Every finding on record at Mountain View Skilled Nursing Community at WLRC

Based on observation, resident and staff interview, medical record review, facility incident review, and policy and procedure review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 3 of 3 sample residents (#4, #6, #7) reviewed for accident hazards. The findings were: 1. Review of the comprehensive MDS assessment dated [DATE] showed resident #7 had a BIMS score of 11 out of 15, which indicated moderate cognitive impairment, and diagnoses which included dementia, seizure disorder, anxiety, nontraumatic intracerebral hemorrhage, fracture of nasal bones, and restlessness and agitation. The following concerns were identified: a. Review of the facility investigation dated 7/4/26 and timed 6:25 AM showed resident #7 was visualized by staff walking next to the paintbrush building and turning towards the [NAME] without staff. [resident #7] was dressed in sweatpants and a t-shirt, she did not have her helmet on and temperature was 56 degrees at that time.Security stated [resident #7] reported she was looking for her backpack, they dropped [resident #7] off to her bedroom on [NAME] at 0634. The facility implemented the following corrective actions and interventions following the incident which included, monitor the resident when out of her room, staff to notify nursing if [resident #7] appears agitated. Staff are to encourage her to wear her helmet.Care plan is updated to increase supervision if [resident #7] exhibits these new behaviors. Two new helmets were ordered to provide alternative options. Review of the facility investigation report dated 7/31/26 and timed 6:30 AM showed resident #7 was found in the Administration parking lot when the [NAME] nurse arrived on campus and staff did not know the resident had left the house. The resident was taken back to [NAME] cottage by another RN who was familiar with the resident. The facility implemented corrective actions and interventions which included, door alarms were placed on all three doors for notification when staff are busy with other residents.Staff will continue to support [resident #7] and monitor [resident #7] when she is awake. b. Interview with the nurse manager on 8/19/26 at 2:23 PM revealed the facility didn't lock the doors during the day and they tried to have a staff member in the common area to monitor residents to prevent residents from eloping or wandering out the front door. She revealed resident #19 had a wanderguard on his/her walker that will make an alarm sound if the resident tried to go out the front door. She revealed the wanderguard system doesn't lock the door to prevent resident exit. c. Interview with RN #1 on 8/20/26 at 10:45 AM revealed the facility turned the door alarms on at night or during the day if staff weren't available to be in the common area. She revealed the facility tried to always have a staff member in the common area to supervise residents. d. Observation of [NAME] cottage on 8/18/26 at 8:44 AM showed there were 3 entry/exit doors. Further observation showed a tab alarm was present on each door, and the front door was unlocked. e. Observation of the common area on 8/20/26 at 9:57 AM showed there were no staff stationed in the common area to supervise residents and car port door couldn't be visualized from the common area. f. Observation on 8/19/26 at 3:46 PM showed resident #16 exited the front door of the cottage, when no staff was present in the common area, and the door alarm was not on and did not sound. Staff were unaware that resident #16 exited the cottage. 2. Review of the admission MDS assessment dated [DATE] showed resident #6 had a BIMS score of 6 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia. The review showed the resident was independent with transfers and was able to walk 150 feet with supervision or touching assistance. Further review showed the resident was marked for wandering behavior which occurred daily, placed the resident at significant risk of getting to a potentially dangerous place, and significantly intruded on the privacy and activities of others. Review of a facility incident dated 8/5/26 and timed 10:30 AM showed the resident left the Sunflower cottage and was found outside. Further review showed the resident was unattended for about 1 minute. Further review showed corrective action included door alarms placed on the door exiting the cottage and continued staff support of the resident. Review of a facility incident dated 8/15/26 and timed 3:25 PM showed the resident left the Sunflower cottage and was found at the Aster cottage. Further review showed the resident left while staff were busy with other residents and corrective action included ensuring one staff member was present with the resident when s/he was awake and not in his/her room. The following concerns were identified: a. Observations during the course of the survey showed the door alarms were not in place at any time at the cottage. b. Observation on 8/19/26 at 10:04 AM showed the resident ambulated to the living room area of the cottage and sat in a recliner. No staff were present at that time and the door alarms were not in place on the exit door. c. Interview with the facility investigator on 8/20/26 at 12:42 PM revealed staff were to put the alarms on the doors when they were short staffed. d. Interview with CNA #1 on 8/20/26 at 9:56 AM revealed the resident had gone out of the facility a couple times and she has heard it happens at night. She revealed the resident thinks his/her vehicle is outside and s/he wants to go look at the cars. She revealed if someone catches the resident trying to leave, they will take him/her to look at the cars. She revealed she was trying to staff the cottage with 3 staff members and sometimes it was difficult. She revealed the cottage had alarms on the doors and staff were expected to alarm the door if they were going to be busy and could not see resident #6. She was not sure how the implementation of alarms was communicated to staff and revealed she learned from another staff member after being off. Further interview revealed if the alarms were not put in place, there was no way for staff to know if a resident left if they were not in the common area at the time. e. Interview with CNA #2 on 8/20/26 at 4:07 PM revealed the administrator had asked her to get some door alarms following one of the incidents and another staff member did not like the alarms, then verbalized concerns to the administrator. The CNA revealed the administrator sent an email to only use the alarms if they were absolutely needed. Further interview revealed staff did not receive formal training on when or how to use the alarms. f. Interview with the DON on 8/20/26 at 8:20 PM DON confirmed staff should remain in the common area with resident #6 or ensure door alarms were in place. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 13 out of 15, which indicated intact cognition, and diagnoses which included non-Alzheimer's dementia, traumatic brain injury, anxiety disorder, depression, psychotic disorder, and post traumatic stress disorder. Further review showed the resident had other behavioral symptoms not directed toward others, such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds, 1 to 3 days during the look-back period and was independent with activities of daily living. The following concerns were identified: a. Review of a facility incident report dated 5/21/26 showed the resident used fingernail clippers to cut him/herself after repeating statements s/he will be dead by morning. The incident review showed CNA #2 had been monitoring the resident after the statements until she was called away and monitoring was transitioned to CNA #3. The Incident review showed CNA #2 notified CNA #3 of resident #4's comments to self-harm and to keep a close eye on [him/her]. The incident review showed when CNA #2 returned, CNA #3 was sitting in the office and reported resident #4 was good and had not come out of his/her room. The incident review showed CNA #2 went directly to resident #4's room where she observed the resident attempt to hide something under his/her pillow. Further review showed CNA #2 identified the resident had a cut mark on the resident's left arm and the resident provided fingernail clippers s/he used to self-harm. b. Interview with CNA #2 on 8/20/26 at 4:07 PM revealed on 5/21/26 resident #4 was having a rough day and made comments s/he intended to self-harm. The CNA revealed she was able to get the resident calmed down before having CNA #3 take over supervision while CNA #2 used the restroom. CNA #2 revealed when she returned to the cottage, CNA #3 was in the office and not supervising resident #4. CNA #2 revealed she went directly to resident #4's room, at which time the resident hid something under his/her pillow, and CNA #2 had scratched his/her arm. CNA #2 revealed resident #4 eventually provided the fingernail clippers to her and the resident was transferred to the hospital. CNA # [NAME] revealed she had told CNA #3 she needed to be with the resident or outside his/her room due to the self-harm comments. CNA #2 revealed the resident obtained a long scratch which was not very deep and had minimal blood similar to like a cat scratch. Further interview revealed when the resident made self-harm statements, staff were expected to place the resident on 1 to 1 care and his/her plan has been that way for 5 years. c. Interview with CNA #3 on 8/20/26 at 4:02 PM revealed on the day of the incident she was told her go to resident #4's cottage because the resident was a 1 to 1 due to self-harm. She revealed she was not at the cottage when the self-harm occurred, only afterwards. She revealed she did not observe the resident's injury. d. Interview with the DON on 8/20/26 at 8:19 PM revealed she expected staff to keep residents in line of sight following statements of self-harm. 4. Review of the policy titled Wandering and Elopement last revised 4/5/22 showed .3. If MDS 3.0 item E1000 A is checked Yes an Elopement Risk assessment will be performed and a care plan updated and revised to ensure safety . 9. Nursing will ensure that resident safety devices/alarms are tested prior to application . 5. Review of the policy titled Suicidal Behavior last revised on 8/13/24 showed .1. Staff shall report any resident suicidal behavior immediately to the nurse. 2. A staff member will remain within direct line of supervision of the resident at all times until they are dismissed by the nurse, mental health professional, or Medical Provider .

Based on medical record review, resident and staff interview, facility incident investigation review, and policy and procedure review, the facility failed to protect the resident's right to be free from misappropriation by a staff member for 1 of 17 sample residents (#10) reviewed for misappropriation. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a brief interview for mental status (BIMS) score of 15 out 15, which indicated intact cognition, and diagnoses which included anxiety disorder, depression, bipolar disorder, post traumatic stress disorder, and visual loss. The following concerns were identified:a. Interview with the resident on 8/20/26 at 3:34 PM revealed money was removed from his/her account without his her knowledge. S/he revealed the facility did not have anything in place to allow or restrict money being used without his/her consent prior to the incident.b. Review of a facility incident report dated 6/16/26 and timed 10:30 AM showed an allegation of misappropriation due to business office staff member #1 paying for obligations she deemed necessary without consent or knowledge of residents or guardians. Further review showed and withdrawal of $5000 was removed from the account to of resident #10 to pay his/her bill at the facility.c. Review of a Resident Trust Account statement for resident #10 during the period of 12/1/25 through 6/10/26 showed a withdrawal in the amount of $5000 on 6/1/26. Further review showed the description was WLRC Maintenance Fund INV #5926.d. Interview with facility investigator #1 on 8/19/26 at 5:34 PM revealed her investigation showed business office staff member #1 would only allow resident #10 to use $10,000 on a stable account because the resident owed the facility money. She revealed $6,000 was removed from the resident's account to pay his/her bill, without the resident's consent. e. Interview with the social worker on 8/20/26 at 8:58 AM revealed resident #10 had about $40,000 in his/her account and needed to spend the money down. She revealed the facility began looking at how much resident #10 could put in a stable account and how much the resident owed the facility. She revealed resident #10 was his/her own guardian and was able to determine how much money s/he wanted to put where and how much s/he wanted to spend. She was told business office staff member #1 would only allow him/her to put $10,000 in the stable account because of how much the resident owed the facility. She revealed business office staff member #1 told her she would only put $10,000 in the stable account and the social worker needed to go with resident #10 to pull $5000 to pay his/her bill at the facility, which the social worker did not feel comfortable doing. She revealed when the resident's account statement arrived, she reviewed it with resident #10 and saw business office staff member #1 had withdrawn $5000, without resident #10's knowledge, to pay his/her facility bill. She revealed resident #10 was upset when s/he learned about the money that was removed, s/he had not agreed to pay the $5000, and the money was not returned to the resident. She revealed resident #10 requested s/he sign for all future withdrawals from his/her account. She revealed after the money was removed, resident #10 became very concerned about his/her money and whether s/he would have enough money. f. Interview with business office staff member #1 on 8/20/26 at 11:46 AM revealed when resident #10 admitted to the facility, they attempted to get different options in place, such as a stable account, process for paying bills, and getting to a qualifying resource amount. She revealed she attempted to coordinate with the social worker and CNA #1 to attain a resolution on outstanding bills for resident #10; however, resolution did not occur. She revealed at the time of admission resident #10 agreed to pay $5000, which was the amount the resident was comfortable and agreeable to pay, toward his/her bill at the facility. She revealed the resident did not sign anything to demonstrate s/he agreed with the amount and there was not another staff member present during the conversation. She confirmed she later removed money from the resident's account to pay his/her facility bill, and she did not notify the resident and the resident did not give permission to remove the funds prior to the withdrawal. 2. Interview with the business office manager on 8/20/26 at 11 AM revealed resident #10 was his/her own guardian and s/he gets very anxious about his/her money. She confirmed the business office didn't have anything signed by the resident to make withdrawals from his/her account. She revealed upon admission, it was agreed resident #10 would pay $5000 per week until s/he was eligible for Medicaid and the administrator or social worker was to take the resident to withdraw the $5000 to pay the bill. She confirmed it was a verbal conversation and the resident did not sign off on transactions. 3. Review of the policy titled Prevention of Resident Abuse, Neglect, and Exploitation last reviewed on 11/6/24 showed .The resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . 'Misappropriation of resident property' as defined in 42 CFR S 483.5, means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .

