, created 6/9/22, shows that R1 has Socially inappropriate/disruptive behavioral symptoms as evidenced by inappropriate affectionate behaviors as well as [R1] at times will accept or initiate intimate behaviors with male residents. [R1] has dementia and is ambulatory. [R1] will wander into others rooms and sit on beds or visit with other residents. [R1]'s dementia prohibits [R1] from recognizing inappropriate touching/behaviors. R2 was admitted to the facility on [DATE] with diagnoses to include stroke, dementia, mood disturbance, insomnia, hypertension, edema, diabetes, and pain. R2's most recent MDS assessment, dated 11/17/22, shows R2's BIMS score of 6, indicating severe cognitive impairment. R2's initial care plan, created 11/7/22, did not include any inappropriate/disruptive behavioral symptoms. R2's care plan was revised on 11/26/22 to include [R2] has socially inappropriate/disruptive behavioral symptoms as evidenced by inappropriate behaviors towards staff and residents. On 12/7/22, Surveyor reviewed the citations issued at the facility's annual recertification survey with an exit date of 6/22/22. The facility received a harm level citation for abuse related encounters with R1. The facility submitted a Plan of Correction (POC) that stated staff education related to intimacy, sexual contact, consent and sexual abuse was completed on 7/13/22. The Surveyor also reviewed the citations issued at a complaint survey with an exit date of 7/21/22. The facility received another harm level citation for abuse related encounters with R1. On 12/7/22 at 12:11 PM, the Surveyor interviewed the NHA-A, who verified that the allegation of abuse on 11/26/22 was substantiated. The Surveyor inquired about the prior incidents that involved R1 and what interventions the facility had implemented. NHA-A stated that after 7/17/22, the facility had implemented a motion sensor alarm in R1's doorway to alert staff when R1 was leaving R1's room. Per NHA-A, this would indicate to staff that they needed to keep an eye on R1 and where male residents were in relation to R1. On 12/7/22 at 9:42 AM, 10:27 AM, 11:14 AM, 12:05 PM, 12:33 PM, 1:14 PM, and 2:03 PM, the Surveyor observed R1 in R1's room. There was no motion sensor or alarm noted in R1's room during any of the above observations. On 12/7/22 the Surveyor reviewed R1's medical record to include care plans and behavior monitoring. R1's medical record did not include any indication that R1 was supposed to have a motion sensor/alarm or what sort of supervision R1 required. On 12/7/22 at 2:07 PM, the Surveyor interviewed CNA-C, who verified that the motion sensor had been down for a while, for sure since 12/5/22 as that was the last day that CNA-C had worked. CNA-C added that it would be hard to keep an eye on [R1] when in another resident's room. On 12/7/22 at 2:35 PM, the Surveyor interviewed Maintenance Director (MD)-D, who stated that sometime this week .before today that the alarm had been placed on MD-D's desk without any indication of what was wrong. MD-D added that MD-D changed the batteries in the alarm and had just placed it back in R1's doorway. This was observed by the Surveyor at 2:30 PM MD-D verified that this was the first time MD-D had to complete any sort of maintenance on R1's motion sensor and that MD-D did not have any system set up to ensure the proper functioning of R1's motion sensor. On 12/7/22 at 3:06 PM, the Surveyor interviewed CNA-E. CNA-E stated that the last time CNA-E worked the night shift, which was 11/17/22, that R1's motion sensor/alarm was not working. The last time CNA-E can remember R1's sensor working properly was October, sometime. On 12/7/22 at 3:12 PM, the Surveyor interviewed Licensed Practical Nurse (LPN)-F. LPN-F stated that R1's alarm was not working on 12/6/22. On 12/7/22 at 3:46 PM, the Surveyor interviewed CNA-G. CNA-G verified that CNA-G came into work at 2 PM on 11/26/22, the date of the incident between R1 and R2. CNA-G stated that CNA-G heard about the incident during shift change because that was when the incident occurred. CNA-G added that after shift change, CNA-G went straight to R1's room to observe and did not hear R1's motion sensor/alarm go off when entering or exiting R1's room. CNA-G added that CNA-G was new and never trained on R1's alarm or supervision requirements. On 12/7/22 at 4:06 PM, the Surveyor interviewed NHA-A. NHA-A verified that there was no system in place to ensure that R1's motion sensor/alarm was effective and/or functioning properly. NHA-A agreed that stricter supervision for R1 would be best and would help ensure staff were assigned and accountable for R1's supervision and safety. NHA-A also agreed that it would be hard to staff to determine who is responsible for R1's supervision on each shift. NHA-A added that after the incident on 11/26/22, staff were educated on how to manage wandering residents. NHA-A provided a copy of the education to the Surveyor. The education included one power point slide titled Working with Wandering Residents. Staff were educated to try: distracting from wandering, steer residents towards a goal, walk with them for a bit, help them look for something, establish behavior patterns, redirect them once you've distracted them, see if all basic needs (eating, drinking, toileting, etc) are met, and included activity ideas such as item sorting, folding clothes, arts and crafts, reading books/magazines, activity boards/mats, and puzzles/games. The education did not include any education related to R1's motion sensor/alarm or any education related to adequate supervision. On 12/7/22 at 2:19 PM, the Surveyor interviewed R2's Power of Attorney for Healthcare (POA-HC). R2's POA-HC stated they were concerned about how R1 was able to get into R2's room without any staff noticing and is wondering what the facility was doing to prevent this from happening again. R2's POA-HC added that this behavior was very uncharacteristic of R2 and that R2 would not have consented to this sexual behavior with R1 prior to having dementia. The failure to prevent sexual abuse from occurring to residents with dementia, created a finding of Immediate Jeopardy. The facility removed the jeopardy on 12/9/22, when it had completed the following: 1. One to one supervision was implemented for R1 during waking hours, 15 minute checks at all times to support location awareness. Care plan updated to reflect the same. 2. Care plan updated to include R2's inability to provide consent for sexual encounters. Enhance supervision implemented to include direct supervision when out of room and 15 minute security checks at all times. 3. Immediate education of staff on duty regarding supervision expectations and responses. Ongoing education continued for staff prior to next working shift. 4. Alarm functioning check added to EMAR (Electronic Medication Administration Record) every shift. 5. All residents were assessed for signs and symptoms of abuse 6. All cognitively intact residents were interviewed regarding safety and abuse. 7. All cognitively impaired residents were evaluated for behaviors indicative of abuse. 8. Law enforcement was notified of sexual encounter.

Based on observation, staff interview and record review, the facility failed to supervise their whereabouts to ensure they did not engage in sexual contact that went beyond hand holding and kissing for 2 Residents (R)(R1 and R2) of 5 sampled residents. The facility was aware that R1, who had a diagnosis of dementia and was assessed to be unable to consent, had a history of sexually intimate encounters. The facility neglected to implement appropriate interventions to supervise and prevent R1 from engaging in sexually intimate encounters with R2, who was also assessed as unable to consent to sexual encounters, and other residents. On 11/26/22, R1 was found in R2's room and R2 was touching R1 in the genital area. The facility concluded the investigation on 12/3/22 and substantiated sexual abuse. Using the reasonable person concept, since R1 and R2 were severely cognitively impaired and assessed as unable to consent to sexual contact, it is likely one or both would suffer harm as a result of the sexual contact. It is also likely that other residents would suffer harm if R1 and R1's cognitive impairment, sexual impulses, and lack of supervision led them to seek out other residents for sexual encounters. Facility failure to supervise R1 when they were aware of the residen'ts previous history of intimate sexual encounters, created a finding of immediate jeopardy that began on 11/26/22. NHA (Nursing Home Administrator) was notified of the immediate jeopardy on 12/08/22 at 4:05 PM.The immediate jeopardy was removed on 12/9/22, however the deficient practice continues at a scope/severity of D while the facility implements its action plan. Findings Include: The facility policy titled Sexual and Intimacy Policy/Procedure, dated 8/8/22, states: The facility .acknowledges its responsibility to protect its' residents who may not be able to consent to sexual relationships. On 12/7/22, the Surveyor reviewed a Facility-Reported Incident (FRI), dated 11/26/22, that indicated R1 and R2 were the affected persons related to an occurrence in which R1 was found in R2's room with R2 rubbing on [R1's] groin/privates. R1 was admitted to the facility on [DATE] with diagnoses to include dementia with behaviors, mood disorder, anxiety, and hypertension (high blood pressure). R1's most recent Minimum Data Set (MDS) assessment, dated 9/23/22, shows R1's Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. R1's care plan, created 6/9/22, shows that R1 has Socially inappropriate/disruptive behavioral symptoms as evidenced by inappropriate affectionate behaviors as well as [R1] at times will accept or initiate intimate behaviors with male residents. [R1] has dementia and is ambulatory. [R1] will wander into others rooms and sit on beds or visit with other residents. [R1]'s dementia prohibits [R1] from recognizing inappropriate touching/behaviors. Interventions include: administer medications per physician orders, avoid over-stimulation, maintain a calm, slow approach, observe and report socially inappropriate behaviors when around others, offer redirection when resident is up wandering, praise [R1] when behavior is appropriate, and when noted episodes of socially inappropriate/affectionate towards other residents, provide redirection, offer 1 on 1 conversations, independent activities or other comfort measures for basic needs. R2 was admitted to the facility on [DATE] with diagnoses to include stroke, dementia, mood disturbance, insomnia, hypertension, edema, diabetes, and pain. R2's most recent MDS assessment, dated 11/17/22, shows R2's BIMS score of 6, indicating severe cognitive impairment. R2's initial care plan, created 11/7/22, did not include any inappropriate/disruptive behavioral symptoms. R2's care plan was revised on 11/26/22 to include [R2] has socially inappropriate/disruptive behavioral symptoms as evidenced by inappropriate behaviors towards staff and residents. On 12/7/22, Surveyor reviewed the citations issued at the facility's annual recertification survey with an exit date of 6/22/22. The facility received a harm level citation for abuse related encounters with R1 .The facility submitted a Plan of Correction (POC) that stated staff education related to intimacy, sexual contact, consent and sexual abuse was completed on 7/13/22. The Surveyor also reviewed the citations issued at a complaint survey with an exit date of 7/21/22. The facility received another harm level citation for abuse-related encounters with R1. On 12/7/22 at 12:11 PM., the Surveyor interviewed the Nursing Home Administrator (NHA)-A, who verified that the allegation of abuse on 11/26/22 was substantiated. The Surveyor inquired about the prior incidents that involved R1 and what interventions the facility had implemented. NHA-A stated that after 7/17/22, the facility had implemented a motion sensor alarm in R1's doorway to alert staff when R1 was leaving R1's room. Per NHA-A, this would indicate to staff that they needed to keep an eye on R1 and where male residents were in relation to R1. The Surveyor asked how often R1 was supposed to be checked on by staff and NHA-A stated as much as they can. On 12/7/22 at 9:42 AM, 10:27 AM, 11:14 AM, 12:05 PM, 12:33 PM, 1:14 PM, and 2:03 PM, the Surveyor observed R1 in R1's room. There was no motion sensor or alarm noted in R1's room during any of the above observations. On 12/7/22 the Surveyor reviewed R1's medical record to include care plans and behavior monitoring. R1's medical record did not include any indication that R1 was supposed to have a motion sensor/alarm or what sort of supervision R1 required. On 12/7/22 at 1:34 PM, the Surveyor interviewed NHA-A regarding the missing motion sensor in R1's doorway. NHA-A stated that it must have broken last