Every finding on record at Nella's at Autumn Lake Healthcare

Based on interview and record review, the facility failed to employ a Certified Dietary Manager with appropriate credentials. The facility also failed to ensure that the Nutrition Services Staff had the County / State specified certification for safe handling of food. This deficient practice had the potential to affect all residents receiving meals in the facility. Facility Census: 96.Findings included:During an interview, on 12/29/25 at 12:35 PM, the surveyor asked Food Service Manager (FSM) #61 if he was a Certified Dietary Manager (CDM), and he stated, No I am not. The surveyor asked if they had a full-time Registered Dietician (RD) on staff, and he said No. During an interview, on 12/29/25 at 1:10 PM, the Administrator and the Director of Nursing (DON) indicated the facility did not have a full-time registered dietitian in the building. She comes to facility once per week and is available remotely as needed.On 12/29/25 at 1:00 PM this surveyor asked FSM #61 for a copy of the staffing policy. He said that the staff belong to the facility and he was contracted through Healthcare Services Group (HCSG). I asked him to provide me with one from HCSG for himself. The surveyor went back at 2:25 PM to ask again for the staffing policy for the FSM and he stated that his supervisor, the District Manager (DM) for HCSG stated the state surveyor could contact HCSG Human Resources (HR) if they wanted a copy of the policy. The surveyor called the phone number provided at 2:39 PM and left a voicemail asking for the policy.On 12/29/25 at 1:01 PM the surveyor asked FSM #61 for a copy of the Food Handler Certificates for the 10 employees in the department that have been employed for longer than 30 days. At 1:55 PM FSM brought the survey team a copy of three (3) of the 10 employees food handler certificates. FSM stated, That is all I have and the facilities HR department takes care of these.On 12/29/25 at 2:15 PM this surveyor spoke to HR #78 about the seven (7) missing food handler certificates and she said, They should be in the kitchen, and the previous FSM took care of this, and she will look for them and get back to me.On 12/30/25 at 8:45 AM this surveyor spoke to HR #78 about the missing food handler certificates. She said that she had found five (5) out of the ten. The surveyor told her that the FSM only gave copies of three (3) out of ten.As of 12/31/25 at 4:56 PM no one from the HCSG HR department has called or emailed this surveyor about the professional staffing policy.

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections by not having paper towels at (2) two of the handwashing sinks in the kitchen. This failed practice had the potential to affect all residents currently living at the facility. Facility Census: 96.Findings included:a) During a walkthrough of the kitchen, on 12/29/25 at 12:50 PM, this surveyor washed his hands at the handwashing sink outside of the Food Services Manager's (FSM) office inside the kitchen and there were no paper towels to dry my hands. The FSM said, Someone must have used the last one and did not refill them. He gave me a cleaning towel to dry my hands with. During the same walkthrough, on 12/29/25 at 12:56 PM, this surveyor noticed that there were no paper towels located at the handwashing sink in the dish room. The FSM stated, There should be, but someone must have forgotten to refill them too.

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to maintain the equipment in safe and clean operating condition. This practice had the potential to affect all of the residents at the facility. Facility census: 96.Findings included:a) During a walkthrough of the kitchen on 12/29/25 at 12:40 PM there were multiple cases of disposable utensils, plates and cups sitting directly on the floor. The surveyor asked Food Service Manager (FSM) #61 if those items are allowed to be sitting directly on the floor, and he said Yes, because they are in boxes and are individually wrapped.There was one (1) bag of opened breadcrumbs in the dry storage room that were not sealed correctly and was not labeled or dated correctly. The FSM acknowledged that they should have been stored and dated properly and will fix it.There were two (2) full size sheet pans of turkey stock located in the walk-in refrigerator with a made date of 12/19/25. There was no use by date on either one. The FSM stated that they should have been thrown out this past weekend.There was one (1) bag of opened parmesan cheese that was sealed correctly but did not have an open or a use by date located in the walk-in refrigerator. The FSM acknowledged it should have had those dates written on it per their policy.One (1) steam table pan of Gelatin was not covered correctly and was dated 12/20/25 without an use by date. The FSM acknowledged that there was a tear in the plastic film covering the gelatin and there was no use by date. He also acknowledged that the gelatin should have been thrown away by 12/27/25.There was some sliced bologna in a sandwich bag without a label or date located in the walk-in refrigerator. The FSM threw it away.The mixer was not covered while not in use. The surveyor asked the FSM if it should be covered while not in use and he stated, Some places do and some places don't.There was ice buildup in the walk-in freezer. The FSM stated that maintenance is aware.The two (2) door reach in refrigerator had debris and liquid spills. The FSM stated he did not have a equipment cleaning schedule, but was working on one.Two (2) ovens were soiled with debris on the inside and needed to be cleaned. One (1) oven rack was sitting directly on the floor. I asked the FSM if it was allowed to sit directly on the floor and he said they usually place it on top of the oven, not on the floor.There was one (1) package of opened flour tortilla's sitting on the prep table that had a use by date of 11/11/25. The FSM threw them away.There was one (1) jar of peanut butter sitting on the prep table that did not have an open or use by date. The FSM stated that it should be dated but they use it all in three (3) days normally.On 12/30/25 at 8:39 AM the can opener in the kitchen was soiled. I asked the FSM if that would be added to the equipment cleaning schedule he is making. He said, Yes it will.