Based on medical record review, resident and staff interview, facility incident review, and policy and procedure review, the facility failed to ensure residents had the right to manage financial affairs and the right to know in advance, what charges a facility may impose against resident funds for 2 of 17 sample residents (#10, #19) reviewed for resident rights. The findings were: 1. Review of a facility incident report dated 6/16/26 and timed 10:30 AM showed an allegation of misappropriation due to business office staff member #1 paid for obligations she deemed necessary without consent or knowledge of residents or guardians. Further review showed a withdrawal of $5000 was removed from the account of resident #10 to pay his/her bill at the facility and $545 from the account of resident #19 for eye glasses the facility was responsible for.2. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a brief interview for mental status (BIMS) score of 15 out 15, which indicated intact cognition, and diagnoses which included anxiety disorder, depression, bipolar disorder, post traumatic stress disorder, and visual loss. The following concerns were identified:a. Interview with the resident on 8/20/26 at 3:34 PM confirmed money was removed from his/her account without his/her knowledge. S/he revealed the facility did not have anything in place to allow or restrict money being used without his/her consent prior to the incident.b. Review of a Resident Trust Account statement for resident #10 during the period of 12/1/25 through 6/10/26 showed a withdrawal in the amount of $5000 on 6/1/26. Further review showed the description was WLRC Maintenance Fund INV #5926.3. Interview with facility investigator #1 on 8/19/26 at 5:34 PM revealed her investigation showed business office staff member #1 would only allow resident #10 to use $10,000 on a stable account because the resident owed the facility money. She revealed an additional $6,000 was removed from the resident's account to pay his/her bill, without the resident's consent. Further interview revealed $800 was removed from resident #19's account to pay for glasses; however, the glasses were supposed to be paid for by the facility.4. Review of a Resident Trust Account statement for resident #19 during the period of 12/1/25 through 6/10/26 showed a withdrawal in the amount of $545 on 5/29/26. Further review showed the description was for glasses Invoice #110018.5. Interview with the social worker on 8/20/26 at 8:58 AM revealed resident #10 had about $40,000 in his/her account and needed to spend the money down. She revealed the facility began looking at how much resident #10 could put in a stable account and how much the resident owed the facility. She revealed resident #10 was his/her own guardian and was able to determine how much money s/he wanted to put where and how much s/he wanted to spend. She was told business office staff member #1 would only allow him/her to put $10,000 in the stable account because of how much the resident owed the facility. She revealed business office staff member #1 told her she would only put $10,000 in the stable account and the social worker needed to go with resident #10 to pull $5000 to pay his/her bill at the facility, which the social worker did not feel comfortable doing. She revealed when the resident's account statement arrived, she reviewed it with resident #10 and saw business office staff member #1 had withdrawn $5000, without resident #10's knowledge, to pay his/her facility bill. She revealed resident #10 was upset when s/he learned about the money that was removed, s/he had not agreed to pay the $5000, and the money was not returned to the resident. She revealed resident #10 requested s/he sign for all future withdrawals from his/her account. She revealed after the money was removed, resident #10 became very concerned about his/her money and whether s/he would have enough money. Further interview revealed the business office billed resident # 19 for glasses that the facility should have paid for because nursing staff lost them, which prevented the resident from getting new shoes due to a lack of money in the resident's account.6. Interview with business office staff member #1 on 8/20/26 at 11:46 AM revealed when resident #10 admitted to the facility, they attempted to get different options in place, such as a stable account, process for paying bills, and getting to a qualifying resource amount. She revealed she attempted to coordinate with the social worker and CNA #1 to attain a resolution on outstanding bills for resident #10; however, resolution did not occur. She revealed at the time of admission resident #10 agreed to pay $5000, which was the amount the resident was comfortable and agreeable to pay, toward his/her bill at the facility. She revealed the resident did not sign anything to demonstrate s/he agreed with the amount and there was not another staff member present during the conversation. She confirmed she later removed money from the resident's account to pay his/her facility bill, and she did not notify the resident and the resident did not give permission to remove the funds prior to the withdrawal. The business office staff member revealed resident #19 did not have money removed from his/her account to pay for glasses and she was not aware the facility was responsible for payment. She revealed there was a form that must be completed when the facility was responsible for a payment, and the business office did not receive that form prior to payment for the resident's glasses. 7. Interview with the business office manager on 8/20/26 at 11 AM revealed resident #10 was his/her own guardian and s/he gets very anxious about his/her money. She confirmed the business office didn't have anything signed by the resident to make withdrawals from his/her account. She revealed upon admission, it was agreed resident #10 would pay $5000 per week until s/he was eligible for Medicaid and the administrator or social worker was to take the resident to withdraw the $5000 to pay the bill. She confirmed it was a verbal conversation and the resident did not sign off on transactions. She revealed the payment for resident #19's glasses were made from the resident's account because residents were responsible for glasses purchases if insurance does not pay, and it was not communicated the facility was responsible for the glasses.8. Review of the policy titled SNF Resident Personal Funds last revised 5/16/25 showed .2. Residents will be encouraged and assisted in managing their financial affairs to the fullest extent possible . Resident accounts will be debited for state-paid, vendor-invoiced approved purchases only after the resident receives all items and the business office receives the corresponding invoices .

Based on observation, medical record review, facility incident report review, facility investigation review, staff interview, resident grievance review, and policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 5 sample residents (#6) reviewed for abuse. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #6 had a BIMS score of 6 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia. The review showed the resident was independent with transfers and was able to walk 150 feet with supervision or touching assistance. The review showed the resident had verbal behavioral symptoms directed towards others and other behavioral symptoms not directed toward others on 1 to 3 days during the look-back period. Further review showed the resident was marked for wandering behavior which occurred daily, placed the resident at significant risk of getting to a potentially dangerous place, and significantly intruded on the privacy and activities of others. Review of the significant change MDS assessment dated [DATE] showed resident #5 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included anxiety disorder. Further review showed the resident had verbal behavioral symptoms directed towards others and other behavioral symptoms not directed toward others on 1 to 3 days during the look-back period. The following concerns were identified:a. Review of a Resident Incident Reporting Form dated 8/13/26 and timed 8 PM showed [Resident #5] came out from room to go in the dining area. other resident [resident #5] yelled and screamed at [him/her], 'you killed children.' [Resident #5] yelled back 'fuck you' and came closer, then other resident pushed [resident #5]. [Resident #5] said 'don't mess with the Marines and went to [his/her] room. Further review showed there was no incident investigation or steps taken to prevent recurrence (Actions.b. Review of a Resident Incident Reporting Form dated 8/17/26 and timed 7:30 AM showed Staff reported that [resident #5] came out of [his/her] room, threw [his/her] water bottle at another resident then just started punching and yelling at [him/her] while the other resident was sitting in [his/her] recliner. Staff called a code green and was able to get [resident #5] off the other resident all while [resident #5] then attacking them and yelling at them to take [him/her] to the rec center. Staff got [resident #5] out the door and security and RT then walked with [resident #5]. Further review showed Description of Resident's Present Health Condition (To include resident orientation per/post incident) was marked as Appears to be getting manic just from how [s/he] has been recently and some days worse than others and Steps taken to Prevent Recurrence (Actions) was marked as To be determined. c. Review of a facility reported incident investigation dated 8/17/26 and timed 7:25 AM showed [Resident #5] went after [resident #6], hitting [him/her] in the head with a water bottle. [Resident #6] has a lump and bruise on [his/her] head. The Summary Findings showed [Resident #6] was yelling at [resident #5]. [Resident #5] reacted physically towards [resident #6] hitting [him/her] with a water bottle and tackling [him/her] to the ground. Staff separated both residents. [Resident #6] was assessed for injuries and [resident #5] left the cottage to remain at baseline. The review showed the Corrective Action was Residents were separated immediately. [Resident #5] left the cottage to remain at baseline with support from facility staff and [resident #6] was assessed for injuries at baseline with support from cottage staff. Further review showed Interventions were Both residents will be supported through counseling and support by staff when interacting with each other.d. Review of a grievance form dated 8/18/26 showed resident #5 reported [Resident #6] annoys me rude[sic], [s/he] is a persistant [sic] asshole. If [s/he] hits the ground, I get mad. Go into blackout. Can't control self. Won't stop. I become violent. Better warn [him/her] to leave me alone. Further review showed Resolution of Grievance/Complaint was Ongoing issue between 2 residents. [Resident #5] can't understand the other resident. Other resident more vocal [and] agitated, delusional. [Resident #5] is currently having a manic cycle. Continue to provide support. [Resident #5] is accepting of this. e. Interview with CNA #1 on 8/20/26 at 9:56 AM revealed resident #5 was currently cycling and didn't understand dementia. The CNA revealed on 8/17/26 resident #5 got upset and threw his/her water cup at resident #6, then went and hit resident #6 in the head because resident #6 told resident #5 to shut up. She revealed resident #6 thought resident #5 was talking too loud and resident #5 walks by others with his/her tablet playing music loudly. The CNA revealed resident #5 wouldn't do anything when staff were around; however, s/he remembers the things resident #6 says and attacks him/her when it was unexpected. The CNA revealed both residents disliked noise and loud people. The CNA revealed staff were expected to be out in the common area anytime resident #5 was in the common area and the resident could not be left alone with other residents. She confirmed the resident had previous altercations before the incident on 8/17/26. Further interview revealed staff were not part of IDT meetings and were not asked for suggestions on behaviors.f. Interview with facility investigator #1 on 8/20/26 at 12:42 PM revealed the altercation on 8/17/26 occurred after previous resident to resident altercations between resident #5 and resident #6 and resident #6 said s/he had pain and sustained a bump following being hit in the head by resident #5. 2. Review of the policy titled Prevention of Resident Abuse, Neglect, and Exploitation last revised on 11/6/24 showed .The resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . 10. Post-investigation, the WLRC Management Investigation Review Team will review the incident(s) and investigations to determine: a. Why the incident may have occurred; b. How to prevent further incidents; c. How care or services may be improved to protect residents; d. What additional training may be needed to prevent occurrences and how to determine staff competency post-training; and e. Which staff will be responsible for implementing identified corrective actions when the actions will be complete, and who will monitor the plan's effectiveness (i.e., QAPI Performance Improvement Plan may be developed) .