night or that maybe R1 took it down. The Surveyor inquired about increased supervision during the time the motion sensor was down. NHA-A provided the Surveyor with documented 15-minute checks for R1 that began on 12/7/22 at 7 AM with no additional documented checks prior to that time. On 12/7/22 at 2:07 PM, the Surveyor interviewed CNA-C, who verified that the motion sensor had been down for a while, for sure since 12/5/22 as that was the last day that CNA-C had worked. CNA-C added that it would be hard to keep an eye on [R1] when in another resident's room. On 12/7/22 at 2:35 PM, the Surveyor interviewed Maintenance Director (MD)-D, who stated that sometime this week .before today that the alarm had been placed on MD-D's desk without any indication of what was wrong. MD-D added that MD-D changed the batteries in the alarm and had just placed it back in R1's doorway. This was observed by the Surveyor at 2:30 PM MD-D verified that this was the first time MD-D had to complete any sort of maintenance on R1's motion sensor and that MD-D did not have any system set up to ensure the proper functioning of R1's motion sensor. On 12/7/22 at 3:06 PM, the Surveyor interviewed CNA-E. CNA-E stated that the last time CNA-E worked the night shift, which was 11/17/22, that R1's motion sensor/alarm was not working. The last time CNA-E can remember R1's sensor working properly was October, sometime. On 12/7/22 at 3:12 PM, the Surveyor interviewed Licensed Practical Nurse (LPN)-F. LPN-F stated that R1's alarm was not working on 12/6/22. On 12/7/22 at 3:46 PM, the Surveyor interviewed CNA-G. CNA-G verified that CNA-G came into work at 2 PM on 11/26/22, the date of the incident between R1 and R2. CNA-G stated that CNA-G heard about the incident during shift change because that was when the incident occurred. CNA-G added that after shift change, CNA-G went straight to R1's room to observe and did not hear R1's motion sensor/alarm go off when entering or exiting R1's room. CNA-G added that CNA-G was new and never trained on R1's alarm or supervision requirements. On 12/7/22 at 4:06 PM, the Surveyor interviewed NHA-A. NHA-A verified that there was no system in place to ensure that R1's motion sensor/alarm was effective and/or functioning properly. NHA-A agreed that stricter supervision for R1 would be best and would help ensure staff were assigned and accountable for R1's supervision and safety. NHA-A also agreed that it would be hard to staff to determine who is responsible for R1's supervision on each shift. NHA-A added that after the incident on 11/26/22, staff were educated on how to manage wandering residents. NHA-A provided a copy of the education to the Surveyor. The education included one power point slide titled Working with Wandering Residents. Staff were educated to try: distracting from wandering, steer residents towards a goal, walk with them for a bit, help them look for something, establish behavior patterns, redirect them once you've distracted them, see if all basic needs (eating, drinking, toileting, etc) are met, and included activity ideas such as item sorting, folding clothes, arts and crafts, reading books/magazines, activity boards/mats, and puzzles/games. The education did not include any items related to R1's motion sensor/alarm or any education related to adequate supervision. On 12/7/22 at 2:19 PM, the Surveyor interviewed R2's Power of Attorney for Healthcare (POA-HC). R2's POA-HC stated they were concerned about how R1 was able to get into R2's room without any staff noticing and is wondering what the facility was doing to prevent this from happening again. R2's POA-HC added that this behavior was very uncharacteristic of R2 and that R2 would not have consented to this sexual behavior with R1 prior to having dementia. The failure to provide adequate supervision of R1 to prevent reoccurence of sexual abuse, created a finding of Immediate Jeopardy. The facility removed the jeopardy on 12/9/22, when it had completed the following: 1. One to one supervision was implemented for R1 during waking hours, 15 minute checks at all times to support location awareness. Care plan updated to reflect the same. 2. Care plan updated to include R2's inability to provide consent for sexual encounters. Enhance supervision implemented to include direct supervision when out of room and 15 minute security checks at all times. 3. Immediate education of staff on duty regarding supervision expectations and responses. Ongoing education continued for staff prior to next working shift. 4. Alarm functioning check added to EMAR (Electronic Medication Administration Record) every shift. 5. All residents were assessed for signs and symptoms of abuse 6. All cognitively intact residents were interviewed regarding safety and abuse. 7. All cognitively impaired residents were evaluated for behaviors indicative of abuse. 8. Law enforcement notified of sexual encounter.

Based on record review and resident and staff interview, the facility did not provide the necessary care and services to maintain the highest practical well being in accordance with the comprehensive assessment and plan of care related to pain management for 1 Resident (R) (R1) of 1 sampled resident reviewed for pain. R1 complained of pain in the left hip starting on 10/6/22. R1 indicated the pain was really bad and pain medication only helped a little. An X-ray was ordered on 10/6/22, but not obtained by the facility. On 10/10/22, R1 went to an orthopedic appointment and was found to have left hip fracture. Findings include: The facility's Abuse and Neglect Policy, dated March of 2018, stated: Neglect means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .Assessment and Recognition 1. The nurse will assess the individual and document related findings. Assessment data will include: a. injury assessment b. pain assessment 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set), dated 9/20/22, indicated R1 required extensive assistance for transfers, dressing and hygiene and limited assistance for bed mobility. R1's BIMS (Brief Interview for Mental Status) assessment, dated 9/20/22, indicated R1 had moderate cognitive impairment. On 10/24/22 at 11:23 AM, Surveyor interviewed R1 and FM (Family Member)-F. R1 indicated the pain started on or before 10/6/22. R1 stated the pain was very severe and at a level 8 on a pain scale of 0-10. R1 stated R1 could tell something was wrong because the pain felt a lot like when R1's right hip was fractured. R1 also stated R1 wanted an X-ray. FM-F stated that on 10/7/22 when FM-F arrived at the facility, R1 was being transferred in R1's room. FM-F stated R1 was screaming in pain and had never before screamed due to pain. FM-F stated R1 and FM-F requested an X-ray; however, an X-ray was not obtained. FM-F stated R1 was in pain for four days until R1's orthopedic appointment on 10/10/22. During the appointment, it was discovered R1 had a left hip fracture. R1 stated the pain was severe for four days. R1 stated pain medication helped a little bit, but didn't last long. R1 again stated the pain was a level 8 out of 10 and indicated the facility just couldn't knock down the pain. On 10/24/22 at 2:44 PM, Surveyor interviewed RN (Registered Nurse)-C. RN-C stated that on 10/6/22, R1 came inside from smoking and RN-C could tell R1 was in a lot of pain. RN-C stated R1 indicated their left hip hurt badly. RN-C stated, I did check for internal rotation, but did not see any at the time. I did call (R1's) primary doctor's office and requested an X-ray. My shift was ending, so I told the PM nurse (RN-D) that (R1) needed an X-ray and the doctor's office was called and to follow up with the X-ray because (R1) was in a lot of pain. I did not return until that following Tuesday (10/11/22) and found that there was no follow up with the X-ray and nothing at all in the nurses' notes. I was upset that (R1) now had a left hip fracture and nothing was done all weekend and (R1) was in pain. I even talked with (NHA (Nursing Home Administrator)-A) and said (NHA-A) might want to call the State and (NHA-A) just said, 'Why?' I said, 'Because (R1) has a left hip fracture.' On 10/24/22 at 2:55 PM, Surveyor interviewed RN-D. RN-D stated RN-D was aware of R1's left leg pain and a call was made for an X-ray. RN-D indicated the doctor's office called back and wanted more specifics related to R1's pain. RN-D stated RN-D asked R1 about the pain and gave that information to RN-E, a nurse in MD (Medical Doctor)-G's office. Surveyor asked RN-D if RN-D followed up with any X-ray orders that came from the MD-G's office. RN-D stated RN-D did not follow-up with any X-ray orders. On 10/24/22 at 4:39 PM, Surveyor interviewed RN-E via telephone. RN-E verified MD-G ordered an X-ray of R1's left hip on 10/6/22, but could not confirm if the order was faxed or called to the facility. On 10/24/22, Surveyor reviewed R1's medical record. A nursing note, dated 10/6/22, stated R1 complained of left leg pain and rated the pain at a level 8 out of 10. R1 requested [MEDICATION(S)] (a narcotic medication used to treat moderate to severe pain), but normally used Tylenol (an analgesic medication used to treat minor aches and pains) for pain relief. The note also stated R1 requested a left leg X-ray. The note indicated an MD was called and the facility was awaiting orders. A Physical Therapy note, dated 10/7/22, contained the following information: Pain present, pain level determined based upon behaviors exhibited by (R1). Behaviors exhibited: (R1) reports having pain in hip with flexion and wheelchair mobility. Does pain limit (R1's) functional activities? Yes, pain limits the following functional activities: Limits tolerance for activity and wheelchair mobility using left lower extremity mostly with hip flexion tasks. What relieves pain: ice, prescribed medications, remaining still. What exacerbates pain: standing, bending, prolonged activity. (R1) states (R1) has had progressive pain in the left hip over the past few days. Nurse was notified of (R1's) pain and ice was applied. A Physical Therapy note, dated 10/8/22, contained the following information: Pain = Unable to determine at this time. (R1) declined any transfers/ambulation due to left hip pain much worse, woke up crying in pain and did not get better until [MEDICATION(S)] was given. Surveyor reviewed R1's MAR (Medication Administration Record) which indicated the following pain medications were administered from 10/6/22 to 10/10/22: Tylenol 325 mg (milligrams) 2 tablets three times daily. The medication was administered at 6:00 AM, 3:00 PM and 9:00 PM on 10/6/22, 10/7/22, 10/8/22 and 10/9/22 and at 6:00 AM on 10/10/22. Tylenol 325 mg 2 tablets every 6 hours as needed. The medication was not administered from 10/6/22 through 10/10/22. [MEDICATION(S)] tablet 5 mg. Take 5 mg (1 tablet) by mouth every 6 hours as needed. The medication was administered on 10/6/22 at 7:46 PM and on 10/7/22 at 4:42 AM, 11:39 AM and 6:08 PM. The MAR (Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] was not administered on 10/8/22, 10/9/22 or 10/10/22. Surveyor asked the facility for documentation of R1's pain assessments from 10/6/22 through 10/10/22. Pain assessments were not provided. The facility provided non-descript nursing notes related to pain. ~A nursing note dated 10/6/22 indicated, R1 complaining of left leg pain, rates 8/10. requesting [MEDICATION(S)], normally uses Tylenol for pain relief. Resident is requesting for a left leg x-ray. Doctor called waiting for orders. ~A physical therapy note dated 10/7/22, indicated Patient has had progressive pain in left hip over past few days. Patient educated to minimize overuse and to ice left hip throughout the day. Nurse notified of patients pain and that ice was applied. ~A physical therapy note dated 10/8/22, indicated Patient declined any transfers/ambulation due to left hip pain much worse , woke up crying in pain and did not get better until took an [MEDICATION(S)]. Surveyor also requested physician assessments of R1's pain; however, no physician assessments were provided. The Surveyor also noted there was no documentation in R1's medical record that a physician was notified of R1's severe pain. On 10/24/22 at 3:05 PM, Surveyor interviewed NHA-A and DON-B regarding R1's pain. NHA-A and DON-B stated that they were not aware R1 was in excruciating pain. NHA-A and DON-B also stated they were not aware until 10/19/22 that R1 was diagnosed with a hip fracture during an orthopedic appointment on 10/10/22. NHA-A and DON-B verified R1 did not return to the facility as anticipated following the 10/10/22 orthopedic appointment. When asked if NHA-A and DON-B were aware why R1 did not return to the facility for a total of nine days following the orthopedic appointment on 10/10/22, DON-B then stated NHA-A and DON-B may have known of the hip fracture; however, there was also concern of a stroke.