Based on observation, staff interview, resident interview and policy review the facility failed to provide a safe, clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the complaint survey. Resident identifiers #73, and #74. Facility census 96. Findings include:a) Water temperature in A Wing shower roomDuring an interview on 12/29/25 at 2:45 PM, Resident #73 who has a Brief Interview for Mental Status (BIMS) of 14 and stated, The showers are not hot, they are luke warm, Sometimes I will just do a bed bath because I know it will be warmer. The problem is, the crap is old.During an interview on 12/29/25 at 3:00 PM Resident #74 who has a BIMS score of 15 said that the showers are not very warm at all. The showers seem to be warmer if its earlier in the day. During an interview and observation on 12/29/25 at 3:10 PM, the Maintenance Supervisor (MS) took the temperature of the shower stall water in shower room (1) one on A wing. The shower stall water ran for approximately (7) seven minutes, in which the temperature only reached 97.4 degrees Fahrenheit. The MS stated, We try to keep it between 105 and 110 degrees. The MS further confirmed that the water was not warm enough for a comfortable shower. b) Cleanliness of A wing shower roomsAn observation on 12/29/25 at 12:30PM of A wing shower room (1) one revealed approximately 20 wash rags stacked on the sharps container, 15 bottles of shampoo, conditioner, lotions and powders in the floor behind the shower room door along with a chair with four (4) towels and ten (10) washrags stacked in it.Further observation of A- hall shower room (2) two revealed approximately 25 wash rags stacked on the sharp container, two (2) towels and four (4) washrags on a chair behind the shower room door, a blue rag that was wet hanging in the shower stall and two (2) towels that appeared dirty in the floor.During an interview and observation on 12/29/25 at 12:45 PM, the Administrator confirmed the dirty towels, wash rags and bottles should not be in the shower rooms.c) Policy reviewA review on 12/30/25 at 10:00 AM, of the policy titled Storage and Management of Personal Hygiene Products, revealed under procedure (1) as follows:Personal hygiene products, including but not limited to soaps, shampoos, lotions and razors should be stored in individual resident rooms or designated personal storage areas to ensure that they are not accessible to other residents. These areas should be clean, dry and secure, preventing the potential for items to be tampered with or cross-contaminated.

Based on observation, record review, and staff interview, the facility failed to ensure the environment over which it had control was as free from accident hazards as possible. Hot water temperatures in resident areas exceeded 120 degrees Fahrenheit (F). This deficient practice was determined to be an immediate jeopardy situation that placed all residents at risk for burns from hot water. Facility census: 91.Findings included:a) Hot water temperatures The facility's policy statement titled Safe Water Temperatures, with no implementation or revision dates given, stated as follows:Direct care staff will monitor residents during prolonged exposure to to warm or hot water for any signs or symptoms of burns, and will respond appropriately. Staff will be educated on safe water temperatures upon employment and on a regular basis. Thermometers will be available as needed for use by all staff. Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperatures (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff.Water temperatures will be set to a temperature of no more than 110 degrees Fahrenheit (43.33 degrees Celsius), or the state's allowable maximum water temperature. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. Documentation of testing will be maintained for 3 years and kept in the maintenance office. On 07/30/25 at approximately 8:00 AM, the hot water temperatures in rooms B #111 and A #127 were noted by surveyors to seem hot to touch.On 07/30/25 at 8:45 AM, the hot water temperature in the sink in room B #111 was checked by the Maintenance Supervisor with the surveyor observing. The water ran for two (2) minutes before the temperature was checked. The temperature was 121.1 degrees Fahrenheit. On 07/30/25 at 8:53 AM, the hot water temperature in the sink in room A #127 was checked by the Maintenance Supervisor with the surveyor observing. The water ran for two (2) minutes before the temperature was checked. The temperature was 126.3 degrees Fahrenheit.The Maintenance Supervisor confirmed the temperatures were too high. He stated he liked to keep the hot water temperatures between 105 to 110 degrees. He stated the building only has one mixing valve that serves all resident rooms and shower rooms. The Maintenance Supervisor stated water temperatures were monitored weekly. He provided documentation for the month of July 2025 showing weekly testing of the water in the shower rooms and six (6) randomly selected resident rooms in each hallway. For the month of July, recorded temperatures did not reach 110 degrees F. The temperature monitoring was last conducted on 07/24/25. On 07/30/25 at 10:30 AM, the facility was informed an immediate jeopardy situation existed due to the water temperature in resident areas exceeding 120 degrees, which placed residents at risk for burns. On 07/30/25 at 4:00 PM, the State Agency