Based on staff interview, medical record review, policy review, and facility incident investigation review, the facility failed to ensure adequate supervision was provided for 2 of 8 sample residents (#2, #14) reviewed for accident hazards. The failure resulted in actual harm to resident #2. The findings were:1.Review of the quarterly MDS dated [DATE] showed resident #2 had a BIMS score of 6 out of 15, which indicated severe cognitive impairment, and had diagnoses of traumatic brain injury, non-Alzheimer's dementia, hemiplegia, and chronic lung disease. Review of the care plan dated 3/7/25 showed the resident had a high to severe risk of choking and aspiration due to the lack of ability to clear his/her throat with textures above puree, and required 1 to 1 supervision and close attention to swallowing during all meals. The care plan showed the resident required a pureed food texture (IDDSI Level: 4) and liquid consistency of moderately thick to extremely thick (IDDSI Level 3-4). Further review showed the resident should not be left around food unsupervised to prevent and reduce risk of choking. The following concerns were identified:a. Review of the facility investigation dated 4/22/25 showed after resident #2 finished her/his meal, which CNA # 3 had been assigned to supervise, the resident had been left at the dining room table while other residents continued to eat. CNA #3 and CNA #7 left the dining area and went to the staff room, and CNA #5 was on a break. When CNA #3 and CNA #7 returned to the dining room they found resident #2 with a slice of pizza. The incident review showed CNA #3 removed the pizza slice from the resident's hands and mouth then left the building for a break. After the pizza was removed from the resident, CNA #5 and CNA #7 observed the resident choking on the remaining pizza and called for help. The incident review showed the nursing staff arrived and provided the resident two to three Heimlich maneuver thrusts and suctioning. Further review showed the incident caused resident #2 to have below normal oxygen levels, required increased supplemental oxygen, and was sent to the ER for evaluation.b. Interview with CNA #3 on 4/24/26 at 1:02 PM confirmed resident #2 was left at the dinner table unsupervised. The CNA revealed she believed the resident was done eating and didn't need further supervision. The CNA confirmed at the time of the incident, there was no staff present in the dining area and the resident obtained pizza from another resident which caused him/her to choke.c. Interview with CNA #7 on 4/24/26 at 2:50 PM confirmed she was with CNA #3 in the staff office after she assisted the resident with the meal, and when she returned to the dining area, resident #2 had pizza in her/his mouth. She confirmed CNA #3 went on break after she removed the pizza from the resident. She confirmed the resident choked on residual pizza after it had been removed, and additional staff responded to clear the resident's airway and send the resident for evaluation.d. Interview with the administrator on 4/24/26 at 4:17 PM revealed the expectation for residents that need supervision varied for each resident, and depended on the areas of supervision that were found in each resident's care plan. 2. Review of the significant change MDS dated [DATE] showed resident #14 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses of moderate non- Alzheimer's dementia, arthritis, osteoporosis and macular degeneration of both eyes. Review of the 11/11/25 and 8/13/25 quarterly MDS assessments indicated the resident had wandering behaviors 1 to 3 days during the look-back period and the impact of wandering had not been assessed. Review of the resident's impaired memory and risk for elopement care plan last revised on 11/18/25 showed interventions which included staff to remain vigilant to the resident's whereabouts and maintain STOP signage on all doors at all times, assure door alarms on outside doors and wander guard are in good working order at all times, and daily reminders for him/her to notify staff when resident is leaving. Further review showed the resident should be assessed for potential physical or emotional reasons for wandering which included depression, need for toileting, water, food or pain relief, restlessness, agitation, symptoms of anxiety, exit watching/seeking, escaping from embarrassment and attempts to find someone in charge. The following concerns were identified:a. Review of a progress note dated 12/9/25 and timed 2 AM showed the resident had been up all night, went to speak with the RN in the medication room to report multiple complaints, and then left the room. At approximately 2:15 AM the back door alarm went off and the CNAs and RN found the resident had attempted to get into the door of the adjacent cottage. The resident had his/her walker with food on it and did not wear a coat. Further review showed the resident had been escorted back to his/her residence, had been assessed, and had been found not to have any injuries.b. Review of a progress note dated 4/18/26 and timed 11 PM showed the resident was believed to have left out the front door as the alarm went off. Staff went to assess the alarm to find the front door open and they were not able to see anyone. Room checks were completed and the resident was found missing. Staff then called security to help look for the resident who then found the resident at 11:10 PM in front of the education building. Further review showed the resident was escorted back to his/her residence, was assessed, and was found to have no injuries. The resident stated that s/he was looking for an administrator to talk with about his/her concerns.c. Review of the medical record showed the resident had 15 incidents of elopements between 1/19/25 and 4/18/26 which resulted in the resident being found outside his/her residence without staff knowledge.d. Interview with the facility investigator #1 on 4/24/26 at 11:20 AM revealed on 12/2/25 at 4 PM she was leaving her temporary office in the Sapphire building and found resident #14 outside on the road with a walker. The investigator revealed the resident was upset that no one would engage with him/her inside the residence. The investigator revealed she was able to get the resident into her office, where they spent approximately 20 minutes talking, and then they walked around the campus before they returned to the resident's home. She revealed the resident had been known to wait until everyone was out of the common area before s/he eloped from the residence. Further interview revealed the investigator believed there was an ongoing debate between staff about what was considered elopement.e. Review of an elopement risk assessment dated [DATE] revealed resident #14 attempted elopement weekly with some successful attempts with interventions in place.f. Review of the care conference meetings for the resident on dates 12/3/24, 2/26/25, 5/27/25, 2/4/26 and 3/6/26 showed no evidence that resident elopement had been discussed and no evidence interventions had been evaluated.g. Interview with the administrator on 4/24/26 at 4:17 PM revealed she treated any resident who left a cottage or went to the green lines without staff knowledge as an elopement. She revealed these designations of boundaries depended on resident specific needs and risks, that were found in individual resident care plans. Further she revealed the resident had a wander guard on his/her walker for being high risk for elopement.h. Review of facility policy titled Wandering and Elopement dated 4/2022 showed . 3. If MDS 3.0 item E1000 A is checked yes an Elopement Risk Assessment will be performed and a care plan updated and revised to ensure safety. 6. A care plan identifying wandering and elopement risk will be implemented on admission with quarterly review and as needed.

Based on observation, staff interview, record review, facility investigation review, and policy review, the facility failed to protect the residents' right to be free from verbal abuse, physical abuse, and sexual abuse by staff and residents for 3 of 8 sample residents (#4,#12,#16) reviewed for allegations of abuse and neglect. This failure resulted in actual harm to resident #16. The findings were: 1.Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 15 out of 15, which indicated normal cognitive function and diagnoses of non-traumatic brain dysfunction, anxiety and schizophrenia. Review of the quarterly MDS assessment dated [DATE] showed resident #16 had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment, and diagnoses which included traumatic brain dysfunction, anxiety and depression. The following concerns were identified:a. Review of the facility incident report dated 3/17/26 showed there had been an incident in the kitchen area between resident #16 and #4 where unknown words were exchanged and resident #4 struck resident #16 in the forehead with a cup. When the staff intervened, resident #4 slipped and fell on the water from the cup. Both residents were separated, removed from the area, and assessed.b. Interview with RN #5 on 4/24/26 at 1:15 PM revealed she left the medication room after she heard a commotion, and saw resident #4 on the ground. She revealed the staff tried to help him/her off the floor and s/he fell again. She revealed when he assessed resident #4 and s/he had a bruise on his/her back and when she assessed resident #16, she found a half circle mark on his/her forehead which looked like the bottom of the cup s/he had been hit with. c. Interview with facility investigator #1 on 4/24/26 at 11:27AM revealed resident #16 had been verbally abusive to staff and continued to mumble negative things when resident #4 retaliated by hitting her/him with the cup. d. Review of a progress noted dated 3/18/26 showed follow up on Head Injury. Assessment first thing this morning. [Resident #16] is awake and alert in [his/her] room. [S/he] reports [s/he] was able to sleep pretty good. Alert to person, place, time and event. Crescent shaped pink area noted to [his/her] left forehead. It does not seem to be tender when I touched the area.2. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 15 out of 15 which indicated normal cognitive function, and had diagnoses of non-traumatic brain disorder, anxiety and schizophrenia. Further review showed the resident had risk for behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) for 1 to 3 days during the look back period. Review of the care plan dated 1/10/24 indicated that all staff followed the protection from harm policy, protocol, and standard operating procedures. Review of the admission MDS assessment dated [DATE] showed resident #6 had a BIMS score of 4 out of 15 which indicated severe cognitive impairment, and had diagnoses which included traumatic brain injury, Parkinson's disease, psychotic disorder and post-traumatic stress disorder. The following concerns were identified:a. Review of a facility investigation dated 7/10/25 showed resident #6 was in the common area with other residents and staff when s/he stated s/he was going to ejaculate on the nurse's face and then told resident #4 s/he was going to put his/her genitals on the resident's back. Resident #6 then proceeded to expose his/her genitals, make inappropriate sexual gestures, and asked others to touch it. Further review showed the resident urinated on the carpet, a code green was called, and resident #4 was removed from the area.b. Interview with RN #7 on 4/23/26 at 2:10 PM revealed resident #6 demonstrated many threatening behaviors she tried to redirect which worked until the resident exposed themselves, made inappropriate sexual gestures, and urinated on the floor, which triggered her to call the code green. Further interview revealed resident #4 had been upset after the interaction and had to be redirected.3. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 15 out of 15, which indicated normal cognitive function, and diagnoses of non-traumatic brain dysfunction, anxiety and schizophrenia. Review of the quarterly MDS assessment dated [DATE] showed resident #12 had a BIMS of 11 out of 15, which indicated moderate cognitive impairment, and diagnoses of intracranial injury, neurogenic bladder, incontinence of bowel and bladder, and hemiplegia. The following concerns were identified:a. Review of the facility investigation dated 3/20/26 showed oncoming staff found resident #12 in his/her clothes from the day before and saturated in urine and feces. The incident review showed feces was also found on the walls, floor, oxygen machine, and on the TV. The incident review showed resident #4 was reported to have been visibly shaking and upset that s/he had to come out of his/her room multiple times during the night to get help and a CNA from another cottage had put resident #12 to bed around 9 PM. Further review showed resident #12's life safety checks were not performed every 30 minutes, CNA #17 and CNA #19 were placed on administrative leave for investigation, and the CNAs were terminated. b. Interview with the facility investigator #1 on 4/24/26 at 11:27AM revealed when she arrived at work on the morning of the incident, she was called to the cottage of the incident where she observed resident #12 was in his/her clothes and shoes from the day before, and there was feces on the resident and all over the room. c. Interview with CNA #21 on 4/24/26 at 12:15 PM revealed he came to work at approximately 6:30 AM the day of the incident and he heard resident #12 yelling for help. When he entered the room, he found the resident had feces all over the room and him/herself, was saturated in urine, and wore clothes and shoes from the previous day. He revealed the resident had a history of digging in his/her brief and spreading his bowel movements when s/he had to sit in them for long periods of time, but he had not seen that behavior from the resident in a year of working there. He revealed he left the room and notified the guide and administrative staff of the situation, cleaned up the resident, and cleaned the room of the mess. He revealed it took him a long time to get the feces off of the resident as it was dried on and difficult to remove. Further interview revealed he was familiar with this resident and the resident did not generally wear his/her shoes and day clothes to bed. d. Interview with social services #1 on 4/24/26 at 4:17 PM revealed when she got to work the day of the incident, the CNAs and guide were frantic about the situation and she instructed them to involve investigations. She observed resident #12's room with feces on walls, bed, floor and TV. She revealed while the staff tended to resident #12, she checked on all the other residents on the unit to make sure harm had not come to anyone else. e. Interview with RN #9 on 4/23/26 at 2 PM revealed she assessed resident #12 after the incident and he did have some redness to the sacral area but no skin break down and it resolved without issue. She revealed resident #4 had been assessed and had calmed down, and had no visible injuries.4. Review of the facility policy titled Prevention of Resident Abuse, Neglect and Exploitation dated 5/14/25 showed . It is the policy and practice of the WLRC that all residents will be protected from abuse and neglect. WLRC will not tolerate any form of resident abuse and will continually monitor facility policies, procedures, training programs, etc., to assist in preventing resident abuse.