Based on record review, interviews and observations, the facility did not ensure 2 of 5 sampled residents (R), R1 and R2, were free from neglect, as the facility failed to assess them to determine if they could consent to sexual contact and, absent this, failed to supervise their whereabouts to ensure they did not engage in sexual contact that went beyond hand holding and kissing. The facility was aware R1 and R2, both with dementia diagnoses, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility neglected to implement appropriate interventions to supervise and prevent R1 and R2 from engaging in sexually intimate encounters with each other and other residents. On 7/17/22, staff found R1 fondling R2's breasts. Using the reasonable person concept, since R1 and R2 were severely cognitively impaired and not assessed as able to consent to sexual contact, it is likely one or both would suffer harm as a result of the sexual contact. It is also likely other residents would suffer harm if R1 and R2's cognitive impairment, sexual impulses and lack of supervision led them to seek out other residents for sexual encounters. Findings include: Neglect is defined in Appendix PP State Operations Manual as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Surveyor reviewed a facility-reported incident (FRI) initial report, dated 7/19/22 at 4:08 PM, that indicated R1 and R2 were the affected persons related to an occurrence in which R1 and R2 were intimate in R1's bed including fondling of R2's breasts. The FRI indicated this occurred on 7/17/22 at 3:00 PM. The FRI indicated the date of discovery was 7/19/22. Facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with a revision date of 7/15/22 defined sexual abuse as, Non-consensual sexual contact of any type with a resident. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Brief Interview for Mental Status (BIMS) score on 6/22/22 was 00/15, which indicated severe cognitive deficits. R1 had an activated power of attorney for health care. There was no assessment to determine if R1 could consent to sexual intimacy. R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's BIMS score on 6/8/22 was 00/15, which indicated severe cognitive deficits. R2's spouse was the guardian of R2. There was no assessment to determine if R2 could consent to sexual intimacy. On 7/21/22, Surveyor reviewed the citations issued at the facility's annual recertification survey with an exit date of 6/22/22. The facility received a harm level citation for abuse related encounters with R1 and R2 as well as R1 and another female resident. The Statement of Deficiency stated the facility did not ensure R2 remained free from sexual abuse when R1 placed R1's hand up R2's shirt, kissed R2 and allowed R2 to sit on R1's lap on multiple occasions. The facility submitted a Plan of Correction (POC) that stated staff education related to intimacy, sexual contact, consent and sexual abuse was completed on 7/13/22. Surveyor reviewed R1's Electronic Medical Record (EMR) which included a progress note, dated 7/17/22 at 3:33 PM, that read: Housekeeping reported to writer that (R2) was in (R1's) room sitting on the edge of the bed, while (R1) was in bed. (R1) was under (R2's) blouse touching the breasts. Staff removed (R2) from (R1's) room under much protest from (R2). Surveyor reviewed R2's EMR which included a progress note, dated 7/17/22 at 3:33 PM, that read: Housekeeping reported to writer that (R2) was in (R1's room) sitting on the edge of the bed while (R1) was resting. (R1) was up under (R2's) shirt fondling breast. Staff asked (R2) to come out of the room and (R2) refused at least 4 times and stated, Why, I am not doing anything wrong. After much persuasion from staff, we ambulated (R2) out of (R1's room) down to (R2's) room. On 7/21/22, Surveyor reviewed R1's care plan which included the following: -Problem Start Date 6/21/22: Behavioral Symptoms: Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by sexually inappropriate behaviors and foul language towards staff and other residents. Goal: R1 will not exhibit socially inappropriate/disruptive behaviors towards staff and will be able to be redirected. Approach Start Date 6/21/22, Edited 6/22/22: Observe and report socially inappropriate/disruptive behaviors when around others. Approach Start Date 6/21/22: Praise when behavior is appropriate. Approach Start Date 6/21/22, Edited 6/22/22: Remove R1 from other residents' rooms and unsafe situations. Approach Start Date 6/21/22, Edited 7/19/22: When R1 begins to become socially inappropriate/disruptive, remain calm and professional. Redirect R1 and educate on appropriate behaviors in a calm manner. Explain to R1 that it is inappropriate and unacceptable. -Problem Start Date 6/21/22: Behavioral Symptoms: Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). R1 requires supervision and redirection from staff. Approach 6/22/22: Remove R1 from other residents' rooms and unsafe situations. Surveyor reviewed R2's care plan which included the following: -Problem Start Date 6/9/22: Behavioral Symptoms: R2 experiences affectionate behaviors including touching, holding hands, hugs and calling other residents honey and sweetheart r/t (related to) R2's dementia. Goal: R2 will not exhibit socially inappropriate/affectionate behavior that interferes with others' well-being. (Edited 6/9/22) Approach Start Date 6/9/22: Observe and report socially inappropriate/affectionate behaviors when around others. Approach Start Date 6/9/22: Praise R2 when behavior is appropriate. Approach Start Date 6/9/22: Remove R2 from other residents' rooms and unsafe situations. Approach Start Date 6/9/22: When R2 becomes socially inappropriate/affectionate, intervene by moving to a quiet, calm environment. -Problem State Date Edited 6/27/22: Behavioral Symptoms: R2 has socially inappropriate/disruptive behavioral symptoms as evidenced by inappropriate affectionate behaviors. Goal: R2 will not exhibit socially inappropriate/disruptive behavior and be easily redirected by staff. (Edited 6/9/22). Approach Start Date: 6/9/22: Assess whether the behavior endangers R2 and/or others. Intervene if necessary. Approach Start Date: 6/9/22: Seat R2 where constant/near constant observation is possible. Approach Start Date: 6/9/22: When R2 becomes socially inappropriate/disruptive, move to a quiet, calm environment. Approach Start Date 6/9/22, Edited 6/27/22: Remove R2 from other residents' rooms and unsafe situations. Approach Start Date 6/9/22: 1:1 (one on one) sessions with R2 as needed. -Problem Start Date 6/9/22, Edited 7/19/22: Behavioral Symptoms: R2 experiences wandering (moves with no rationale or purpose, seemingly oblivious to needs or safety). Approach Start Date: 7/19/22 with an end date of 7/19/22: Remove resident from other residents' rooms and unsafe situations. Allow for resident to engage in positive forms of intimacy such as hugging, holding hands, and sitting close to one another. Re-direct resident from negative forms of sexual behavior. On 7/21/22 at 8:50 AM, Surveyor interviewed day shift Licensed Practical Nurse (LPN)-C who indicated R1 was on 30-minute checks by staff related to an incident that occurred earlier that week. On 7/21/22 at 9:00 AM, Surveyor interviewed R2 who was unable to recite the current day, month or year. When asked about intimacy, R2 responded it means you love them and also that intimacy can involve touching. R2 was ambulatory without staff assistance. On 7/21/22 at 10:40 AM, Surveyor attempted to interview R1. R1 indicated the year was 19 something. Upon further attempts to interview R1, R1 did not answer. R1 appeared to not understand questions and was sleepy. R1 utilized a wheelchair for mobility. On 7/21/22 at 9:33 AM, Surveyor interviewed night shift LPN-D who indicated there were no residents currently on 15 or 30-minutes checks. During the interview, Nursing Home Administrator (NHA)-A came into the nurses' station and joined the conversation. LPN-D stated to NHA-A that LPN-D was not aware of a resident being on 30 minute checks. NHA-A indicated that R1 and R2 were on checks due to the recent situation and then explained that R2 wandered into R1's room on Sunday (7/17/22) and R1 fondled R2's breast. LPN-D stated to NHA-A that LPN-D was not aware of the incident with R1 and R2. NHA-A explained to LPN-D that R1 and R2 were being checked on due to them gravitating to each other and can be inappropriate at times. NHA-A further explained that sometimes R1 initiated and sometimes R2 initiated the interactions. Surveyor asked NHA-A if 30 minutes checks were supposed to be conducted at that time by staff. NHA-A answered no. LPN-D asked NHA-A if LPN-D saw an incident between R1 and R2 should LPN-D initiate 30 minutes checks or direct supervision? NHA-A stated, Maybe we should change our approach. NHA-A explained that thought came after having spoken to OMB-F. NHA-A stated HKP-E walked in and saw R1 fondling R2's breast. HKP-E redirected R2, but indicated redirection was difficult. NHA-A stated, So maybe our approach is not working and maybe they want to be together. NHA-A then clarified with LPN-D that R1 was still on supervision at all times. Surveyor requested clarification from NHA-A as to the extent of supervision being performed. NHA-A confirmed that when R1 was in the dining room, staff followed R1 into the dining room. NHA-A confirmed staff did not sit outside R1's room door when R1 was in R1's room. NHA-A stated that sitting outside a resident's room was considered direct supervision. Surveyor then continued interviewing NHA-A without LPN-D present. NHA-A indicated the interaction between R1 and R2 occurred around 3:00 PM on Sunday 7/17/22; however, staff did not report the interaction to NHA-A or Director of Nursing (DON)-B. NHA-A stated NHA-A found a progress note in the EMR on Tuesday morning (7/19/22) during a morning meeting. NHA-A later confirmed NHA-A reported the occurrence to the State Agency (SA) on 7/19/22 in the afternoon. (Documents indicated the facility-reported incident was submitted on 7/19/22 at 4:08 PM.) When asked what interventions were in place for R1 and R2, NHA-A stated supervision was on R1's care plan and that R1 had to be under staff supervision when out of R1's room. NHA-A stated, Staff have to keep eyes on (R1). NHA-A also stated R1 and R2 were on separate wings. NHA-A stated, They are still trying to seek out one another, unless we do a 1 on 1 intervention (a process where staff stays with a resident at all times), they could slip out and do anything. NHA-A stated NHA-A contacted R1's managed care organization (MCO) because maybe (R1) should be in a different facility or on a 1 on 1. NHA-A confirmed the facility did not attempt to initiate 1 on 1 staff supervision for either resident. Surveyor asked NHA-A if staff understood the meaning of supervision and NHA-A indicated that, since 7/19/22, NHA-A was conducting education with staff. NHA-A confirmed the trainings were with day and PM shift but not night shift yet. NHA-A stated, With (R1 and R2) it is about going over the consent thing; it is their choice. When asked to explain that statement, NHA-A indicated I have packets the Ombudsman gave me and I went over it with residents in a resident meeting about them having rights to have intimacy like holding hands, a kiss on the cheek, but when it comes to groping people and fondling breasts that is different. NHA-A stated hugging in the hallways was OK, but from the facility's standpoint, something