accepted the following Plan of Correction: Corrective Measures for Resident(s) Affected: The maintenance director adjusted the mixing valve to the hot water on 07/30/25 at approximately 10:30 AM and flushed the remaining hot water. The facility will continue to monitor all residents' rooms' water temps immediately, then in 30 minutes, then in one-hour times 4 hours, and then every shift in affected resident rooms. Any out-of-range temperatures will be reported to the NHA [Nursing Home Administrator] and DON [Director of Nursing], and the hot water to that sink and/or shower will be shut off. Anticipated date of compliance is 07/30/25. Identification of others with the potential to be affected: All facility residents have the potential to be affected. On 07/30/25 at 10:30 AM the facility-initiated water temperature checks in each resident's room to ensure temperatures are in the safe temperature range of 95-110 degrees. Each shift starting 07/30/25 supervisor will check water temperatures in affected resident rooms to ensure that temperatures are in the safe temperature range of 95-110 degrees. Any out-of-range temperatures will be reported to the DON and NHA< and the hot water to that sink will be shut off. The anticipated date of compliance is 07/30/25. Measures to Prevent Recurrence: Facility Safe water temperature policy has been reviewed by Corporate Compliance Nurse. The Director of Nursing or designee-initiated education with all departments on the safe water temperature policy. Education included safe water temperature ranges for hot water and the need to report findings such as water temperature being too hot or cold, redness or burns or any problem with water temperatures to the supervisor and maintenance immediately. The anticipated date of compliance is 07/30/25. The facility Orientation Process will be adjusted to include a review of the safe water temperature policy. Anticipated date of compliance will be 07/30/25 and ongoing. The nursing supervisors will receive education on obtaining a water temperature and the need to immediately check the temperature upon notification of staff memers of water temperature concerns. The anticipated date of compliance is 07/30/25. The Facility Administrator completed one on one education with the maintenance department. This education included a review of the safe water temperature range of no greater than 110 degrees and no less than 95 degrees. The maintenance department was educated of the need to monitor hot water temperatures for all hot water sources weekly and document their findings. This education included steps to be taken if the hot water temperature is determined to be out of range. The anticipated date of compliance is 07/30/25. Monitoring of Corrective Measures: The Facility Maintenance Director will complete random audits of facility hot water temperatures to ensure that temperatures are in the safe temperature range of 95-110 degrees. The audits will occur on the following schedule: Daily until 100% compliance is noted for four (4) consecutive weeks, and then monthly for a minimum of three months or until such time that substantial compliance has been achieved. Audit results will be forwarded to the facility QAPI (Quality Assurance and Performance Improvement) committee. On 07/31/25, the facility's in-service sign-sheets regarding Safe Water Temperature Awareness and Reporting were reviewed. The in-service content was as follows: Department(s): All Staff (Nursing, Maintenance, Housekeeping, etc.) Purpose: To ensure resident safety by maintaining appropriate and safe water temperatures throughout the facility and to comply with facility policy and regulatory standards. Water temperature safety is a critical aspect of resident care in long-term care facilities. Older adults are at greater risk of burns and scalds due to thinner skin, slower reaction times, and reduced sensation. Ensuring water temperatures remain within safe limits protects residents from harm. Key Points Covered: 1. Resident Safety First Staff must monitor residents during bathing or other prolonged exposure to hot water. Watch for any signs of discomfort, burns, or redness and respond immediately. 2. Temperature Limits Hot water temperature should not exceed 110 degrees F (43.33 degrees C) or the state-regulated maximum. If water is uncomfortably hot or cold, staff must report it right away. Facility uses mixing valves or thermostatic controls to regulate water temperature to the point of use. 3. Staff Responsibilities All staff will receive education on safe water temperatures during orientation and periodically thereafter. Thermometers are available for staff use when needed. 