Based on staff interview, medical record review, facility investigation review, professional standard review, and policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 8 sample residents (#10) reviewed for quality of care. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a BIMS score of 9 out of 15, which indicated moderate cognitive impairment, and had diagnoses which included nontraumatic brain dysfunction, schizoaffective disorder, depression and hypertension. Review of the resident's care plan last revised on 3/19/26 showed a history of delirium, cognitive loss, depression and non-compliance with taking medications. Further review showed the resident did not believe s/he had medical issues and s/he did not need medications. The care plan showed nurses were to approach the resident calmly to inform him/her when it was time for his/her medication and if s/he refused, nursing would politely accept his/her refusal, walk away, and may attempt again later. The following concerns were identified:a. Review of a progress note dated 1/22/26 and timed 3:41 PM showed the resident received his/her monthly Invega medication and it was administered to L [left] flank [the side of the torso between the lower rib cage and the top of the hip bone] area after transfer to w/c [wheelchair] from van. Resident did not flinch or express discomfort or change facial expression during administration.b. Review of a facility investigation dated 11/21/25 showed resident #10 was taken out to eat by the DON and the behavioral analyst. During the outing, the DON administered an Invega injection through the resident's clothing, after the resident refused the medication earlier. The incident review showed the DON stated Sensory modulation techniques were implemented to improve resident tolerance of the injection procedure. Resident provided sensory items, including keys, a beaded lanyard with textured material, and alcohol wipes, were utilized to provide tactile distraction and reduce perceived discomfort during administration. For resident and staff safety, and to reduce risk of physical struggle or injury, the ordered medication was administered via intramuscular injection to the left deltoid through clothing, utilizing nursing clinical judgement based on the resident's history of aggression and inability to safely expose the injection site. Site landmarking was confirmed as accurately as possible under the circumstances. Further review showed the resident wasn't interviewed due to him/her being asleep during the investigation.c. Interview with the DON on 4/23/26 at 3:07 PM revealed resident #10 was given recent Invega injections with the guardian's informed consent. The staff discussed trying new distraction techniques and dining outings, as the resident was food motivated, and the guardian agreed to these trial interventions. Further interview revealed the guardian agreed the resident did need the injection to have an overall improved wellbeing and the resident has a high level of paranoid delusions without medications.d. Interview with social services #1 on 4/24/26 at 4:17 PM revealed she had attempted to contact administration due to resident #10 being taken off campus to sneak a shot on him/her after s/he refused the medication that morning. This made her uncomfortable and she felt the resident should be able to refuse. She went to investigations to get them to check in on the situation since she couldn't get a hold of administration.2. Review of the manufacturer prescribing information for Invega Sustenna showed .Invega Sustenna is intended for intramuscular use only. Do not administer by any other route. Avoid inadvertent injection into a blood vessel. Administer the dose in a single injection; do not administer the dose in divided injections. Inject slowly, deep into the deltoid or gluteal muscle.3. Review of Wolter Kluwer's Lippincott Nursing Procedures [Kindle Version], 9th edition, 2023 page 2127 through 2143 showed .IM injection.the site for an IM injection must be chosen carefully, taking into account the patient's general physical status and the purpose of the injection. IM injections shouldn't be administered at inflamed, edematous, or irritated sites or at sites that contain moles, birthmarks, scar tissue or other lesions. IM injections require sterile technique to maintain the integrity of the muscle tissue. avoid distractions and interruptions when preparing and administering medications to prevent medication errors. to locate deltoid injection site find the lower edge of the acromial process and the point on the lateral arm in line with the axilla. Insert the need 1 to 2 inches below the acromial process, usually 2 or 3 finger breadths, at a 90-degree angle.to locate ventrogluteal Have the patient sit, stand, lie laterally, or lie supine. Locate the greater trochanter of the femur with the heel of your hand. Then spread your index and middle fingers from the anterior superior iliac spine to as far along the iliac crest as you can reach. Insert the needle between the two fingers at a 90-degree angle to the muscle.4. Review of the facility policy titled Administering and Documenting Medications dated 4/1/22 showed .medications shall be administered in a safe and timely manner, and as prescribed.3. Medications must be administered in accordance with the orders, including any required time frame. Staff should consider individual needs and preferences when evaluating medication administration times.20. Staff shall follow established WLRC infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medication, as applicable.

Based on observation, resident and staff interview, and record review, the facility failed to ensure necessary behavioral health care and services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 13 sample residents (#1) who was reviewed for behavioral health interventions. This failure resulted in actual harm to resident #1. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a brief interview for mental status score of 15 out 15, which indicated s/he was cognitively intact, and had diagnoses which included cerebral vascular accident, non-Alzheimer's dementia, seizure disorder, traumatic brain injury, anxiety disorder, depression, and psychotic disorder. Further review showed the resident had verbal behavioral symptoms directed toward others 1 to 3 days during the look-back period. Review of the care plan for resident #1 dated 4/3/2024-Present showed Behavioral Symptoms: Baseline Behaviors [resident #1] has exhibited verbal and physical behavioral symptoms directed at self and others. The interventions included When [resident #1] becomes frustrated with other residents, staff will support [resident #1] to plan to ignore and work with them when [s/he] encounters them, rather than calling them names. Staff will offer redirection with preferred activities. Staff will contact nursing if interventions are not effective. Nursing will contact provider if further interventions such as one on one are necessary (which needs to be ordered by the provider). Respond in a calm voice; maintain eye contact. Remove from area if [resident #1] is verbally abusive to others. Escalated behavior management: If [resident #1] is physically or verbally aggressive towards other residents, including threat of harm to other residents, [resident #1] may be assisted from the vicinity of other residents, for other residents' safety. The following concerns were identified:a. Review of a facility incident report dated 5/14/25 showed resident #1 accused resident #2 of stealing his/her food from the pantry. Resident #2 got angry at the accusation and threw a laundry basket at resident #1. Resident #1 attempted to kick resident #2 and then both residents attempted to hit each other. The residents were in a bearhug style and resident #2 attempted to pull resident #1 out of his/her wheelchair. Further review showed no physical injuries were identified.b. Review of a facility incident report dated 6/25/25 showed resident #1 was in an elevated behavior due to outside stimuli and was being aggressive physically and verbally towards other residents in the unit. There were no injuries or outcomes identified.c. Review of a facility incident report dated 7/14/25 showed at approximately 2 AM, resident #1 was yelling at resident #2. Resident #1 was calling resident #2 a Fucking Retard and stating resident #2 should die. Resident #1 turned his/her music full blast and started kicking [his/her] door which upset resident #2. Resident #2 stated s/he had enough, obtained a pitcher of water, threw the water on resident #1, and threw punches at resident #1. The residents ended up in the hallway with resident #2 holding onto [resident #1]'s shirt trying to punch and kick [him/her]. After the residents were separated, the RN assessed the residents and identified an abrasion to the leg of resident #1 where resident #2 had kicked him/her. d. Review of a facility incident report dated 9/17/25 showed resident #2 became aggressive towards resident #1 after resident #1 was calling staff and residents derogatory names and yelling at others. Resident #2 threw cold water on resident #1 then grabbed resident #1's glasses off his/her face and threw them on the floor. Resident #1 stated resident #2 broke his/her glasses; however, witnesses stated resident #2 bent the glasses then resident #1 broke them completely.e. Review of an incident report dated 9/19/25 showed resident #1 had returned from a nature ride and was unloaded on the sidewalk in front of his/her house. Resident #3 was driving his/her wheelchair down the sidewalk towards the Sunflower unit as that was where his friends lived. The incident showed words were exchanged by resident #1 and resident #3 who is non-verbal, and resident #3 hit resident #1 in the head and ran his/her wheelchair into resident #1. Resident #1 hit resident #3 and stated s/he had a right to defend him/herself. The residents were separated and assessed. Further review showed both residents had minor injuries that were treated by the facility.f. Review of a facility incident report dated 9/25/25 showed resident #1 was calling staff and other residents derogatory names. The resident went to his/her room. Resident #2, who was upset by the name calling, went to resident #1's room, threw a beverage on resident #1, jumped on resident #1, and punched resident #1. g. Review of a facility incident report dated 9/27/25 showed resident #1 provoked resident #2 by getting in front of him/her and calling resident #2 an asshole. Resident #2 became escalated and threw juice and the cup at resident #1 and called resident #1 a fucking asshole. 2. Interview with CNA #1 on 10/15/25 at 12:01 PM revealed on 9/19/25 resident #1 and 2 other resident had gone on nature ride. The CNA revealed after resident #1 was assisted off the bus, he heard another staff member say stop it. The CNA revealed when he turned around, ho observed resident #1 and resident #3 swinging at each other and observed them hit each other. The CNA revealed when the altercation was over, resident #1 had a scratch on his/her chin and resident #3 a red area on his/her head and eye. The CNA revealed the following day resident #3 had a black eye. Further interview revealed resident #1 claimed resident #3 had pushed him/her off the sidewalk and hit him/her. 3. Interview with CNA #2 on 10/15/25 at 10:38 AM revealed resident #3 got along with everyone except resident #1. Following the incident on 9/19/25, the CNA revealed resident #3 was fearful. The CNA revealed she had observed resident #1 resident #3 a retard and stated resident #3 would get mad. She revealed she was unsure what to do with resident #1 because when staff told him/her to stop making statements towards others, resident #1 would increase the statements. The CNA revealed resident #2 had gone after resident #1 because resident #2 was protective of staff and other residents and resident #1 antagonizes other residents and staff. The CNA was unsure what interventions were effective to redirect resident #1.4. Interview with CNA #3 on 10/25/25 at 12:23 PM revealed on 7/14/25 resident #1 was upset when s/he woke up. She revealed the resident was calling people derogatory names. She revealed resident #2 was trying to stay out of it by staying in his/her room. The CNA revealed she asked resident #1 to stop calling others names; however, when s/he was told s/he could not make a phone call, resident #1 got upset and chased after the CNA. The CNA revealed she had called security and when resident #2 came out of his/her room s/he heard the statements resident #1 was making, grabbed some water, and headed to resident #1's room. The CNA revealed by the time she made it to the room, resident #1 was soaked and resident #2 was trying to punch resident #1 while resident #1 was hitting resident #2 on top of the head with a television remote. The CNA revealed after the residents were separated, resident #2 was still angry and was yelling at resident #1. The CNA revealed resident #1 was always agitating others and when staff attempt to redirect him/her, it was not always effective. The CNA revealed resident #2 often stayed in his/her room to avoid resident #1. The CNA revealed once when resident #3 came to the house to visit her, resident #1 stated When you are done playing with the retard, I need a napkin. The CNA revealed on a different occasion resident #1 stated Oh my god, you guys play with [him/her] like [s/he] is a fucking 3-year-old in regards to resident #3. Further interview revealed resident #3 indicated s/he was afraid of resident #1 and when they shared a house, resident #3 would remain in his/her room to avoid resident #1. 5. Interview with RN #1 on 10/15/25 at 11 AM revealed resident #3 was non-verbal and got along with everyone except # resident #1 because s/he called resident #3 retarded. The RN revealed following the altercation on 9/19/25 resident #3 shook his/her head no when asked if s/he was ok, then pointed to his/her arm and head. The RN revealed resident #3 had some scratches and his/her eye was red. The RN revealed resident #1 had other incidents with individuals due to derogatory statements. The RN revealed resident #2 had been in incidents with resident #1 after resident #1 had made derogatory statements to others. 6. Interview with CNA #4 on 10/15/25 at 11:21 AM revealed resident #1 called the other residents retards and upsets the other resident. The CNA revealed resident #2 gets really upset and has a hard time calming down. The CNA revealed resident #1 will make derogatory statements for hours and the staff don't have any interventions to get resident #1 to stop.7. Interview with CNA #5 on 10/15/25 at 11:39 AM revealed resident # 1 called other derogatory names and upset other residents. The CNA revealed the only intervention was to tell the resident to stop which was effective sometimes and wasn't effective other times.