further than that in a room was not OK. NHA-A explained further interventions that included bringing R1 and R2 to the dining room at separate times with R2 not being brought to the dining room until others were seated and the meal was about to be served, seating R1 and R2 at tables apart from each other with their backs to one another and staff regularly checking on both residents to see where they were due to R2 having a habit of wandering into other rooms. NHA-A stated monitoring R2's location was not just to ensure R2 was not in R1's room, but other residents' rooms as well. NHA-A also listed keeping both residents busy with activities as an intervention. NHA-A stated, We are trying to keep with the interventions, but they like each other. At first when I read the progress note, I thought (R2) was the victim, but then I saw (R2) was in (R1's) room. I am trying to decide who is the victim, so I decided to report. NHA-A added that R2 was difficult to redirect from R1's room and that got me thinking maybe we aren't doing the right thing because (R2) obviously wants to be there. NHA-A indicated NHA-A updated R1 and R2's care plans on 7/19/22 after becoming aware of the occurrence. NHA-A added, We decided to keep them (R1 and R2) away from each other and staff to keep their eyes out for both of them. NHA-A confirmed the intervention was supervision (not direct supervision). NHA-A verified NHA-A did not discuss the intervention with night shift since the Sunday (7/17/22) occurrence between R1 and R2; however, NHA-A educated day and PM shift staff. NHA-A stated the goal was still to redirect R1 and R2 when they were near each other. NHA-A then reverted back to the question, But are we supposed to do more to allow them to have private time, that is what we are going over - is our intervention even appropriate or not? Are we the ones maybe not doing the right things in terms of allowing this to happen? On 7/21/22 at 10:45 AM, Surveyor interviewed Registered Nurse (RN)-H who at first stated RN-H was aware of the recent occurrence between R1 and R2. Surveyor explained the details of the occurrence and then RN-H stated, I was not aware of Sunday (7/17/22). I have seen them (R1 and R2) do other things. RN-H explained RN-H was aware of R1 and R2 kissing and R1 rubbing R2. RN-H stated, That is pretty common behavior and it took a long time of us (staff) complaining to get anything done about it. They (management) were like, 'Awe it's OK, it's cute'. RN-H indicated RN-H did not think the matter was resolved yet. On 7/21/22 at 10:56 AM, Surveyor observed R2 seated in the dining room with no staff present. At 11:05, R2 was still in the dining room with staff coming and going. At 11:07 AM, a male resident entered the dining room and sat at a table next to R2. No staff were in the dining room at that time. At 11:10 AM, staff entered the dining room and left again. From 11:11 to 11:15 AM, no staff were in the dining room. At 11:17 AM, NHA-A entered the dining room, observed R2 and then left the dining room. At 11:22 AM, staff brought R1 into the dining room and placed R1 at a table next to R2 (approximately 10 feet apart) facing R2. At 11:23 AM, DON-B looked into the dining room from the hall and left. No seating changes were made. From 11:27 to 11:29 AM and 11:33 to 11:35 AM, no staff were in the dining room. R1 and R2 were still seated at adjacent tables throughout the mealtime observation. On 7/21/22 at 11:42 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who indicated R2 usually sat at the table behind R1, not next to R1. On 7/21/22 at 11:43 AM, Surveyor interviewed CNA-J who stated CNA-J worked at the facility 8 months and never saw R1 and R2 sit back-to-back (as indicated by NHA-A earlier). CNA-J was not aware of the intervention. On 7/21/22 at 11:51 AM, Surveyor interviewed NHA-A who verified NHA-A saw R2's placement in the dining room. NHA-A indicated R2 usually sat one table back than where R2 was today and usually R1 and R2 were back to back (not facing each other) as they were today. NHA-A stated, (R2) was in the dining room early today. On 7/21/22 after the lunch meal, NHA-A provided Surveyor with an updated care plan for R1. NH-A stated after reviewing R1's care plan, the facility added an intervention to allow intimacy. NHA-A stated the facility added the intervention because of an Ombudsman training packet that discussed positive intimacy. NHA-A stated, If we try to keep them busy doing other things and try to remove them from any contact with each other and they do enjoy being with one another . (NHA-A did not complete the sentence). NHA-A stated, It (Ombudsman training materials) says it's OK to have family included in decisions but it's really mostly collectively talking with staff and (R1) does have inappropriate behaviors; however, they (R1 and R2) like each other. (R2) enjoys being with (R1) if they are seeking each other out. Is it fair to (R2) because (R1) can have inappropriate behaviors? We are still working through what is in line, but we should at least stop telling them (staff) that they should be redirected. We need to balance that out yet. NHA-A confirmed that an evaluation or assessment related to the ability to give consent was not conducted with either R1 or R2 by the facility. Surveyor reviewed R1's updated care plan which now included an approach, dated 7/21, that read: Allow (R1) to express positive forms of intimacy such as hugging, holding hands and kissing. Re-direct and remove when displays negative forms or sexual language. Provide supervision to and from dining room. On 7/21/11 at 1:21 PM, Surveyor interviewed LPN-G. LPN-G confirmed that HKP-E reported to LPN-G that R2 was seated on R1's bed and R1 was observed fondling R2's breasts on 7/17/22. LPN-G explained that staff were trained that holding hands and kissing were OK, but doing sexual acts was not OK. LPN-G stated LPN-G did not personally witness R1's hands up R2's shirt. LPN-G verified LPN-G did not do an assessment of R1 or R2. LPN-G also confirmed not updating R1 or R2's care plan with interventions to prevent further occurrences. LPN-G explained that after the occurrence, LPN-G told PM CNAs to keep R2 in R2's room and that during supper, LPN-G had staff stay in the dining room with R1 and R2. LPN-G indicated LPN-G told the night shift nurse that evening about the occurrence, but was not sure if the night nurse implemented interventions. On 7/21/22 at 2:30 PM, Surveyor was present in the nurses' station when day shift LPN-C told PM nurses, We are putting (R1) on checks due to (R1's) behaviors. Surveyor interviewed RN-K about R1 and R2. RN-K stated, It is more so (R2) (who initiates intimate interactions). LPN-C added that in the past R1 initiated intimate interactions; however, in the past month, R1 did not initiate interactions. LPN-C confirmed R1 had a decline in health. On 7/21/22 at 2:35 PM, Surveyor interviewed PM shift CNA-M who indicated R1 went into other residents' rooms; however, CNA-M believed it was due to R1 liking windows and when R1 saw a window, R1 headed toward it. CNA-M indicated both R1 and R2 sought each other out and stated R2 went to R1's room and R1 sought out R2 in the dining room. On 7/21/22 at 2:37 PM, Surveyor interviewed PM shift CNA-N who indicated R1 sought out R2 in the dining room and R2 sought out R1 by entering R1's room. NHA-A provided Surveyor with the Ombudsman training material that NHA-A mentioned. The document was titled Recommendation for Addressing Resident Relationships and the date on the training was March 2014. Page 3 of the document outlines four guidelines on which to base an assessment to determine a person's ability to consent to a sexual action. The four guidelines are listed as follows: * The individual must understand the distinctively sexual nature of the conduct. * The individual recognizes his/her body is private and that he/she has the right to refuse to engage in sexual activity. * The individual recognizes the sexual contact may create possible health risks and physical consequences. * The individual needs to understand there may be negative social or societal response to the sexual behavior. The document further stated, A resident relationship policy should include procedures on how to assess for consent to sexual contact. These four guidelines, from case law, are recommended as the basis for an assessment. NHA-A confirmed NHA-A previously read the portion of the Ombudsman training document related to determining a person's ability to consent. NHA-A indicated that fondling breasts was not acceptable behavior. NHA-A confirmed that there was no evaluation or assessment of either R1 or R2's ability to consent to intimate/sexual encounters. On 7/21/22, Surveyor reviewed the training NHA-A presented on 7/13/22 to facility staff. The training included the above four guidelines to determine capacity to appraise personal conduct. NHA-A indicated the Ombudsman training document was obtained from a sister-facility and not directly provided by an Ombudsman, but that NHA-A did reach out to the OMB-F regarding R1 and R2. NHA-A provided an email between NHA-A and Ombudsman, dated 7/20/22, that read: NHA-A to OMB-F: I was wondering if it is possible for you to come to (the facility) sometime and do an in-service regarding resident relationships, intimacy and sexuality? OMB-F to NHA-A: .Do you have specific areas of concerns, questions you want me to focus on? NHA-A to OMB-F: .I have two residents currently that both have dementia and seem to be drawn to one another. There is such a gray area when it comes to consent and their POAs (powers of attorney) are aware, but we know it doesn't make it right. I (NHA-A) am currently working on care planning for these two residents. I also put in a reportable (FRI) as the female resident wandered into the male resident's room and staff walked in on him fondling her breasts. I put both of them as the affected persons as it is hard to distinguish who was the initiator. Their BIMS are both indicative of severe impairment. On 7/25/22 at 8:23 AM, Surveyor interviewed OMB-F who confirmed NHA-A contacted OMB-F via email on 7/20/22 and they spoke briefly on the phone as well. OMB-F indicated there were no interactions with NHA-A prior to 7/20/22 regarding R1 and R2 or sexual interactions between residents. OMB-F confirmed that both R1 and R2 required an evaluation/assessment to determine if they could be consensual to intimate/sexual encounters given their diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . OMB-F stated, Evaluation is the first step. OMB-F indicated once the evaluation was completed and if an ability to consent to intimacy/sexual interactions was clarified, the next step was to have a safe plan in place to allow intimacy in a private setting. OMB-F confirmed the evaluation to determine ability to consent with each resident should be completed timelier than weeks after the intimate/sexual interaction occurred and should have been completed within days of the occurrence. OMB-F added that the facility should always monitor for change in the involved residents, at which time an evaluation for the ability to consent should be repeated.