4. Reporting Procedure Any complaints of extreme water temperatures or evidence of burns/redness must be reported to a supervisor and/or maintenance immediately. Use professional judgement; if water feels too hot to the touch, it may be unsafe for resident use. 5. Maintenance Role Maintenance will check water heater settings and tap temperatures in all hot water circuits weekly and as needed. And address equipment failures and unsafe readings without delay. Any identified issues with temperatures out of range will be adjusted by maintenance and if necessary, outside vendor if unable to correct. All water temperature checks will be documented, and any corrective actions needs will be kept on file. Staff Acknowledgement: I have received training on the Safe Water Temperature policy. I understand the importance of monitoring and reporting unsafe water conditions to protect our residents from harm. On 07/31/25 at 10:00 AM, staff were interviewed regarding steps to take if the water was too hot in the resident's room or in the shower rooms. The staff gave correct responses. On 07/31/25, the Maintenance Supervisor was interviewed regarding monitoring of hot water temperatures and steps to be taken if the water was too hot. The Maintenance Supervisor gave correct responses. The Maintenance Supervisor provided documentation of the water monitoring conducted overnight. The last monitoring was completed on 07/31/25 at 10:00 AM. No water temperatures exceeded 104 degrees F. The Maintenance Supervisor performed the following testing with the surveyor in attendance:At 10:00 AM, the sink in room B 111 was 102.3 degrees F.At 10:05 AM, the sink in room A 127 was 101.6 degrees F.At 10:10 AM, the sink in the A hallway resident toilet was 103.2 degrees F.At 10:15 AM, the sink in the B hallway resident toilet was 103.8 degrees F.The maintenance supervisor stated the resident toilet sinks were the resident-accessible areas closest to the mixing valve. Immediate Jeopardy was abated 07/31/25 at 10:20 AM.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. For five (5) of six (6) residents reviewed for the care area of advance directives, the Physician Order for Scope of Treatment (POST) forms were incomplete. For two (2) of three (3) residents reviewed for the care area of beneficiary notices, the beneficiary notices were incomplete. For one (1) of six (6) residents reviewed for the care area of nutrition, the admission weight documentation was incorrect. Resident Identifiers: #86, #60, #21, #4, #94, #62, #72, and #84. Facility census: 91. Findings included:a) Resident #72 The facility failed to verify and document the legal authority of the resident’s designated representatives, failed to ensure the validity and proper execution of the resident’s POST (Physician Orders for Scope of Treatment) form, and failed to retain complete documentation of consent for high-risk physical interventions. The resident’s record included a signed Checklist for Surrogate Selection dated 11/17/22 identifying Son #1 as the medical power of attorney (MPOA). However, the most recent POST form on file, dated 11/18/22, reflected only a verbal consent and lacked a physical signature from either of the resident’s officially recognized representatives. The witness signatures were minimally legible and marked by a strikethrough, offering insufficient assurance of proper execution or witnessing. At the time the POST form was completed, the [NAME] Virginia Department of Health and Human Resources (DHHR) was listed as the official healthcare surrogate. No documentation was found to demonstrate communication with DHHR regarding transition of decision-making authority, nor were there clinical notes indicating that surrogate authority had been formally transferred or discontinued. Despite documentation indicating that Son #1 visited frequently and maintained regular contact by phone, the facility did not initiate follow-up to obtain a valid POST with written, verified consent from the authorized representative(s), nor did it clarify which individual currently held legal authority to direct care decisions. On 08/04/2025 at 12:30 PM, this surveyor interviewed the facility’s Social Worker regarding the process for obtaining written signatures on POST forms. When asked how the facility ensures that POST forms are fully executed with physical signatures, the Social Worker stated that she does not have an official process in place for securing signatures following verbal acknowledgements. She explained that while she “sometimes” mails the forms to out-of-state representatives, they are “more often than not” unreturned. She was unable to provide documentation showing any follow-up efforts related to Resident #72’s POST form or confirmation that it had been physically signed by the authorized representative. These failures created ambiguity regarding the resident’s legal representation and undermined the validity of the POST form on file, placing the facility at risk for acting on treatment orders without properly verified consent. Additionally, the medical record contained a Consent for Use of Side Rails dated 07/17/2023, recommending the use of partial side rails on both sides for “Transfers T&R” (turning and repositioning). The form listed associated risks, including entrapment, bruising, injury from falls, and reduced mobility. However, in the section designated for representative authorization, the form stated only “verbal consent obtained.” No signature, printed name, date, or legal designation was provided to confirm that the resident’s MPOA had authorized the intervention. The absence of a completed signature block rendered the consent form invalid and incomplete. On 08/05/2025, this surveyor interviewed the facility’s Social Worker, who stated that LPN #36 was responsible for obtaining consent for bedrail use. Upon review of the resident’s authorization form, the Social Worker confirmed it stated “verbal consent obtained” but was unable to identify who provided the consent or whether a representative had been contacted. She stated she was unfamiliar with the