Based on medical record review, staff interview, facility incident review, and policy review, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 of 13 sample residents (#2, #3) reviewed for allegations of abuse. This failure resulted in actual physical harm to resident #2 and resident #3. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a brief interview for mental status score of 14 out 15, which indicated s/he was cognitively intact, and had diagnoses which included schizophrenia and bipolar disorder. Further review showed the resident had physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others on 1 to 3 days during the look-back period. The following concerns were identified: a. Review of a progress note for resident #2 dated 5/14/25 and timed 11:27 PM showed D: Resident to resident aggression. A:Resident [#1] came out of [his/her] room and wanted in the pantry. Resident said everything needed to be locked due to other resident. [Resident #1] then went back to [his/her] room. Staff reported was in the kitchen making popcorn for resident #2]. Resident came out of [his/her] room and asked to call provider [name]. Other resident came toward [#1] with [his/her] laundry basket. [Resident #1] yelled at other resident to stay away and [resident #2] charged at [him/her] and swung at him. [Resident #1] fought back. (The other resident [#2] threw the basket toward [resident #1]). Nurse was called and separated both residents. No injuries noted. [Resident #2] was on floor as other resident was trying to go after [him/her] (pushing toward [him/her] with [his/her] chair) but reports no injury and was not hit by other resident. Guardians, ROC called. Talked to Social Worker [name] about incident. notified providers and DON by email. P: Nursing to follow up as needed.b. Review of a facility incident report dated 5/14/25 showed resident #1 accused resident #2 of stealing his/her food from the pantry. Resident #2 got angry at the accusation and threw a laundry basket at resident #1. Resident #1 attempted to kick resident #2 and then both residents attempted to hit each other. The residents were in a bearhug style and resident #2 attempted to pull resident #1 out of his/her wheelchair. Further review showed no physical injuries were identified.c. Review of a progress note for resident #2 dated 7/14/25 and timed 7:35 AM showed D: Resident to resident incident. A: [NAME] code was called after this resident went after [resident #1] because [s/he] was yelling insults at another resident and was playing [his/her] music way loud and being disruptive. by staff report [resident #2] threw water on [resident #1] through [his/her] doorway and then tried to punch [him/her]. This nurse arrived shortly after green code called. [Resident #2] was actively to hit and kick [resident #1]. [S/He] was redirected by this nurse to create distance and get them calmed down. Another nurse called [name], NP for one time order hydroxyzine 25 mg. there were no injuries noted. P: Nursing to follow up as needed.d. Review of a facility incident report dated 7/14/25 showed at approximately 2 AM, resident # 1 was yelling at resident #2. Resident #1 was calling resident #2 a Fucking Retard and stating resident #2 should die. Resident #1 turned his/her music full blast and started kicking [his/her] door which upset resident #2. Resident #2 stated s/he had enough, obtained a pitcher of water, threw the water on resident #1, and threw punches at resident #1. The residents ended up in the hallway with resident #2 holding onto [resident #1]'s shirt trying to punch and kick [him/her]. After the residents were separated, the RN assessed the residents and identified an abrasion to the leg of resident #1 where resident #2 had kicked him/her. e. Review of a progress note for resident #2 dated 9/17/25 and timed 7:32 PM showed D- Behaviors A- [resident #2] became aggressive towards another resident today. The other resident was calling staff and residents derogatory names and yelling at others. [Resident #2] threw cold water on the other resident then grabbed the other residents glasses off of [his/her] face and threw them onto the floor. A code green was called and Behaviorist [name] took [resident #2] to [his/her] room to help [him/her] calm down, later security also went to [resident #2]'s room and then took [him/her] for a short walk outside. [Resident #2] came back more calm. P- Continue to provide supportive cares. f. Review of a facility incident report dated 9/17/25 showed resident #2 became aggressive towards resident #1 after resident #1 was calling staff and residents derogatory names and yelling at others. Resident #2 threw cold water on resident #1 then grabbed resident #1's glassess off his/her face and threw them on the floor. Resident #1 stated resident #2 broke his/her glasses; however, witnesses stated resident #2 bent the glasses then resident #1 broke them completely.g. Review of a facility incident report dated 9/25/25 showed resident #1 was calling staff and other residents derogatory names. The resident went to his/her room. Resident #2, who was upset by the name calling, went to resident #1's room, threw a beverage on resident #1, jumped on resident #1, and punched resident #1. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #3 long-term and short-term memory was not impaired and had diagnoses which included cerebral palsy, seizure disorder, and anxiety disorder. The resident had no physical or verbal behavioral symptoms directed toward others during the look-back period. Further review showed the resident used a motorized wheelchair. The following concerns were identified:a. Review of a progress note dated 9/19/25 and timed 11:38 PM showed D:Resident to Resident altercation A: During shift change we received a call by staff about resident to resident altercation. It was unclear by staff at what started the altercation but staff witnessed residents outside sunflower with residents side by side in wheel chairs with [resident #3]'s good side closer to the other resident. Both residents were seen hitting each other before staff could break them up. The other resident has been known to taunt [resident #3] and call [him/her] a retard on several different occasions. Upon assessment [resident #3] has some right eye swelling, and bruising is noted as well as a small scrape. There is also a small pin point size mark on [resident #3]'s right outer thumb with no bleeding visualized. There is a blood blister on right pointer finger and right knuckle that are not related to altercation. Head injury check list was initiated. Resident is alert and able to respond by nodding head and following commands VS and neuro check were all WNL to resident baseline. Resident does report pain to right side of face above eye, Tylenol was administered will continue to monitor for effectiveness. Nursing notified administrator [name] and ROC [name] around 18:50. Guardian notified about altercation informed Guardian about how the residents were found fighting and that the cause of altercation was unknown, but it was someone that [resident #3] had a history with. Let guardian know about swelling and bruising to eye and small injury on thumb, guardian expressed understanding and stated that [resident #3] can hold a grudge and has a temper. Let guardian know we will continue to follow up with any changes P: Will continue to monitor.b. Review of an incident report dated 9/19/25 showed resident #1 had returned from a nature ride and was unloaded on the sidewalk in front of his/her house. Resident #3 was driving his/her wheelchair down the sidewalk towards the Sunflower unit as that was where his friends lived. The incident showed words were exchanged by resident #1 and resident #3 who is non-verbal, and resident #3 hit resident #1 in the head and ran his/her wheelchair into resident #1. Resident #1 hit resident #3 and stated s/he had a right to defend him/herself. The residents were separated and assessed. Further review showed both residents had minor injuries that were treated by the facility.c. Interview with CNA #1 on 10/15/25 at 12:01 PM revealed on 9/19/25 resident #1 and 2 other resident had gone on nature ride. The CNA revealed after resident #1 was assisted off the bus, he heard another staff member say stop it. The CNA revealed when he turned around, ho observed resident #1 and resident #3 swinging at each other and observed them hit each other. The CNA revealed when the altercation was over, resident #1 had a scratch on his/her chin and resident #3 had a red area on his/her head and eye. The CNA revealed the following day resident #3 had a black eye. Further interview revealed resident #1 claimed resident #3 had pushed him/her off the sidewalk and hit him/her. 3. Interview with CNA #2 on 10/15/25 at 10:38 AM revealed resident #3 got along with everyone except resident #1. Following the incident on 9/19/25, the CNA revealed resident #3 was fearful. The CNA revealed she had observed resident #1 resident #3 a retard and stated resident #3 would get mad. She revealed she was unsure what to do with resident #1 because when staff told him/her to stop making statements towards others, resident #1 would increase the statements. The CNA revealed resident #2 had gone after resident #1 because resident #2 was protective of staff and other residents and resident #1 antagonized other residents and staff.4. Interview with CNA #3 on 10/25/25 at 12:23 PM revealed on 9/25/25 resident #1 was upset when s/he woke up. She revealed the resident was calling people derogatory names. She revealed resident #2 was trying to stay out of it by staying in his/her room. The CNA revealed she asked resident #1 to stop calling others names; however, when s/he was told s/he could not make a phone call, resident #1 got upset and chased after the CNA. The CNA revealed she had called security and when resident #2 came out of his/her room s/he heard the statements resident #1 was making, grabbed some water, and headed to resident #1's room. The CNA revealed by the time she made it to the room, resident #1 was soaked and resident #2 was trying to punch resident #1 while resident #1 was hitting resident #2 on top of the head with a television remote. The CNA revealed after the residents were separated, resident #2 was still angry and was yelling at resident #1. The CNA revealed resident #1 was always agitating others and when staff attempt to redirect him/her, it was not always effective. The CNA revealed resident #2 often stayed in his/her room to avoid resident #1. The CNA revealed once when resident #3 came to the house to visit her, resident #1 stated When you are done playing with the retard, I need a napkin. The CNA revealed on a different occasion resident #1 stated Oh my god, you guys play with [him/her] like [s/he] is a fucking 3-year-old in regards to resident #3. Further interview revealed resident #3 indicated s/he was afraid of resident #1 and when they shared a house, resident #3 would remain in his/her room to avoid resident #1. 5. Interview with RN #1 on 10/15/25 at 11 AM revealed resident #3 was non-verbal and got along with everyone except resident #1 because s/he called resident #3 retarded. The RN revealed following the altercation on 9/19/25 resident #3 shook his/her head no when asked if s/he was ok, then pointed to his/her arm and head. The RN revealed resident #3 had some scratches and his/her eye was red. The RN revealed resident #1 had other incidents with individuals due to derogatory statements. The RN revealed resident #2 had been in incidents with resident #1 after resident #1 had made derogatory statements to others. 6. Review of the facility policy titled Prevention of Resident Abuse, Neglect, and Exploitation dated 5/14/25 showed .It is the policy and practice of the WLRC that all residents will be protected from abuse and neglect .

Based on facility incident report review, state survey agency incident database review, staff interview, and policy and procedure review, the facility failed to ensure timely reporting of allegations of abuse for 2 of 13 sample residents (#1, #2) reviewed for allegations of abuse. The findings were: 1. Review of a facility incident report dated 9/27/25 and timed 4 PM showed resident #1 called resident #2 an asshole and resident #2 threw a cup of juice on resident #1.2. Review of the state survey agency incident database showed the incident was reported on 9/30/25 at 8:12 AM, 3 days after the incident occurred.3. Interview with facility investigator on 10/15/25 at 12:46 PM confirmed the incident was not reported timely. She revealed the incident occurred on a Saturday and at that time, they did not have any staff members who had access to the incident database that worked on the weekends. 4. Review of the facility policy titled Prevention of Resident Abuse, neglect, and Exploitation dated 5/14/25 showed .3. WLRC staff will report the allegation to the Wyoming Healthcare Licensing and Survey (HLS) website immediately, but not later than: Two (2) hours after the allegation is made if the events that cause the allegation involve abuse OR result in serious bodily injury; or Twenty-four (24) hours after the allegation is made, if the events that cause the allegation do not involve abuse AND do not result in serious bodily injury .