Based on record review and staff interview, the facility did not ensure 2 Residents (R) (R16 and R26) of 13 residents reviewed were free from sexual abuse. The facility did not ensure R16 remained free from sexual abuse when R23 was alleged to have placed hand in the pubic area of R16. Using the reasonable person concept, since R16 is not able to communicate feelings, it is likely a dependent resident unable to defend self would experience chronic or recurrent fear/anxiety when touched inappropriately and when the perpetrator continues to enter room. The facility did not ensure R26 remained free from sexual abuse when R23 has placed their hand up R26 shirt, kissed R26 and allowing R26 to sit on lap of R23 on multiple occasions. Findings include: Surveyor reviewed facility provided policy named Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised on 5/25/22. Included in the policy stated: C. PREVENTION: ABUSE POLICY REQUIREMENTS; It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and whom to report concerns, incidents and grievances without the fear of reprisal or retribution. D. IDENTIFICATION: ABUSE POLICY REQUIREMENTS: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated. E. INVESTIGATION: ABUSE POLICY REQUIREMENTS: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. F. PROTECTION: ABUSE POLICY REQUIREMENTS: It is the policy of this facility that the resident(s) will be protected from the alleged offender(s). Sexual abuse, is defined at as non-consensual sexual contact of any type with a resident. Willful, as defined and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 1. R16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's Minimum Data Set (MDS) assessment dated [DATE] stated R16's Brief Interview for Mental Status (BIMS) score was unable to be completed no resident is rarely/never understood. R16 has an activated Power of Attorney (POA) for health care. Surveyor interviewed POA of health care who had no concerns with the care R16 was receiving. On 6/20/22 at 9:26 AM, Surveyor interviewed R27, roommate of R16, who explained about two weeks ago R23 entered their room and approached R16 and R23 placed their hand in the pubic area of R16 and began to make a rubbing motion. R27 explained that the call light was put on and the inappropriate behavior was reported to the staff who removed R23 from R27 and R16's room. R27 continued to explain that R23 has also touched other residents in the facility but has not hurt R27. R27 further explained there has been many observations of R23 touching other residents in the lobby and dining areas which is upsetting to R27. R27 reported that R23 was currently in the hospital and the last time R23 was in R27 & R16's room was on 6/18/22. Surveyor reviewed R23's medical record and progress notes dated 6/18/22 at 8:59 PM, Was wandering into other residents rooms and upsetting them throughout PM shift. Was redirected many times. Was given Tylenol 650 mg at 9:00 PM. Surveyor reviewed R27's medical record. R27's Minimum Data Set (MDS) assessment dated [DATE] stated R14's Brief Interview for Mental Status (BIMS) score was 14/15 which shows no cognitive impairment. On 6/20/22 at 9:42 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who explained that R27's call light was on and R23 was in R27 and R16's room. At that time R23 was removed from R27 and R16's room. R27 reported to CNA-D that R23 inappropriately touched R16 in the pubic area. CNA-D immediately reported incident to Licensed Practical Nurse (LPN)-C. R23 was found near R16 window and R16 was in bed covered up. CNA-D explained that R23 will often wander the hallways and end up in other residents' rooms. CNA-D explained that this occurred about two weeks ago and R27 was upset about the incident. On 6/20/22 at 9:54 AM, Surveyor interviewed LPN-C who denies receiving allegation reported by CNA-D and explained it didn't happen since R23 was not close to R16 when CNA-D entered the room. LPN-C did verify that R23 will wander into other residents' rooms and had been observed kissing, touching and holding hands with R26 on a regular basis. Re-direction of behaviors is the approach taken when actions are observed. On 6/20/22 at 9:49 AM, Interviewed Nurse Aide Trainee-F who explained that R23 will wander the hallways often. On 6/21/22 at 9:20 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Regional Director (RD)-E DON-B explained that R23 will wander the hallways and has a fancy for one certain resident but has not been informed of another incident and was not informed of the incident between R23 and R16. NHA-A explained that R23 has a care plan explaining behaviors and intervention to re-direct when observed kissing or touching other residents. NHA-A uses the Department of Health services flow sheet on resident-to-resident interaction to help guide incidents reported and investigated. NHA-A verified that incidents related to R23 should have been reported and further investigation and further education is needed. NHA-A further validated it was important to protect all residents in the facility regardless of cognitive status. On 6/21/22 at 1:50 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-G who received the report of R23 entering R16 room and touching and rubbing R16's pubic area. ADON-G was told by LPN-C since R23 was found near the window when the light was answered the allegation couldn't have taken place. ADON-G also mentioned that CNA-D reported R27's statement of seeing R23 touching R16 along with where R23 was found that day. No further investigation was completed or reported. Surveyor reviewed R16's medical record and progress notes which showed no evidence of incident. Surveyor reviewed grievance file and no evidence of above incident. 2. R26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Minimum Data Set (MDS) assessment dated [DATE] stated R26's Brief Interview for Mental Status (BIMS) score was 00/15 which indicated severe cognitive deficits. R26's spouse was guardian for R26. Surveyor interviewed guardian who had no concerns with the care R26 was receiving. Surveyor reviewed R26's medical record and progress notes that indicated the following incidents: -On 12/12/21 at 1:12 PM Resident went and sat in a male resident's lap. Told her to get off of him as this was inappropriate. The male resident said he wanted her to sit there. She stated that she was going to stay there. She was guided to the dining room and sat at a far table so she would not be close to him. -On 4/22/22 at 2:12 PM, Noted to be kissing male peer- redirected. -On 5/30/22 at 9:49 AM, Made self available to be hugged by male resident. -On 6/5/22 at 3:37 PM, Separated from male peer. Redirected with/some difficulty. R23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's Minimum Data Set (MDS) assessment dated [DATE] stated R23's Brief Interview for Mental Status (BIMS) score was 05/15 which indicates severe cognitive deficits. R23 has an activated power of attorney (POA) for Health Care. Surveyor Reviewed R23's medical record and progress notes that indicated the following incidents: -On 12/12/21 1:11 PM, Resident was in the hallway with his hand up the back of a females shirt. Told him to stop. He began to swear at writer. Took him to his room and told him that kind of behavior will not be tolerated. -On 2/13/22 at 1:06 PM, Resident has been seeking out the female residents. Difficult to redirect away from females. -On 4/22/22 at 2:52 PM, Patient pleasant and cooperative. Found attempting to go into other resident rooms. Able to redirect with no problem. Observed by another RN kissing another resident female and intervened. Took medications and meals with no issues this shift. -On 5/28/22 6:24 AM, Resident R23 approached Resident R26 while walking in the hallway. R23 was waving to R26 and calling R26 honey. LPN-H separated them and R23 went to the dining room but before that R23 rammed R20 in R20's wheelchair with R23's wheelchair. I was standing there and told him to move away from them. R26 then went into the dining room and sat at R26 table and R23 rapidly followed R26. LPN-H once again separated them and R23 used some foul language on LPN-H. Will notify Administrator of occurrences. -On 5/30/22 at 10:07 PM, Reported incident of inappropriate behavior with other residents to both DON and Administrator. On 6/21/22 at 9:20 AM, Surveyor interviewed NHA-A, reviewed recorded entries, and NHA-A verified there should have been investigations and reporting on above documented occurrences. Further review of R26 and R23's medical record showed no documentation of POA or Guardian updates regarding R26 and R23 encounters and intervention to prevent. Surveyor interviewed other staff who confirmed that R26 and R23 have been observed holding hands, kissing, touching, and needing continuous re-direction. On 6/21/22 at 1:50 PM, Surveyor interviewed ADON- who explained these behaviors between R26 and R23 have been taking place for months. Re-directions doesn't always work since R26 will at times get angry when the facility will separate them. R23 resides on 200 wing and R26 resides on 100 wing to promote more distance yet they often spend time in the dining area. R26 lives on the right side of 200 wing second room from the end of the hall. When R26 goes back to their room they will tend to enter many rooms on the right side of the hallway. R16 is three rooms before R26's room. Surveyor reviewed R23's care plan intervention and no evidence of intervention to assist R26 or prevent R26 from entering rooms while on the way to their room. On 6/22/22 at 8:15 AM, NHA-A explained the facility has placed calls to R23 and R26's families to communicate sexual behaviors. NHA-A is planning to reach out to the ombudsman and increase education on sexuality and intimacy in nursing homes, abuse and how to keep others safe. They are reviewing care plan intervention for R26 as the only intervention listed of re-directing R23 from other residents, was not working.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision to prevent elopement. Resident #1 had a history of [REDACTED]. The facility did not develop an effective plan for supervision, which resulted in Resident #1 being able to leave the facility on multiple occasions and, at times, proceed towards a state highway. This placed Resident #1 at risk for serious harm, injury, or death as he was found walking down a busy state highway. The immediate jeopardy began on 1/19/14 when Resident #1 first demonstrated the ability to leave the facility unbeknownst to staff and walk down a road without regard for safety. The Director of Nursing was informed by surveyor # of the jeopardy on 4/08/14. The immediate jeopardy was removed on 3/26/14, but the noncompliance remained at scope/severity level of D (potential for more than minimal harm/isolated) as the facility still needs to fully implement their policies and procedures related to supervision of residents. Findings include: The facility's undated Wander/Elopement Policy and Procedure states: POLICY: Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement. PROCEDURE: All residents who are at risk for harm because of elopement will be assessed. *New admissions: The admitting nurse will determine if the resident is at risk for elopement based on the resident's previous history and/or behavior, as well as the current assessment. *Current residents: A change of condition may determine if a resident is a new risk for wandering, or is no longer a risk. A new assessment will be done to determine the intervention. *Residents at risk will have an assessment done on admission, then quarterly, or if a change of condition arises. A resident at risk will have a wanderguard placed around their wrist or other determined body part and be placed on the "wanderer list." *The safety committee will review wandering risks on a monthly basis. *The resident's care plan will be developed or modified by the interdisciplinary team to indicate the resident is at risk for elopement and specific individual interventions will be developed to encourage alternate behavior from attempting to exit the building. *Should an elopement occur: The contributing factors, as well as the interventions tried, will be documented in nurses' notes and an incident report will be filled out. Update administrator and director of nursing immediately. *If a resident repeatedly walks or attempts to exit the building, an alternative placement may be considered, as well as new interventions, and care plan revised. *Upon return to the facility: Examine the resident for injuries, institute immediate interventions to prevent another elopement, but not limited to 15 minute check times and 1 hour checks until further notice, update MD (Medical Doctor) and family and report findings and condition of resident. The facility's undated Smoking Policy states: 1. Smoking will be permitted in designated areas only. The designated smoking area for residents, employees, families and visitors is at the back patio. 