consent process used by the nurse. In a follow-up interview, LPN #36 confirmed that she obtained verbal consent but had forgotten to document the name of the individual who gave it. She explained that she typically tried to complete authorizations and consents at admission and obtained verbal or written consent “as she is able.” She acknowledged the omission and apologized. b) Resident #4 On 07/30/2025 at 12:42 PM, Resident # 4's Physician's Orders for Scope of Treatment (POST) form was reviewed. Verbal consent was given on 04/24/25 with only one witness signature obtained. Resident #4's POST form was not given to the responsible party to review and sign. 0n 7/31/2025 at 10:20 AM, the Social Worker confirmed the signatures for the POST forms when verbal consent was given were not obtained and POST forms were not sent to the responsible party. The Social Worker stated, I do not send anything. c) Resident #94 07/31/2025 at 9:12 AM , Resident #94's Advance Beneficiary Notice (ABN) was reviewed for a Medicare Part A Skilled Service Episode beginning 03/11/2025 with ending date 03/27/2025. Verbal Consent was obtained from the resident's Health Care Surrogate (HCS) on 03/25/25. On 07/31/2025 at 09:27 AM, the Social worker confirmed there was no attempt by the facility to obtain signatures. The Social Worker stated, I just got the verbal consent. and That would be a lot of postage. The social worker then stated, I guess I could start mailing them. The facility's policy and procedure for Advance Beneficiary Notices: Delivery Requirements stated, d. If the notice cannot be hand-delivered (for example such as in the case of an incompetent resident and the representative is out of town) a telephone notice shall be made, followed up immediately with a mailed, emailed faxed or hand-delivered notice. Documentation shall comply with form instructions regarding telephone notices. d) Resident #62 07/31/2025 at 9:12 AM , Resident #62's Advance Beneficiary Notice (ABN) was reviewed for a Medicare Part A Skilled Service Episode beginning 02/27/2025 with ending date 04/04/2025. Verbal Consent was obtained from the resident's Medical Power of Attorney (MPOA) on 03/25/2025. On 07/31/2025 at 09:27 AM, the Social worker confirmed there was no attempt by the facility to obtain signatures. The Social Worker stated, I just got the verbal consent. and That would be a lot of postage. The social worker then stated, I guess I could start mailing them. The facility's policy and procedure for Advance Beneficiary Notices: Delivery Requirements stated, d. If the notice cannot be hand-delivered (for example such as in the case of an incompetent resident and the representative is out of town) a telephone notice shall be made, followed up immediately wit a mailed, emailed faxed or hand-delivered notice. Documentation shall comply with form instructions regarding telephone notices. e) Resident #21 Physician's Orders for Scope of Treatment (POST) form guidance A POST form is a document that outlines a patient's preferences for medical treatment, particularly in situations involving serious illness or end-of-life care. For residents that do not have the capacity to make medical decisions, the form can be completed by their Medical Power of Attorney [MPOA] or Health Care Surrogate. According to the manual titled Using the POST Form: Guidance for Health Care Professionals, available on-line at www.wvendoflife.org, If the incapacitated patient’s MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient’s MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. Resident #21 Review of Resident #21's medical record showed a POST form dated 05/14/24. Verbal consent for the POST form had been obtained from the resident's MPOA. The consent was witnessed by two (2) staff members who signed the form. However, a signature from the MPOA had not been subsequently obtained. On 07/30/2025 at 1:52 PM, Resident #21's MPOA was interviewed. She stated she visited the resident almost every week. f) Resident #60 Review of Resident #60's medical record showed a POST form dated 07/26/24. Verbal consent for the POST form had been obtained from the resident's Health Care Surrogate (HCS) but the form was not signed by any staff members who witnessed the verbal consent. Additionally, a signature from the HCS had not been subsequently obtained. g) Resident #85 Review of Resident #85's medical record showed a POST form dated 08/21/23. Verbal consent for the POST form had been obtained from the resident's MPOA but the form was only signed by one (1) staff member who witnessed the verbal consent. Additionally, a signature from the MPOA had not been subsequently obtained. h) Resident #84 A record review on 07/31/25 at 9:30 AM, revealed that Resident #84 was admitted to the facility and had an admission weight of 140.7 pounds (lbs.). Her weight on 07/07/25 was 110 lbs. Further record review showed that Resident #84 was admitted to this facility from (an area hospital named) with a discharge weight of 128 lbs. During a telephone interview on 08/04/25 at 12:58 PM, The Registered Dietician (RD) stated, I did my assessments by her actual admission weight taken the next day after her admission which was 116.4 lbs. During an interview on 08/04/2025 at 3:20 PM, The Director of Nursing (DON) confirmed that the admission weight in the chart was incorrect and that it should have been struck out.