Based on medical record review and staff interview, the facility failed to arrange for specialized services to meet the resident's needs as identified on the Preadmission Screening and Resident Review (PASARR) level II for 1 of 2 sample residents (#9) reviewed. The findings were: 1. Review of the 8/8/24 annual MDS assessment showed resident #9 was admitted to the facility on [DATE] from an inpatient psychiatric hospital. The resident was coded as having been evaluated by a Level II PASARR and determined to have a serious mental illness. The resident had a BIMS score of 3 out 15, which indicated severe cognitive impairment, with inattention and disorganized thinking. In addition, the resident had diagnoses which included anxiety disorder, depression, bipolar, and psychotic disorder. Review of the 1/13/23 PASARR Level II Determination Summary Report showed the resident met the state definition of mental illness and recommended rehabilitative services to be provided in the nursing facility to include a minimum of annual comprehensive psychiatric evaluation to clarify the current psychiatric diagnosis and appropriate treatment plan. The following concerns were identified: a. Review of the resident's medical record showed the last psychiatric evaluation was completed on 2/1/21. b. Interview with the social services director on 1/24/25 at 9:56 AM confirmed an annual comprehensive psychiatric evaluation had not been completed as indicated on the PASARR Level II Determination Summary Report.

Based on medical record review, staff interview, policy and procedure review, and review of CDC immunization recommendations, the facility failed to ensure residents were offered pneumococcal immunizations based on CDC recommendations for 1 of 5 sample residents (#3) reviewed for immunizations. The findings were: 1. Review of the 10/21/24 quarterly MDS assessment showed resident #3 was admitted to the facility on [DATE]. The resident was [AGE] years old. The following concerns were identified: a. Review of Section O of the 10/21/24 quarterly MDS assessment showed the resident's pneumococcal vaccine was not up-to-date and had not been offered. b. Review of the resident's medical record showed no evidence the resident had been previously vaccinated. c. Interview with the DON on 1/24/25 at 12:47 PM confirmed the resident had not been offered the vaccine. 2. Review of the 4/5/22 Vaccination of Residents policy showed All residents will be offered vaccines that aid in preventing infectious disease unless the vaccine is medically contraindicated or the resident has already been vaccinated. 3. According to the CDC Vaccines and Immunizations by age located at https://www.cdc.gov/vaccines/by-age/index.html (accessed on 1/30/25) showed CDC recommends pneumococcal vaccination for all adults who never received a pneumococcal conjugate vaccine and are age [AGE] years or older.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to provide a written notice of transfer for 1 of 2 sample residents (#4) reviewed for facility-initiated transfers. The findings were: 1. Review of a 12/16/24 nurse progress note showed resident #4 was transferred to the hospital for an acute change of condition. Further review showed no evidence the facility issued a written transfer notice to the resident or the resident's representative. 2. Interview with the social services director on 1/24/25 at 10:51 AM revealed she was unable to locate the transfer notice. 3. Review of the 10/28/24 Transfer or Discharge; notice of; Appealing and Emergency Discharge policy showed .When a resident is temporarily transferred on an emergency basis to an acute care facility, the Social Worker, designee, or Nurse will provide verbal confirmation of transfer to the resident and family member or legal representative immediately or as soon as practicable. The resident and/or representative will also be notified by the Social Worker or designee in writing (i.e., a completed Notice of Resident Transfer or Discharge form) .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to provide written information on the bed-hold policy for 1 of 2 sample residents (#4) reviewed for facility-initiated transfers. The findings were: 1. Review of a 12/16/24 nurse progress note showed resident #4 was transferred to the hospital for an acute change of condition. Further review showed no evidence the facility issued written information on the bed-hold policy to the resident or the resident's representative at the time of the hospitalization . 2. Interview with the social services director on 1/24/25 at 10:51 AM revealed she was unable to locate the bed-hold notice. 3. Review of the 9/24/24 Bed Hold and Return policy showed .a. Upon admission and prior to any transfer, residents and/or their representatives will be provided written information regarding State and facility bed hold policies, which address holding a resident's bed during periods of absence (hospitalization or therapeutic leave) .

Based on staff interview and policy and procedure review, the facility failed to conduct an annual review of its infection prevention and control program (IPCP). The census was 13. The findings were: 1. Review of the facility's IPCP policies showed the following concerns: a. The Antibiotic Stewardship policy showed it was approved on 3/11/22 with no evidence the policy had been subsequently reviewed. b. The Written Exposure Control Plan & Health Outbreak Guidelines policy was approved on 4/5/22 with no evidence the policy had been subsequently reviewed. c. The Vaccination of Residents policy was approved on 4/5/22 with no evidence the policy had been subsequently reviewed. d. The Infection Prevention and Control policy was approved on 5/18/23 with no evidence the policy had been subsequently reviewed. 2. Interview with the DON on 1/24/25 at 12:47 PM confirmed the IPCP policies had not been reviewed annually as required.

Based on observation, staff interview, review of policy and procedures, and 2022 FDA Food Code review, the facility failed to ensure a sanitary environment in 2 of 2 food preparation areas (main kitchen, Sunflower cottage). The census was 8. The findings were: 1. Observation in the main kitchen on 10/25/23 at 11:03 AM showed walk-in freezer #2 had a sign posted on the door which said floors may be icy. Continued observation showed ice was built up on the floor, ceiling, and fans throughout the freezer, including on walk ways. 2. Observation on 10/25/23 at 11:05 AM showed the [NAME] dual oven #1 had dirt, grease, debris, and dead flies on the top. Further observation showed 4 additional oven racks were stored on top of the oven. 3. Observation on 10/25/23 11:09 AM showed the [NAME] dual oven #2 had dirt, grease, debris, and dead flies on the top. Further observation showed 3 additional oven racks were stored on top of the oven and the oven was in use. Interview with kitchen staff member #1 confirmed the oven was being used to prepare turkey for the evening meal. Interview with dietary manager #2 on 10/25/23 at 11:41 AM confirmed the ovens had not been cleaned recently. 4. Observation of meal preparation in the main kitchen on 10/25/23 11:05 AM showed kitchen staff member #1 and kitchen staff member #2 were wearing hair nets; however, the hair net was positioned in a way that allowed the staff members' bangs to be uncovered. Kitchen staff member #1 had bangs which were curled and were long enough to reach the middle of her forehead and kitchen staff member #2 had straight bangs which were long enough to reach to her eyes. Further observation showed kitchen staff member #3 was handling resident food and had a full beard, which was not covered or restrained. 5. Observation of meal preparation in the Sunflower cottage on 10/25/23 at 12:09 PM showed 2 staff members removed items from storage containers sent by the main kitchen and placed the food on a plate to be served to residents. No hair restraints were utilized. 6. Interview with dietary manager #1, dietary manager #2, and the dietitian on 10/25/23 at 11:27 AM revealed that previously the janitorial staff cleaned all the kitchen equipment; however, the process at that time was to complete a work order for equipment like the ovens to be cleaned. They revealed the walk-in freezer had been an ongoing problem and after being fixed, the ice build up began about a month later. They revealed they were unable to keep it free from ice buildup. Further interview revealed the facility has always allowed hair restraints to be positioned in a way bangs were not covered. It was confirmed hair and beard restraints should be worn when preparing food in the kitchen and in the cottage. 7. According to Food Code 22, U.S. Public Health Service: 2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 8. According to Food Code 22, U.S. Public Health Service: 4-601.11 .(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified related to the use of psychotropic medications for 3 of 5 sample residents (#1, #2, #8) reviewed for unnecessary medications. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #1 had diagnoses which included cerebrovascular attack, transient ischemic attack, or stroke, non-Alzheimer's dementia, seizure disorder, traumatic brain injury, and a psychotic disorder other than schizophrenia, physical behavioral symptoms directed toward others which occurred on 1 to 3 days during the look-back period, and verbal behavioral symptoms directed toward others which occurred on 1 to 3 days during the look-back period. Further review showed the resident received antipsychotic medication on an as needed basis since the prior assessment and a gradual dose reduction was attempted on 6/12/23. Review of the physician's orders showed the resident received trazadone (sedative/hypnotic) 5 milligrams (mg) by mouth at bedtime for insomnia, sertraline (antidepressant) 100 mg by mouth daily for unspecified psychosis, factitious disorder imposed on self with combined psychological and physical signs and symptoms, and violent behavior, risperidone (antipsychotic) 2 mg by mouth at bedtime and 1 mg by mouth in the morning for unspecified psychosis and anxiety disorder, and lorazepam (antianxiety) 1 mg by mouth as needed 3 times per week for anxiety. The following concerns were identified: a. Review of the behavior monitoring for August 2023, September 2023, and October 2023 showed no evidence specific target symptoms were identified for each medication prescribed. b. Review of the care plan effective 7/11/2022 to present showed no evidence specific target symptoms were identified for each medication prescribed. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had diagnoses which included non-Alzheimer's dementia. Further review showed the resident had delusions, wandered 1 to 3 days during the look-back period, received antipsychotic medication on an as needed basis, and had no gradual dose reduction attempted. Review of the physician orders showed the resident received escitalopram (antidepressant) 10 mg by mouth daily for depression and aripiprazole (antipsychotic) 10 mg by mouth daily for delusional disorders and sequelae of viral encephalitis. The following concerns were identified: a. Review of the behavior monitoring for August 2023, September 2023, and October 2023 showed no evidence specific target symptoms were identified for each medication prescribed. b. Review of the care plan effective 7/11/2022 to present showed no evidence specific target symptoms were identified for each medication prescribed. 3. Review of the admission MDS assessment dated [DATE] showed resident #8 had diagnoses which included depression and had other behavioral symptoms not directed toward others which occurred on 4 to 6 days during the look-back period. Further review showed the resident received antipsychotic medication on 7 out of 7 days, antianxiety medication on 7 out of 7 days, and antidepressant medication on 6 out of 7 days during the look-back period. Review of the physician orders showed the resident received olanzapine (antipsychotic) 7.5 mg by mouth at bedtime for major depressive disorder with psychotic features, desvenlafaxine (antidepressant) extended release 100 mg by mouth daily for major depressive disorder with psychotic features, and clonazepam (antianxiety) 1 mg by mouth three times per day for major depressive disorder with psychotic features. The following concerns were identified: a. Review of the behavior monitoring for August 2023, September 2023, and October 2023 showed no evidence specific target symptoms were identified for each medication prescribed. b. Review of the care plan effective 9/8/2023 to present showed no evidence of psychotropic medication specific target symptoms were identified for each medication prescribed. 4. Interview with the DON on 10/25/23 at 12:04 PM confirmed the facility did not have specific target symptoms identified for each psychotropic medication prescribed. 5. Review of the facility policy titled Psychotropic Medication Use dated 4/1/22 showed .1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The medical provider and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 3. The medical provider will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of psychotropic medications .8. Diagnoses alone do not warrant the use of psychotropic medication. In addition to the above criteria, psychotropic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; and: (1) The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) Behavioral interventions have been attempted and included in the plan of care, except in an emergency .