2. ...If the resident fails to adhere to the smoking policy or there is a change in condition which prevents the resident from smoking safely unattended, then the rules of supervision will be applied. 3. Smoking by residents on the premises is permitted only when supervised by facility staff or visitors. The only exception to the supervision rule is when a resident has been assessed by the Social Worker or designee and determined to be able to safely carry their own tobacco products and smoke unattended in the designated area. The exception must be care planned by the interdisciplinary team and approved by the attending physician. If the resident fails to adhere to the facility smoking policy or there is a change in condition which prevents the resident from smoking safely unattended, then the rules of supervision will be applied. The type of supervision (group versus individual) will be determined by the resident's medical condition. The resident must be within direct view of the smoking supervisor and in reasonably close proximity of the supervisor. The supervisor must be able to respond quickly in the event of an emergency. In addition, the supervisor (whether staff or visitor) must be aware of these responsibilities. On 4/7/14, surveyor # reviewed the medical record for Resident #1. [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Resident #1 has a court appointed guardian. The resident's most recent MDS (Minimum Data Set), dated 3/26/14, indicated the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15/15. The resident required minimal assistance of staff for ADLs (Activities of Daily Living) and was noted to exhibit wandering behavior. On 4/8/14 at 8:05 a.m., surveyor # spoke with G (Guardian)-F. G-F stated, "I came to the facility shortly after resident #1 was admitted and gave 2-1/2 hours of extensive history on (resident's) elopement issues, suicidal ideation and family dynamics. There was an interim social worker, not SW-C, who was given all the history." Upon review of resident #1's careplans, surveyor # noted the resident had multiple care plans to address psychotropic medication, skin integrity, medical issues, nutrition, ADLs and comfort; however, the resident did not have a care plan to address the resident's history of and risk for elopement and suicidal ideation. A nursing note, dated 12/2/13, stated, "Resident wanted to leave facility this shift at approximately 7:00 p.m. Was at the front door with coat on. Weepy and making statements such as, 'Nobody cares about me,' 'Nobody will let me do what I want to do,' 'I want to be near my kids and they want to send me away from here.' Resident was spoken to at length and redirected back to room." 1. A nursing note, dated 1/17/14, stated, "Staff reported that resident was upset and took cane, jacket and wheelchair to front door. Resident was out the front door and walking on the road in front of the facility." The note further indicated the resident was upset that a monthly check did not arrive which would have allowed the resident to buy cigarettes. The writer discussed with the resident the potential restrictions to the resident's independence (alarms and caretrackers) if the resident continued to leave or attempt to leave the facility. 2. A nursing note, dated 1/19/14, stated, "At approximately 3:45 p.m., staff told writer that resident was outside and walking down road. Writer went out main entrance and saw resident propelling self slowly down north shoulder of road in wheelchair. (Resident) did not have a jacket on, was in a t-shirt and pants." The note further indicated the writer "reviewed yesterday's conversation emphasizing potential loss of independence due to potential use of alarms and wanderguards if (resident) doesn't exercise the courtesy of informing staff when leaving the building." Surveyor # noted that according to www.friendlyforecast.com, the temperature in Montello, WI on 1/19/14 at 3:00 p.m. was 32 degrees. Surveyor # noted interventions on the resident's Psychotropic Drug Use care plan, dated 1/20/14, to "ask resident to inform staff when goes outside, to dress appropriate for the weather, to take a walkie talkie and to encourage resident to stay inside the building when it's cold." A social services note, dated 1/21/14, stated, "This writer talked with resident and DON (Director of Nursing). Explained importance of resident telling staff when resident is going outside. Resident was informed that if (resident) continues to go outside without staff being aware, a wanderguard will be put in place for safety." No other interventions were put in place despite two elopements in three days. 3. A nursing note, dated 1/27/14, stated, "Received phone call that resident was at MD (Medical Doctor)-D's office. Office personnel had witnessed resident slip and fall on road hitting back of head. Writer spoke with MD-D related to placing wanderguard on resident upon return. MD-D gave verbal order to place wanderguard. Resident's court-appointed guardian notified of event and requested resident be evaluated by ER (emergency room )." An additional nursing note on 1/27/14 indicated a wanderguard was placed on the resident. On 4/8/14 at 3:30 p.m., surveyor # mapped the distance from the facility to MD-D's office as 0.25 miles. 4. A nursing note, dated 1/29/14, stated, "Writer observed resident sitting outside with CNA (Certified Nursing Assistant). Writer saw code alert bracelet, damaged, sitting on telephone desk. CNA stated resident ripped off code alert bracelet, and went outside and refused to re-enter building." The wanderguard (code alert) was reapplied to the resident's left ankle. Surveyor # also noted an intervention, dated 1/31/14, on the resident's Behavioral Symptoms care plan for "wanderguard on ankle or arm and wheelchair, check daily." 5. A nursing note, dated 2/2/14 at 1:22 p.m., stated, "Noted by staff that there was wanderguard alarm on floor by where this resident was sitting. Resident's legs were inspected. Noted no wanderguard on. Resident taken to room. Resident admitted to taking it off and refused to have it put back on." During the same encounter, the resident eventually consented to having the wanderguard reapplied to the left ankle. 6. A nursing note, dated 2/2/14 at 11:00 p.m., stated, "Writer went to check that wanderguard secured on left ankle per current orders and resident said that (resident) took wanderguard off because it was too tight. Checked both legs and no wanderguard visible." The resident indicated it was stowed on the top shelf of the wardrobe behind a belt and socks. A nursing note, dated 2/3/14, stated, "New wanderguard put on right wrist." Surveyor # noted another intervention, dated 2/10/14 to "monitor resident when outside smoking, make sure wanderguard is on at all times both on right arm and wheelchair and check frequently." 7. A nursing note, dated 2/11/14, stated, "Resident sitting in wheelchair at door to medication room with lobby door alarm going off continuously before supper. Resident ripped wanderguard off left wrist and alarm stopped, reattached by Med Tech in shift." 8. A nursing note, dated 3/2/14, stated, "Resident was angry, took wanderguard off and went out front door despite staff requesting resident not go out the door. Writer and another nurse went out with resident and got resident back in right away. Wanderguard put back on right wrist." 9. A nursing note, dated 3/6/14 at 6:55 p.m., stated, "Received call from Marquette County Sheriff's Department that person in a wheelchair was on Forest Lane heading east towards Highway 22. RN (Registered Nurse) responded." A nursing note, dated 3/6/14 at 7:00 p.m., stated, "RN responded and once out on Forest Lane in front of MCC (Montello Care Center) saw dark silhouette on road toward Highway 22; noted no reflective tape or lights on object; up close identified silhouette as person sitting in wheelchair at stop sign at intersection of Forest Lane and Highway 22; had dark jacket on and hood pulled up over head; when asked to identify self, resident would not respond; when RN leaned down in front of hood, identified person as resident...; truck pulled up along side and driver stated that he'd called police when he saw person wheeling self on darkened street, afraid he'd get hit by car; shortly thereafter, police car pulled up behind with officer coming up to ensure situation under control; RN pushed wheelchair back to MCC with resident approval and on nearing main entrance, resident stated that (resident) that was upset that another resident had punched (resident) in the (expletive) face and that (resident) should've punched that resident back." After further discussion with RN related to the incident, resident #1 "got up from wheelchair and started walking towards main entrance and shouted, 'I'm done with this. I'm not doing anything anymore. I'm not taking my pills. I'm not wearing the wanderguard...I'll just rip it off and you know I'll do it because I've done it many times before.'" On 4/8/14 at 3:30 p.m., surveyor #0571 mapped the distance to State Highway 22 as 0.3 miles. Because Resident #1 was close to getting on the highway, the chances for being seriously hurt increased. According to the Center for Problem-Oriented Policing, most vehicle-pedestrian accidents occur between 5:30 PM and 11 PM and speed affects the chances for survival: " ...a pedestrian hit at 40 miles per hour has an 85 percent chance of getting killed, whereas the likelihood goes down to 45 percent at 30 miles per hour and 5 percent at 20 miles per hour. " (<http://www.popcenter.org/problems/pedestrian_injuries>). A nursing note, dated 3/6/14 at 7:10 p.m., stated, "When resident returned to building through main entrance, wanderguard bracelet on resident's wrist activated alarm system; appears that resident departed premises after being allowed to smoke cigarette on back patio." Upon review of the facility's investigation, surveyor # noted resident #1 left the facility just before 7:00 p.m. on 3/6/14 without notifying staff. Staff brought the resident back to the facility after police were notified by a passing motorist. Surveyor # also noted a written statement by NHA (Nursing Home Administrator)-A that stated, "I told (resident) that (resident) did good not to hit/hurt someone else. By leaving the facility without notification is what (resident) did wrong. (Resident) has done this before, and (resident) acknowledges this." A social services note, dated 3/7/14, stated, "Resident placed on smoking supervision per Administrator, DON and SS (Social Services)." 