Based on observation, and staff interview the facility failed to store, distribute and serve food in accordance with professional standards for food service safety. This failed practice was a random opportunity for discovery and the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility census: 91. Findings include: a) Kitchen An observation on 08/05/25 at approximately 12:45 PM revealed the cook was starting to fix plates. The first plate the cook pulled out of the plate holder was wet. The cook then placed a tuna hoagie and chips on the plate. The cook then handed the plate to the kitchen aide to put on the tray cart. The cook then pulled out the next plate that was wet and put chopped tuna on it. The State Agency (SA) asked, Are all of those plates wet? The Certified Dietary Manager (CDM) started pulling plates from the plate holder and all the plates that she pulled off were wet. The CDM stated, Go get Styrofoam trays from our emergency stock and serve lunch on those today? The CDM then went to check out the dishwasher and stated, I found the problem, the dishwasher was out of the dry assist for the dishes. The CDM further confirmed that the serving plates were wet and could draw bacteria.

Based on observation, staff interview, and record review the facility failed to provide an ongoing program of activities to meet the needs and interest of each resident. This failed practice was found true for (3) three of (6) six residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #5, #74, #83. Facility Census 91.Findings include: a) Resident #5 During the initial observation on 07/30/25 at 10:30 am, showed Resident #5 lying in her bed, patting her blanket. Resident was hollering out. No stimulation was on in the resident's room.A record review on 08/04/25 at 1:00 PM, revealed an activity care plan initiated 05/27/25 for Resident #5 that reads as follows: Focus:Activities. Goal:Will have the opportunity to enjoy activities of choice through the next review date. Interventions:Activities staff to provide in room visits and 1:1 visits.Invite/encourage resident to attend activities daily.Provide resident with a calendar of scheduled activities.Remind resident at least 15 minutes prior to start of activity.Resident requires assistance with mobility to and from activities. Further record review revealed an admission Activity Assessment that has the following marked as interest for Resident #5: crafts, music, being outdoors, watching TV, gardening, puzzles, animals, cooking, baseball games, and Bible study. A review of the Activity Participation Record (APR) for 05/25 to 08/25 revealed that Resident #5 had not received any one-to-one visits. An observation on 08/04/25 at 2:15 PM, Showed Resident #5 lying in her bed, hollering out curse words. No stimulation was on in the resident's room. During an interview on 08/04/2025 at 2:50 PM, The State Agency (SA), asked The Activity Director (AD) if he felt that Resident #5's care plan was personalized for activities. The AD replied, No, but I do not do my own care plans. The person that does the MDS does them. The AD confirmed that Resident #5 was not receiving one-to-one visits as care planned and that her care plan was not individualized to meet her needs. During an interview on 08/05/25 at 1:00 PM, The AD stated, When my staff does the coffee cart in the mornings, they are supposed to be turning on residents' TV's. I will definitely get on this and check into it. b) Resident #74 During the initial observation on 07/30/25 at 1:30 PM showed Resident #74's room door was shut due to being on contact precautions. During an interview on 07/30/25 at 1:30 PM, Nursing Assistant (NA) #60 opened Resident #74's door and stated, We keep the door shut due to them being on contact precautions. NA #60 confirmed that no stimulation was on in Resident #60's room. A record review on 08/04/25 at 12:30 PM, revealed a Quarterly Activity Progress note that read as follows: Resident does not attend any activities. Resident is sometimes out in the dining area watching tv or in her room. Activities staff will continue to encourage resident to attend activities of her interest. Activities staff will also continue to complete in room visits once daily for this resident . Activities staff will complete one on ones twice weekly for this resident. Further record review revealed an Activity care plan that reads as follows:Focus: Social isolation r/t inability to makeneeds/wants known she has severe MRwhich limits her attention span. Goals:Needs are met, continue goals.The residents needs will bemet through next review. Interventions: Activities staff to provide in room visits and 1:1. Invite/encourage the resident's family members to attend activities with the resident in order to support participation. Monitor nutritional status. The resident needs, adequate nutritional intake tomaintain normal activity level. Monitor/document for impact of medical problems on activity level. Resident requires assistance with mobility to and from activities.The resident needs assistance/escort activity functions. Further record review revealed that Resident #74 was admitted to the facility in 2016, and no activity assessments could be found. A review of the Activity Participation Records for 05/25, 06/25, and 07/25 revealed that according to the care plan Resident #74 was scheduled for 26 one to one visit and only received 18. An observation on 08/04/25 at 2:15 PM, Showed Resident # 74's door was shut due to being on contact precautions. The State Agency (SA) knocked and asked permission to come in. The resident was sitting in her geri chair, and no stimulation was on in the room. During an interview ON 08/04/25 at 2:40 PM the Activity Director (AD) stated, I do not know why but I could not find an activity assessment on her. There has not been one done. She has been here since 2016; I have been doing this just for a year and I did not catch it. The State Agency (SA) asked the AD why her care plan was not personalized with her interest? The AD replied, I do not know, I do not do my own care plans, the MDS person does them. He confirmed that Resident #5's care plan was not personalized, and that she was not receiving one-to-one visits as scheduled. During an interview on 08/05/25 at 1:00 PM, The AD stated, When my staff