Based on resident fund account review, staff interview, and facility investigation review, the facility failed to protect the residents' right to be free from misappropriation of resident property by a staff member for 5 of 9 sample residents (#2, #3, #4, #5, #6). Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 9/1/23. The findings were: 1. Review of a facility incident report dated 7/12/23 showed accounting staff identified several receipts for resident item purchases they determined were questionable. The incident report showed all the receipts were provided for residents #2, #3, #4, #5, and #6 by CNA #1. An investigation was initiated and the CNA was placed on leave pending the investigation. The following concerns were identified: a. The incident report showed the facility interviewed the CNA on 7/14/23 at 9:30 AM and the CNA admitted she took money intended for resident purchases and generated the receipts on a computer in her office. The incident report review showed the CNA admitted to taking approximately $450.00 from April 2023 through June 2023. Further review showed the residents were not interviewed due to mental status, law enforcement was notified on 7/12/23 at 1:59 PM, the Department of Family Services was notified on 7/12/23 at 1:56 PM, and the resident representatives were notified on 7/12/23 between 2:05 PM and 2:20 PM. b. Review of the Client Served Funds Request logs for April 2023, May 2023, June 2023, and July 2023 confirmed there were unaccounted for funds for residents #2, #3, #4, #5, and #6. Review of the receipts attached to the logs showed some of the receipts for the same vendor did not have the same format or information, such as a bar code or vendor telephone number. c. Review of an Administrative Leave with Pay letter issued to the CNA dated 7/12/23 showed the leave was effective on 7/12/23 and the CNA signed a copy of the letter on 7/14/23. d. Review of an email to the facility from CNA #1 dated 7/14/23 at 2:06 PM showed the CNA admitted to taking the money intended for resident purchases and then created receipts for purchases which were not made. e. Review of a Notice of Conclusions dated 7/18/23 showed the facility verified misappropriation of resident property. f. Review of an email from the Wyoming State Board of Nursing showed that agency was notified of the incident on 7/19/23. 2. Review of the Wyoming State Board of Nursing website for CNA #1 on 10/24/23 showed the CNA certificate was Inactive-Suspended as of 8/8/23. 3. Attempted interview with CNA #1 on 10/24/23 at 1:41 PM revealed there was no answer and the recorded message indicated the mailbox was full and could not accept messages at that time. 4. Interview with the administrator, support services administrator, and accounting manager on 10/25/23 at 4:17 PM revealed the CNA was also a guide and as a result, had access to resident funds. The interview revealed the previous process for obtaining resident funds for purchases was for staff members to submit a form indicating the amount of money needed and the indication for use. After the submission was made, money would be issued for resident purchases directly from the resident's account and the staff member was expected to submit receipts when the purchase was made. The interview revealed when the business officer received some receipts from CNA #1 that did not match previous receipts obtained from the same vendors, an investigation was initiated. The interview confirmed CNA #1 admitted to creating the receipts on a facility computer because she was keeping the money. The interview revealed the first identified date of misappropriation from residents by CNA #1 was 4/7/23 and the last date was 7/7/23. The interview revealed during the investigation audits were performed and identified the total amount of misappropriated money from the residents was $887.32, which was returned by the facility to the individual resident accounts and no additional residents were identified. The interview revealed the residents were not prevented from making additional purchases as a result of insufficient funds following the misappropriation. Further interview revealed a new process for resident purchases was implemented following the incident which included a timeline of 1 week to submit left over money and receipts for resident purchases, a tracking log to monitor all outstanding money and receipts, all funds and receipts must be turned in by the approved staff member in person, the staff member was required to participate in accounting of the receipts and funds at the time of submission, and each purchase was required to be documented in detail, including the amount spent for each resident, what was purchased, and initialed by the individual who made the purchase. The interview revealed the new process was implemented on 9/1/23.

Based on medical record review, staff and resident interviews, and review of incident reports and facility documentation, the facility failed to protect the resident's right to be free from physical abuse by a client from another facility for 1 of 1 sample residents (#1) reviewed for abuse allegations, which resulted in physical and psychosocial harm. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 10/6/23. The findings were: 1. Review of the 9/12/23 significant change Minimum Data Set (MDS) assessment showed resident #1 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. 2. Review of a progress note dated 9/19/23 showed the resident attended work for a little while, but then came home due to an altercation. 3. Review of an incident report submitted to Healthcare Licensing and Surveys (HLS) showed on 9/19/23 a client (#C1) from another facility (located on the same campus) attacked resident #1 at the resident's work station. It was documented the resident received a scratch near his/her armpit and a torn shirt. 4. On 10/9/23 at 3:19 PM security officer #1 stated on 9/19/23 while on foot patrol he encountered client #Cl, who was upset at resident #1 for something s/he had said. The security guard went to the training center where resident #1 was working and asked him/her to apologize to client #C1. He stated he was observing from around the corner when client #C1 entered the training center and went over to resident #1. He stated resident #1 started to apologize to client #C1 when client #C1 grabbed the resident by the shirt, and tore his/her shirt. The security guard separated the residents and other staff arrived to help. 5. During an interview on 10/9/23 at 3:30 PM security guard #2 stated when her arrived to the training center on 9/19/23 he saw security guard #1 had ahold of client #C1, who was trying to get to resident #1. He stated resident #1 was in his/her wheelchair and was not fighting back. 6. On 10/9/23 at 3:45 PM shift supervisor #1 stated he was attending a training at the training center on 9/19/23 and during a break he came around the corner and heard resident #1 stating s/he wouldn't apologize to client #C1, and client #C1 was ripping the shirt off of resident #1. He stated security was present. 7. During an interview on 10/9/23 at 4:27 PM resident #1 stated on 9/19/23 s/he encountered client #C1 outside who yelled at him/her. Resident #1 stated s/he ignored it and went to work at the training center. S/he stated security guard #1 came to him/her and asked if s/he could apologize to client #C1 and s/he said OK. Resident #1 stated client #C1 came in and started yelling. Resident #1 stated s/he said sorry and then client #C1 grabbed his/her hand and slammed it on the desk. S/he stated the client then grabbed him/her and ripped their shirt. The resident stated s/he received a scratch near his/her shoulder and forearm. The resident stated as a result of the altercation, s/he was afraid of client #C1. The resident stated I hate to be scared, but I am. 8. On 10/10/23 at 8:30 AM Professional Development Center (PDC) instructor #1 stated on 9/19/23 she didn't observed the actual incident between client #C1 and resident #1 because security had already intervened when she came upon it. She stated that she did talk to resident #1 after the incident. She stated resident #1 was visibly shaken with a trembling voice. She stated resident #1 had a ripped shirt. 9. During an interview on 10/10/23 at 9 AM resident rights advocate #1 stated client #C1 attacked resident #1 on 9/19/23. She stated the resident had a ripped shirt and a small scratch. She stated she would consider the incident substantiated for abuse because the client did get ahold of the resident and ripped his/her shirt. 10. During an interview on 10/10/23 at 11:06 AM registered nurse (RN) #1 stated she assessed resident #1 after the incident. She stated the resident had a little scratch that s/he claimed was from client #C1. She stated it could have been because the resident did have a ripped shirt. She stated since the incident the resident has said s/he is afraid of client #C1. 11. Review of a progress note dated 9/19/23 by RN #1 showed Upon assessment, [resident] had no redness or bruising noted to shoulders although [s/he] was claiming [his/her] pain was a 9 and now was a 12. Did have a small scratch to right inner shoulder. Left forearm where [resident] had a scab was also opened now but unknown if that was from other resident or [resident] picked at it as [s/he] is known to pick at [his/her] skin .although [resident] reports that other resident did that as well . 12. Review of facility documentation and interview with the nursing home administrator on 10/10/23 at 1:24 PM revealed the facility already had a plan of correction for F600 in place prior to this incident, and it continued after the incident. Compliance was determined to be met on 10/6/23. The actions taken by the facility included: a. The client from the other facility (#C1) had his/her work route changed so s/he would not be in the same building as resident #1. b. All residents have had their care plans updated to reflect risk of abuse. c. Staff education related to abuse, with focus on resident to resident abuse, was completed on 9/19/23, 9/26/23, and 10/3/23. Additional trainings are scheduled. Trainings were scheduled weekly for one month then monthly for two months. d. Audits were completed related to abuse and monitored in quality assessment and performance improvement (QAPI) meetings. Audits are continuing. There have been no other allegations of abuse since this incident.

Based on review of medical records, staff interview, review of facility investigations and incident reports, and review of policy and procedures, the facility failed to protect the resident's right to be free from physical and mental abuse by a resident for 1 of 4 residents (#3) reviewed for abuse. This failure resulted in harm to resident #3, who sustained bruising and expressed continued fear of resident #4. The findings were: Review of the quarterly MDS assessment dated [DATE] for resident #4 showed the resident had diagnoses which included CVA, non-Alzheimer's dementia, seizure disorder, TBI, and psychotic disorder. Further review showed the resident had a BIMS score of 13/15, indicating intact cognition. Review of the resident's reported behavior showed behavioral symptoms of hitting, kicking, pushing, scratching, grabbing, threatening others and screaming and cursing at others occurred 1 to 3 days every week. Review of the annual MDS assessment dated [DATE] for resident #3 showed the resident had diagnoses which included renal insufficiency, osteoporosis, a history of fractures, and non-Alzheimer's dementia. Further review showed the resident had a BIMS score of 7/15 indicating severe cognitive impairment. Review of the resident's behavior documentation included delusions along with weekly physical and verbal behaviors directed at others. The following concerns were identified: 1. Review of the facility investigation of a 7/23/23 at 10:20 PM incident between resident #4 and resident #3 showed resident #4 was in the bath and resident #3 was in the kitchen eating. Resident #4 came out of the bath and instead of going around the kitchen to get back to [her/his] room, [s/he] went through the kitchen, demanding resident #3 move [her/his] fat ass out of the way. When resident #3 did not move out of the way fast enough resident #4 made a fist and hit resident #3 on the shoulder and forearm. CNA #1 intervened and resident #4 attacked her making several contact punches to her chest. Resident #4 continued to chase and threaten staff members. As the incident progressed resident #4 yelled, regarding resident #3, that if [s/he] caught resident #3 [s/he] would f**king kill [him/her] and hoped [s/he] would die and rot in hell. 2. Review of photographs taken at the time of the incident showed the left arm of resident #3 had several red marks. During the assessment resident #3 stated to the nurse s/he was scared and shooken [sic] up. 3. Review of the facility's 7/24/23 incident report related to this incident showed the facility identified reddish-purple bruises on [resident #3's] forearm which appeared to be the markings from knuckles where [resident #4] hit [him/her.] 4. Interview with resident #3 on 8/15/23 at 10:15 AM revealed I avoid [resident #4]. [S/He] scares me. 5. Interview conducted with CNA #2 and CNA #3 on 8/15/23 at 10:30 AM revealed care provided for resident #4 was in flux from day to day, and [his/her] response to the methods used to intervene with aggressive behavior varied. 6. Interview with the facility human rights advocate/investigator on 8/15/23 at 11 AM revealed she had received statements from all of the staff who witnessed the occurrence and determined the incident did constitute abuse as defined. 7. Review of the policy and procedure titled Prevention of Resident Abuse, Neglect, and Exploitation dated 6/20/22 showed The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined .It is the policy and practice of the Wyoming Life, Resource Center (WLRC) that all residents will be protected from abuse and neglect. WLRC will not tolerate any form of resident abuse and will continually monitor WLRC policies, procedures, training programs, etc., to assist in preventing resident abuse.