10. A social services note, dated 3/17/14, stated, "Resident took off wanderguard bracelet to wrist and exited front entrance at approximately 2:00 p.m. Resident redirected back into facility by staff. This writer accompanied resident back to resident's room and reapplied wanderguard bracelet to right wrist. DON applied new wanderguard bracelet to wheelchair." A social services note, dated 3/20/14, stated, "Daughter was concerned due to resident stating, '(resident) wasn't going to stay here anymore, (resident) was leaving, all (resident) has to do is say (resident) is going to smoke a cigarette and leave.'" 11. A nursing note, dated 3/22/14, stated, "Resident's mood very low and began expressing suicidal thoughts. Also said that (resident) wanted to go to jail and that (resident) would be better off. Resident also admitted to wanting to leave the facility at this time. Writer advised resident against it. Immediately after writer entered the building, resident proceeded to motor wheelchair down the sidewalk at rear of building. Writer and another staff member escorted resident back into building." 12. A nursing note, dated 3/26/14 at 9:47 a.m., stated, "Resident ambulated in hall without walker. Went into activity room and through physical therapy room and exited building. Motion alarm on right wrist. DON and writer out to assist resident back into building. Resident assisted back into room. When asked what (resident) was doing, (resident) refused to answer writer. Sat in chair in room, looked down and stated, 'There is no help for me.'" 13. A nursing note, dated 3/26/14 at 10:20 a.m., stated, "Resident was in (resident's) room when the staff nurse came and stated resident was out of the building again and walking down the side of the street. DON, Administrator and nursing staff went out. Resident returned to the facility and was taken to the office and talked to by the Administrator and DON. Resident stated (resident) was going for a walk. Resident then decided not to talk anymore, was taken to room and 1:1 was started around the clock." A social services note, dated 3/26/14 at 11:19 a.m., stated, "Resident exited building by going through activity and therapy rooms at approximately 9:45 a.m. Wanderguard in place on right wrist. Brought back into building by staff. Staff walked resident back to resident's room. Resident was placed on 30 minute checks." 14. A social services note, dated 3/26/14 at 11:20 a.m., stated, "Resident exited facility through window of resident's room at approximately 10:00 a.m. Dietary Manager was on way to store when she saw resident walking east on Forest Lane. Dietary Manager immediately notified staff. Dietary Manager and DON assisted resident back to facility." Additional social services notes on 3/26/14 indicated SW (Social Worker)-C was in contact with the resident's guardian and agency staff involved in the resident's care to make discharge arrangements due to increased elopement attempts and safety concerns. The resident was subsequently discharged to a behavioral health center for a short-term stay until permanent placement arrangements were finalized. The final nursing note, dated 3/26/14 at 3:14 p.m., stated, "Resident was directed by (agency) to be transferred to another facility due to mood changes and elopement and not having any respect for the resident's safety or the safety of the facility. Resident left facility with two staff members for another facility." On 4/7/14 at 9:20 a.m., surveyor # interviewed SW-C regarding resident #1. SW-C reiterated the events of 3/6/14 and the resident's elopement and subsequent discovery on State Highway 22. SW-C stated, "I got involved the following morning. (DON-B) came in the same night and did interviews. I made a call to (agency staff) and (resident's) guardian. We placed (resident) on a smoking supervision because (resident) left the building. (Resident) was discharged on [DATE] not because of this issue, but due to elopement issues. (Resident) eloped out the front door, was taken back to (resident's) room, eloped out the window and was on Highway 22. It was in (resident's) best interest to discharge because we were worried (resident) would get hit by a car. The Dietary Manager saw (resident) outside and notified staff. (Resident) had a wanderguard on, but didn't have smoking supervision at that time. Smoking supervision started on March 7th. (Resident) was on Highway 22 again on March 26th after going out the window. (Resident) attempted to go out the front door, but was brought back. (Resident) was discharged on [DATE]th." On 4/7/14 at 12:00 p.m., surveyor # again interviewed SW-C who confirmed resident #1 did not have a care plan to address elopement concerns or suicidal ideation. SW-C indicated that smoking supervision meant the resident was to be in view of staff which could include staff being outside with the resident or viewing the resident from the nurses' station. SW-C indicated an elopement care plan had been discussed as well as not allowing the resident outside to smoke without staff prior to the incident on 3/6/14. SW-C confirmed that outside supervision started on 3/7/14. On 4/7/14 at 1:45 p.m., surveyor # interviewed DON-B who verified there was no elopement care plan for resident #1 and stated, "I put 2 wanderguards on (resident). We got (resident) right away the time (resident) walked out. Then (resident) went out the window about 8 minutes later. There was always someone watching (resident) outside. The nurse always stayed at the desk or got someone to replace her if she had to leave." DON-B indicated the facility was not aware of the resident's extensive psychiatric, behavioral and elopement history prior to admittance. On 4/8/14 at 8:00 a.m., surveyor # interviewed RN-E, an RN for the agency involved with the resident's care, who stated, "The facility requested the resident be moved out as soon as possible because they didn't have the staff to keep the resident safe. They told us they couldn't provide enough staff to do 1:1. It was impromptu. The resident eloped twice within 5-10 minutes." On 4/8/14 at 8:05 a.m., surveyor # interviewed G-F who stated, "The resident was eloping pretty regularly. We tried to find alternative placement. We were struggling with the facility's ability to keep the resident safe. One time at dusk, the resident was found by the police at a stop sign in a wheelchair. The facility said they would do 15 minute checks after that. (Resident) had a heart attack, was in the hospital and had to discharge from the group home to the nursing home. (Resident) had always been in high behavioral settings, but needed more medical care after the hospitalization . The facility had a good therapy department and was close to the resident's family. (Resident) is manipulative and got staff on (resident's) side. (Resident) made staff think the agency and myself were against (resident). Staff didn't believe the resident would walk off. The agency met with them to develop a safety plan. The agency wanted to meet with the DON to talk about what they could do to keep the resident safe. They (facility) called us and said (resident) needs to go. They wanted us to find another place and said (resident) couldn't stay there. The facility said they could not do 1:1. They said (resident) needed to leave that day because they couldn't keep (resident) safe. Staff let (resident) outside to smoke alone. There was a plan in place to move the resident to another facility. That facility needed to replace the flooring in what was to be (resident's) room and couldn't take (resident) until 4/4/14. The facility couldn't wait that long." On 4/8/14 at 9:10 a.m., surveyor # interviewed SW-G, an agency social worker/case worker for resident #1. SW-G stated, "The facility gave notice they couldn't manage (resident) because (resident) was eloping. From there, we went into active process to find a placement for (resident). In that process, there were more elopements. My colleague was called on a more emergent basis and told she needed to find something that day. We asked for time to find a place to address (resident's) high behavioral issues. It was hard to find a place within 24 hours. We found emergency placement where the resident stayed until we could find permanent placement in the least restrictive environment. Montello is extremely high traffic. We were in communication all the time. (Resident) wanted to stay because the facility was closer to (resident's) daughter. The behavioral and medical needs were so high. We were concerned with how the facility would manage (resident's) behaviors. We had some issues with behaviors due to lack of training for (resident's) manipulation of staff. (Resident #1) is good at what (resident) does. They put wanderguards on. (Resident) eloped when outside for a smoke. Staff would take the wanderguards off. You can't leave (resident) alone." SW-G indicated the resident's history involved passive/aggressive behavior, elopement and suicidal ideation including refusing to eat after taking insulin and trying to stand in traffic. On 4/8/14 at 9:32 a.m., surveyor # interviewed NHA-A and DON-B who indicated discharge planning was in place prior to 3/26/14 and the facility was talking with agency staff and G-F who were looking for placement. DON-B stated on the day of discharge, "(Resident) walked down the hallway to therapy to get a cane. I brought (resident) back in. One of the LPNs (Licensed Practical Nurses) took (resident) to smoke and then back to (resident's) room. The LPN came to my office to see if we should start 30 minute checks and (resident) was out the window." NHA-A stated, "We made phone calls immediately and started direct 1:1 supervision." DON-B stated, "SW-C called the agency to tell them the resident eloped again. The person supposed to be in charge was not in that day. The agency said they'd get (resident) out of here. They said (resident) will be removed. They were working on placing (resident) and had to get a room set up. The room wasn't done and they needed another week." When surveyor # asked if the facility had initiated 15 minutes checks or 1:1 supervision prior to 3/26/14, NHA-A asked, "Did we need to do the 1:1? We watched and kept an eye on (resident). (Resident) is manipulative and a good salesperson. We had supervision. The way the building is set up, it's easy to see where everyone is. I never saw it coming. I never thought (resident) would go out the window. We couldn't have done the 1:1 with (resident) as far as availability of staff. It would've been difficult." When surveyor # asked if staff ever removed the resident's wanderguard, DON-B stated, "No. (Resident) had a wanderguard that would have to be removed by a scissors." On 4/8/14 at 11:30 a.m., surveyor # interviewed NHA-A regarding staff education following the elopement incidents. NHA-A stated the facility hadn't done formal training with staff; however, they would be addressing supervision, elopement and care planning in the near future. Because the facility had no other residents who were actively attempting to elope, the immediate jeopardy that began on 1/19/14 was removed on 3/26/14 when Resident #1 was transferred out of the facility.