does the coffee cart in the mornings, they are supposed to be turning on residents' TV's. I will definitely get on this and check into it. c) Resident #83 During the initial observation on 07/30/25 at 1:30 PM showed Resident #83's room door was shut due to being on contact precautions. During an interview on 07/30/25 at 1:30 PM, Nursing Assistant (NA) #60 opened Resident #83's door and stated, We keep the door shut due to them being on contact precautions. NA #60 confirmed that no stimulation was on in Resident #83's room. A record review on 08/05/2025 at 11:30 AM, revealed an Activities care plan for Resident #83 that reads as follows: Focus: Activities. Goal: Will have the opportunity to enjoy activities of choice through the next review date. Interventions: Activities staff to provide in room visits and 1:1. Provide resident with a calendar of scheduled activities. Remind resident at least 15 minutes prior to the start of activities. Resident requires assistance with mobility to and from activities. Further record review revealed an Annual Activities assessment dated [DATE] with current interest indicated as follows: Music, Watching TV, Talking/conversing, and animals. None of the above interests are indicated in the care plan. A review of the Activity Participation Records (APRs) for 05/25, 06/25, and 07/25 shows that from 07/11/25 to present Resident #83 had only received (1) one, one to one visit. An observation on 08/04/25 at 2:15 PM, Showed Resident #83's door was shut due to being on contact precautions. The State Agency (SA) knocked and asked permission to come in. The resident was lying in the bed, and no stimulation was on in the room. During an interview on 08/04/25 at 2:50 PM, The State Agency (SA), asked The Activity Director (AD) if he felt that Resident #s 83's care plan was personalized for activities. The AD replied, No, but I do not do my own care plans. The person that does the MDS does them. The AD confirmed that Resident # 83 was not receiving one-to-one visits as care planned and that her care plan was not individualized to meet her needs. During an interview on 08/05/25 at 1:00 PM, The AD stated, When my staff does the coffee cart in the mornings, they are supposed to be turning on residents' TV's. I will definitely get on this and check into it.

Based on policy review, resident interviews, record review and staff interview, the facility failed to ensure residents and/or responsible party as well as required staff were included in care plan meetings. In addition, a care plan was not revised when new medications were added. This failed practice affected three (3) of 27 sample residents. Resident identifiers: #38, #86, #11. Facility census: 91.Findings included: a) Resident #11 On 08/04/2025, Resident # 11's Pharmacy Orders were reviewed. Two psychotropic medications, Tramadol and Lorazepam, were not included on the resident's comprehensive care plan. On 08/05/2025 at 08:51 AM, the Director of Nursing (DON) confirmed the medications were not included on the care plan and stated, Tramadol was recently started. and Okay. b) Resident #38 The Nursing Home Administrator (NHA) provided a copy of the policy titled Comprehensive Care Plans with a date reviewed/revised of 04/28/25 on 08/05/25 at 4:00 PM. A review of the policy found the following: The comprehensive care plan will be prepared by the interdisciplinary team, that includes, but is not limited to: the attending physician or non-physician practitioner designee involved in the resident 's care .' ; a Registered Nurse with the responsibility for that resident; a nurse aide with responsibility for the resident; a member of the food and nutrition services staff; the resident and the resident's representative, to the extent practicable. On 07/30/25 at 1:26 PM when Resident #38 was interviewed, she stated that she did not know what a care plan was. Resident #38's Brief Interview Mental Status (BIMS) score was 15 which reflects cognition is intact. The Social Worker (SW) was asked on 08/04/25 at 12:04 PM for evidence of care plan meetings as none were found in Resident #38's Electronic Medical Record (EMR). The SW produced a notebook on 08/04/25 at 12:10 PM with a form titled Care Plan Cheat Sheet. A review of the care plan cheat sheet found the Resident's Annual Minimum Data Set (MDS) had no evidence of who attended the care plan meeting 07/08/25. An interview was conducted on 08/04/25 at 1:40 PM with the SW. When asked to explain the facility care plan process, she stated that she (SW) and the MDS coordinator get the information to complete the paper Care Plan Cheat sheet and care plan from the EMR. No other disciplines are involved in the care plan process. She does mail a letter to the responsible party at either the beginning or end of each month but does not follow up to see if they are planning on attending the meeting. She does not send or give a letter or invite in-house residents to attend the meeting or go to the resident’s room to go over the care plan with the resident. c) Resident #86 On 07/30/25 at 11:22 AM when Resident #86 was asked about her care plan, she did not know what a care plan was. Resident #86's Brief Interview for Mental Status (BIMS) score was 15 which reflects cognition is intact. The Social Worker (SW) was asked on 08/04/25 at 12:04 PM for evidence of care plan meetings as there were none in Resident #38's Electronic Medical Record (EMR). The SW produced a notebook on 08/04/25 at 12:10 PM with a form titled Care Plan Cheat Sheet. A review of the care plan cheat sheet found for the Resident's admission Minimum Data Set (MDS) found no evidence of who attended the care plan meeting. An interview was conducted on 08/04/25 at 1:40 PM with the SW. When asked to explain the facility care plan process, she stated that she (SW) and the MDS coordinator get the information to complete the paper Care Plan Cheat sheet and care plan from the EMR. No other disciplines are involved in the care plan process. The SW mailed a letter to the responsible party at either the beginning or end of each month but did not follow up to see if they were planning on attending the meeting. She did not send or give a letter or invite in-house residents to attend the meeting or go to the residents room to go over the care plan with the resident.