Based on medical record review, staff and resident interviews, and review of facility documentation, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 2 sample residents (#1) reviewed for abuse allegations. This failure resulted in physical and psychosocial harm to resident #6. The findings were: 1. Review of the 3/13/23 quarterly minimum data set (MDS) assessment showed resident #1 had diagnoses including traumatic brain injury, seizure disorder, and psychotic disorder, and scored a 15 out of 15 on the brief interview for mental status (BIMS) indicating intact cognition. Review of a progress note dated 3/6/23 showed the resident was displaying aggressive behavior towards staff. The note read .A third staff member came in, and took [resident name] to the ground. 2. Review of the facility's Client Right Investigation Report showed an allegation of physical abuse which occurred on 3/6/23 at approximately 4:15 PM involving resident #1 and certified nurse aide (CNA) #1. The allegation was reported by staff #2. CNA #3 and CNA #4 were witnesses to the incident. Staff #2 stated he saw CNA #1 pull the resident out of the wheelchair and the resident hit his/her back and head on the floor. He stated he then saw the CNA hit the resident as the CNA sat on top of the resident. Further review of the report showed the facility's investigation conclusion was Allegation of abuse is verified. There is enough evidence presented through written statements that [CNA #1] did in fact pull [resident] from [his/her] wheelchair by [his/her] leg/ankle, resulting in [resident] landing on the floor. It cannot be determined if that force caused any injuries. There is not enough evidence presented witness statements or pictures proving that [CNA #1] punched [resident.] 3. Review of facility investigation documentation showed the following written statements: a. On 3/6/23 Staff #2 wrote .witness a staff pull a client out of [his/her] wheelchair Cient hit [his/her] back and [his/her] head on the floor then the staff hit the client as he sat on top of [him/her]. b. On 3/7/23 CNA #3 wrote .[resident] continued to hit and kick .[CNA #1] then grabbed [resident's] leg and started to pull [resident] out of [his/her] chair. When I realized what he was doing I tried to let [resident] down as easy as I could, so that [s/he] wouldn't be injured. c. On 3/7/23 CNA #4 wrote .[CNA #1] came in and grabbed [resident] by ankle and pulled [resident] out of wheelchair to floor and then held [resident] down . 4. Further review of the facility's Client Right Investigation Report showed the resident was interviewed by the facility investigator and a Department of Family Services (DFS) caseworker on 3/9/23. The resident stated that staff beat him/her up but s/he could not remember their names. The resident was asked if s/he was punched and s/he said yes, but could not remember where. S/he said maybe it was my side but could not remember which side. 5. Review of a progress note by RN #5 dated and timed 3/6/23 at 5:20 PM showed at 5:10 PM she assessed the resident following the incident which showed .2 purple bruises under the left upper arm. Bruise #1 is maroon in color, linear and approx 2 cm x 1 cm. Bruise #2 is round, light purple 2 cm x 2 cm. The note also showed the resident had superficial scratches to both arms which the resident stated was from self harm. There was also a superficial wound to the resident's forehead that appears to be an old wound that may have been opened up . 6. Further review of the Client Right Investigation Report showed registered nurse (RN) #5 met the facility investigator on 3/7/23 at 10:30 AM to assess resident #1. There was a large blue, red and purple bruise and scrapes near the bruise on the mid to lower part of the ribcage area on the left side. When [RN] saw the bruise on [resident's] back she said I didn't see that yesterday. [RN] asked [him/her] where [s/he] got the bruises and [resident] said from the staff- couldn't remember his name, beat him/herself up .We asked [resident] if [s/he] could show me [his/her] left arm near the inner bicep and tricep area. There were several bruises, different sizes, all appeared to be recent as they were red, blue and purple with several scratches on inner arm area and on armpit and one on chest area, close to the armpit. I photographed all bruising and scratches/scrapes .[RN] said that the bruising on [his/her] back was from when [s/he] was throwing [himself/herself] around in the wheelchair, as it would match up that part of [his/her] chair and that [s/he] throws [himself/herself] really hard. 7. On 3/30/23 at 3:17 PM CNA #3 was interviewed. He stated resident #1 was trying to hit and kick him/herself and CNA #4 while the resident was in the wheelchair. He stated CNA #1 grabbed the resident's leg and pulled and the resident landed on the floor. He stated he was surprised. He stated he had a hold of the top part of the resident and tried to lower the resident when that happened. He further stated CNA #1 did not say anything to them prior. He stated he did not see CNA #1 punch the resident. 8. On 3/30/23 at 3:23 PM staff #2 was interviewed. He stated he worked in supply and was in the house [facility] that day. He stated CNAs #3 and #4 were trying to keep resident #1, who had tried to leave in his/her wheelchair, in the house. He stated CNA #1 then walked over and grabbed the resident's leg and pulled. He stated the resident came out of the wheelchair and hit the floor. He stated the other CNAs had a hold of the upper part of resident at first, but the resident still hit the floor. He stated CNA #1 then hit the resident in the side with his fist while the resident was on the ground. He stated what he observed looked very intentional and was straight up abuse to me. 9. During an interview on 3/30/23 at 3:35 PM CNA #4 stated during the incident resident #1 was swinging at them. He stated CNA #1 came in and got ahold of the resident by the ankle and pulled the resident onto the floor from the wheelchair. He described it as a firm pulling motion and stated the resident landed on his/her back. He stated he was shocked that happened. He stated there was no communication from CNA #1 prior to that. He did not observe the CNA hit the resident. He stated after the incident CNA #1 told him he thought the resident would be safer to deal with on the floor. 10. On 3/30/23 at 4:47 PM CNA #1 was interviewed. He stated that the resident did hit the floor when s/he came out of the wheelchair and I was the unlucky one holding [her/him]. He stated he tried to communicate with the other CNAs by using his eyes (looked down to the floor) to show his intention that they should get the resident onto the floor from the wheelchair. He stated he didn't verbally say anything. He stated when the resident was kicking at him, the resident slid a little down in the wheelchair. He grabbed the resident's ankle and the resident slid out and landed on his/her back. He stated the other CNAs looked dumb founded. He stated when the resident was on the floor s/he was trying to hit him, so he laid across the resident. He stated he did not hit the resident. 11. On 3/31/23 at 9:13 AM resident #1 was interviewed. When asked how staff treated him/her, the resident replied good except for the staff on the house, [name of CNA #1]. The resident stated that staff person was suspended or fired, and I'm glad. During the interview, s/he described two incidents involving CNA #1. The resident mentioned being grabbed out of the wheelchair and stated he punched me. The resident also mentioned being slammed into a wall. The resident did not know the dates. The resident stated after the second incident, s/he was taken to his/her room by security. The resident stated after the second incident s/he had bruising to the back which the facility took pictures of. The resident stated s/he has PTSD and that added to it .nothing but nightmares since. 12. On 3/31/23 at 11:50 AM the nursing home administrator (NHA) stated since the incident staff received education. However, she stated the facility had not implemented any audits or monitoring and had not had a quality assurance (QA) meeting since the incident.

Based on medical record review, staff and resident interviews, and policy and facility documentation review, the facility failed to ensure a restraint was the least restrictive alternative and used for the least amount of time for 1 of 1 sample residents (#1) with restraints, which resulted in psychosocial harm. The findings were: 1. Review of the 3/13/23 quarterly minimum data set (MDS) assessment showed resident #1 had diagnoses including traumatic brain injury, seizure disorder, and psychotic disorder, and scored a 15 out of 15 on the brief interview for mental status (BIMS) indicating intact cognition. The assessment showed the resident did not use restraints. Review of the facility's Client Right Investigation Report for an incident on 3/6/23 showed All security involved [security officers #1, #2, #3] assisted with putting [resident] in the suicide vest and stated that they have had no training on how to get it on and that they hold [resident] while staff put on the vest. The following concerns were identified: a. Review of a written statement dated 3/7/23 by security guard #1 showed .[security guard #2], [security guard #3)] and I assisted staff in getting [resident] into the smock. [Security guard #2] and I did a modified side body hug for [his/her] arms and [security guard #3] took care of [resident's] good leg. b. Review of a written statement dated 3/7/23 by security guard #2 showed .Received a call from [social worker] who said that [resident] needed to be placed in a suicide smock . c. Review of a written statement dated 3/7/23 by security guard #3 showed .[resident's] behavior escalated. Me and the other security guards assisted with the smock and side body support . d. Review of a written statement by certified nurse aide (CNA) #4 dated 3/7/23 showed .Suicide vest was called for and the four of us applied the vest to [resident]. [Resident] resisted and fought against vest being applied. e. Review of a progress note by RN #5 dated and timed 3/6/23 at 5:20 PM showed at 5:10 PM she assessed the resident following an incident. The resident was in a suicide smock at the time of the assessment. The nurse documented .2 purple bruises under the left upper arm. Bruise #1 is maroon in color, linear and approx 2 cm x 1 cm. Bruise #2 is round, light purple 2 cm x 2 cm. The note also showed the resident had superficial scratches to both arms which the resident stated were from self harm. There was also a superficial wound to the resident's forehead that appears to be an old wound that may have been opened up . f. Further review of the Client Right Investigation Report showed registered nurse (RN) #5 met the facility investigator on 3/7/23 at 10:30 AM to assess the resident #1. There was a large blue, red and purple bruise and scrapes near the bruise on the mid to lower part of the ribcage area on the left side. When [RN] saw the bruise on [resident's] back she said I didn't see that yesterday. [RN] asked [him/her] where he got the bruises and [resident] said from the staff-couldn't remember his name, beat [him/her] up .We asked [resident] if [s/he] could show me [his/her] left arm near the inner bicep and tricep area. There were several bruises, different sizes, all appeared to be recent as they were red, blue and purple with several scratches on inner arm area and on armpit and one on chest area, close to the armpit. I photographed all bruising and scratches/scrapes .[RN] said that the bruising on [his/her] back was from when [s/he] was throwing [himself/herself] around in the wheelchair, as it would match up that part of [his/her] chair and that [s/he] throws [himself/herself] really hard. g. Interview on 3/31/23 at 8:48 AM with social worker #1 revealed he told security to use the suicide vest on the resident on 3/6/23 but he stated there was miscommunication. He stated he did not mean for security to physically hold the resident in order to put it on. He stated the suicide vest should be a choice for the resident, and if the resident doesn't want to wear it, 1:1 staff can be utilized for safety. h. During an interview on 3/31/23 at 9:58 AM security guard #2 stated they were told to put the suicide vest on the resident. He stated the resident was hitting them, and so they used a 2 person body hug while the resident was in bed in order to get the vest on him/her. He stated the 2 person body hug was a MANDT [behavioral crisis intervention program] procedure in order to control the resident's arms so s/he couldn't hit. He stated it restricted the movement of the arms. i. Interview on 3/31/23 at 9:13 AM with the resident #1 revealed s/he was put in bed and security staff and a CNA grabbed the restraint vest and put it on him/her. The resident stated s/he didn't want to wear it and staff held him/her down to put it on. The resident stated s/he has PTSD and that added to it .nothing but nightmares since. j. During interviews on 3/30/23 at 3 PM and on 3/31/23 at 10:56 AM the nursing home administrator (NHA) stated the suicide vest/smock was not a restraint because it was a velcro sleeveless smock that allowed freedom of movement and access to the body. However, the NHA acknowledged that security staff used MANDT procedures to hold the resident in order to put the vest on. She stated the facility did not consider MANDT procedures restraints and therefore the MDS assessment was not coded for restraints and the facility did not get orders for emergency use of MANDT holds. She further stated that she agreed that documentation related to MANDT holds needed to be better, and did not show how long the MANDT procedure was used or that the MANDT hold was released as soon as possible. k. Review of The Mandt System. Student Workbook, curriculum 2.0 (undated) provided by the facility showed the techniques/holds, including the side body hold, were identified as restraints. The Glossary of Terms included .Physical restraint- The application of sanctioned physical techniques by one of more certified individuals that reduces or restricts the ability of an individual to move their arms, legs, or head freely. l. On 3/31/23 at 11:50 AM the facility administrator stated MANDT holds were considered restraints. m. Review of the medical record for resident #1 showed no documentation related to the MANDT hold on 3/6/23, such as alternatives tried or how long the resident was restrained. Review of physician orders showed no order for the emergency use of a restraint on 3/6/23. n. Review of the facility's policy Use of Physical Restraints (dated 4/1/22) showed .Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less-restrictive interventions are feasible. a. The Director of Nursing Services has the authority to order the use of emergency restraints. The Medical Provider must be notified of such use and the reason for the order. b. Orders for emergency restraints may be received by telephone and shall be signed by the physician within forty-eight (48)hours .Documentation regarding the use of restraints shall include: .c. How the restraint use benefits the resident by addressing the medical symptom; d. The type of physical restraint used; e. The length of effectiveness of the restraint time; and f. Observation, range of motion and repositioning flow sheets.