Based on record review and staff interview, the facility did not ensure that 1 (resident #5) of 4 sampled residents reviewed for weight loss from a total sample of 11 residents, maintained acceptable parameters of nutritional status. Resident #5 was readmitted with documented [MEDICAL CONDITION] and was treated with diuretics. Approximately 6 weeks after re-admission, resident #5's physician's progress note documentation indicated that the resident's physical exam revealed no significant ankle [MEDICAL CONDITION]. Resident #5's documented weight decreased from 235 pounds on 10/1/12 to 183 pounds on 2/5/13. Resident #5 experienced a significant weight loss of 22% in a 4 month period. The facility did not identify a clinical explanation for the weight loss, nor were interventions put into place to maintain parameters of nutritional status. Although the facility was aware that resident #5's appetite had decreased, the facility did not obtain routine weights for 3 of the 6 months following the resident's re-admission, did not consult with the Registered Dietician regarding the resident's weight loss and did not consult with the physician regarding laboratory testing to determine the extent of resident #5's nutritional decline. Findings include: The undated facility policy and procedure entitled, "Resident Weights Policy and Procedure," indicated, "2. After admission weight has been completed residents are to be weighed monthly unless otherwise directed by a doctor or nurse...5. All weights that have 5% loss or gain in a one month period need to be re-weighed immediately. 6. Charge nurse will contact the resident's physician with weight gain or loss of 5% in one week, or 5% in one month. 7. The Director of Nursing or designee may contact the registered dietician as need for further recommendations." On 7/10/13, surveyor # reviewed the medical record of resident #5. The undated facesheet contained within the medical record indicated resident #5 was initially admitted to the facility 4/13/12 and readmitted to the facility 8/23/12 with [DIAGNOSES REDACTED]. Resident #5's hospital discharge summary dated 8/23/12 indicated that the resident had 2 + to 3 + [MEDICAL CONDITION] of the extremities and [MEDICATION NAME] (diuretic) 80 mg (milligrams) daily was included in the medications ordered at the time of discharge. The most recent quarterly MDS (Minimum Data Set Assessment) dated 5/1/13 indicated that resident #5 was independent with set up help only for eating and scored a 12 out of 15 on the BIMS (the higher the score, the more cognizant). This MDS revealed resident #5 had experienced a weight loss and was not on a physician prescribed weight loss plan. Resident #5's physician's documented the following in the progress notes: * 10/3/12 - "no significant ankle [MEDICAL CONDITION]" * 11/7/12- "No ankle [MEDICAL CONDITION]" * 1/13/13- "No significant leg [MEDICAL CONDITION]" * 2/13/13- "No ankle swelling" * 3/20/13- "No significant ankle [MEDICAL CONDITION]" A review of resident #5's weights revealed the following: * 8/03/12 - 248 lbs. * 8/06/12 - 248 lbs. * 8/23/12 - 247 lbs. (readmitted from hospital) * no weight was recorded in the month of September 2012 * 10/01/12 - 235 lbs. (12 lb loss = 4.9% in 39 days; since 8/23/12) * 11/12/12 - 232 lbs. (3 lb loss = 1.3% in 42 days; since 10/01/12) * no weight was recorded in December 2012 * no weight was recorded in January 2013 * 2/05/13 - 183 lbs. (52 lb loss = 22.4% in 85 days; since 11/12/12 and 55 lb loss = 23.4% in 127 days; since 10/01/12) * 6/12/13 - 188 lbs. Resident #5's "Alteration in Nutrition" written plan of care dated 5/30/12 included "10/18/12, Mechanical soft (diet), ground meats, NCS (No Concentrated Sweets), NAS (No Added Salt)....weight as ordered by physician or monthly...11/12, supplements between meals, snacks between meals." The 5/30/12 written plan of care entitled, "Alteration in diabetes related to imbalanced nutrition," indicated "weigh resident monthly or as ordered by MD...monitor appetite daily..." CNA (Certified Nursing Assistant) notes documented resident #5's meal intakes as percentages. From 8/23/12 through 7/10/13, these percentages varied significantly, ranging from 0% (no appetite) to 100% (normal appetite). Nursing and dietary documentation in resident #5's medical record did not reveal an investigation to correlate appetite and meal intakes to a clinical justification for variances. A dietary note dated 2/8/13, documented by DSM (Dietary Services Manager)-G indicated "Resident has had a weight loss of over 10 % in past 90 days related to poor appetite. Was unable to get out of bed to obtain past 2 months weights. Supplements offered, (accepts) at times." A 2/12/13 care conference note written by DON (Director of Nursing)-D indicated, "No nursing issues addressed by wife." A 2/12/13 care conference note written LPN (Licensed Practical Nurse)-I indicated, "CP (Care Planning) meeting held, goals reviewed with wife. No changes noted, slow decline in weight..." A 2/12/13 care conference note written SW (Social Worker)-J indicated, "Care Plan Conference held this date...Resident has had no significant changes in his overall status...will continue to monitor and review in 90 days or as needed." An "Annual Nutrition Assessment" note for resident #5 dated 7/1/13, written by RD (Registered Dietician)-H indicated "Resident is receiving a general texture, renal, NCS diet for IDDM (Insulin Dependent Diabetes Mellitus) and [MEDICAL CONDITION]. Appetite and intake remain good. Resident prefers to eat in his room...weight has been stable at 188 lbs. Estimated calorie needs: 1972 kcal (kilocalorie's), Estimated protein needs: 85 grams, Estimated fluid needs: 2125 cc (cubic centimeters)/day. Resident receives a supplement BID (twice daily) with meals for increased calories and protein....Will continue to monitor weight and intake. This note is the only note written by RD-H for resident #5. On 7/10/13 at 3:00 p.m., surveyor # interviewed DON-D regarding resident #5. DON-D verified the facility protocol and expectation was to obtain resident's weights monthly. Surveyor # interviewed DON-D regarding no documented weights for resident #5 for September 2012, December 2012 and January 2013. DON-D indicated resident #5 could not stand on the scale. When interviewed regarding the availability of an alternative for obtaining weights for resident's who could not stand, DON-D stated a resident could be lifted via a mechanical lift into a wheel chair and weighed on the wheel chair scale. On 7/12/13 at 9:50 a.m., surveyor # interviewed DSM-G who verified the RD was not notified or consulted in February 2013 when it was discovered resident #5 had a severe weight loss. DSM-G stated supplements had been initiated 11/12 and no additional interventions were added to resident #5's plan of care after 2/5/13, when the resident lost 49 lbs. DSM-G confirmed that residents unable to stand for weight measurement can be mechanically lifted and weighed while seated in a wheel chair. DSM-G indicated weights are obtained by nursing staff, (either CNA's or nurses). When interviewed regarding resident #5's severe weight loss that had not been addressed by staff, DSM-G indicated, "because (resident #5) was not weighed for 2 months." On 7/12/13 at 12:15 p.m., surveyor # interviewed DON-D regarding resident #5. DON-D verified documentation of consultation with the physician regarding resident #5's severe weight loss could not be provided. DON-D provided physician progress notes [REDACTED]. DON-D also provided a copy of a fax to the physician of resident #5 dated, 1/27/13 which stated "Resident noted with weight loss over last month or so." This communication did not indicate specifics as to how much weight was lost and over what span of time. Additionally, DON-D verified a physician response was not returned and a follow up call to obtain a physician response was not documented. DON-D verified no laboratory tests to include protein or [MEDICATION NAME] levels were ordered to determine the extent of resident #5's nutritional deficits related to the severe weight loss. DON-D stated nutritional supplements for resident #5 were initiated 11/12 and no interventions were initiated after the severe weight loss was identified on 2/5/13. DON-D verified a reason for the decreased appetite and weight loss for resident #5 was not determined. On 7/12/13 at 12:25 p.m., surveyor # interviewed RD-H who verified she made facility rounds monthly, printed computerized weight records for review every visit and discussed problem areas with DON-D. RD-H indicated her usual practice was to document an admission assessment, noting caloric, protein and fluid requirements for each resident. RD-H stated a follow up assessment would be conducted annually thereafter, unless a change in condition warranted another review. Resident #5's medical record did not include a dietary admission assessment and the only documentation found in the medical record written by RD-H regarding resident #5 was dated 7/1/13. RD-H stated she did not recall a discussion with DON-D or DSM-G regarding resident #5's severe weight loss, but should have been notified when any significant or severe weight loss was identified. RD-H indicated she usually documented a discussion or consultation regarding specific residents in their medical record and verified that she did not document in resident #5's record prior to 7/1/13. RD-H stated "The mistake here was not weighing (resident #5) for 2 months."