Based on record review and staff interview, the facility failed to develop and/or implement individualized care plans related to Activities, Depression, and Post Traumatic Stress Syndrome (PTSD). This failed practice was found true for (7) seven of 27 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers #5, #74, #83, #9, #13, #42, and #72. Facility census 91. a) Resident #9 Under the Activities Section of the Care Plan, the goal was Will have the opportunity to enjoy activities of choice through the next review date. Interventions were: Invite/encourage resident to attend activities daily. Provide resident with a calendar of scheduled activities. Remind resident at least 15 minutes prior to the start of the activity. Resident requires assistance with mobility to and from activities. However, the Care Plan did not state what activities the resident enjoys doing. This resident has diagnoses of PTSD, Anxiety, and Depression. Her Care Plan included Anxiety but did not address Depression or PTSD at all. b) Resident #13 A review of Resident #13's Care Plan revealed it was not personalized for the activities she liked to do. Under the Activities Section of the Care Plan, the goal was Will have the opportunity to enjoy activities of choice through the next review date. Interventions were: Invite/encourage resident to attend activities daily. Provide resident with a calendar of scheduled activities. The Care Plan does not state what activities the resident enjoys doing. The medical record contains progress notes dated 07/15/25, completed by the Activities Director, of resident attending bingo and social activities. When asked about the resident's preferred activities, the Director of Activities could state some of the things the resident enjoyed doing. When asked about why these were not included in the Care Plan, the Director stated he is not invited to attend the care plan meetings. This interview occurred on 08/04/2025 at 2:45 PM. During an interview with the Social Worker #6, on 08/04/25 at approximately 1:40 PM, when asked about the process for establishing a resident's Care Plan, she stated she normally developed the Care Plan by going through the medical record of the resident. When asked if she had a sign-in sheet for the people attending the Care Plan meetings, she stated she did not keep one. When asked if Dietary, Nursing, Activities, etc. attended the Care plan meetings, she stated, “no.” When asked if the resident or the resident's representative were invited to the meetings, she stated, “occasionally.” c) Resident #42 On 07/30/2025 at 12:19 PM, Resident #42's care plan was reviewed. The resident's care plan did not address the resident's diagnosis of Post-Traumatic Stress Disorder (PTSD). On 08/04/2025 at 01:27 PM , the Director of Nursing and Social Worker confirmed the resident's comprehensive care plan did not include PTSD. d) Resident #72 The most recent MDS, dated [DATE], indicates that the resident experiences pain that interferes with both sleep and daily function. This is documented under Section J (Pain Management), with responses marked “Yes” to both pain interference questions. Review of the resident’s care plan reveals a pain goal that reads: “Resident reports occasional pain. Staff to monitor and offer PRN medications.” However, this care plan lacks measurable objectives, timeframes, and person-centered details such as pain location, frequency, or severity. No evidence of interdisciplinary input or individualized planning related to pain goals or preferences was found. The July and August 2025 MARs confirm that Acetaminophen 650 mg PO Q6H PRN was administered for pain, but no scheduled pain medications were noted. While the TAR includes general documentation of PRN effectiveness, there was no ongoing evaluation or reassessment documented to determine whether the pain management approach remained adequate. Progress notes from 05/14/2025 and 06/11/2025 describe the resident as complaining of back or leg pain, including the statement, “It’s sore today, probably the weather.” No documented follow-up, care plan revision, or interdisciplinary discussion was noted in response. Close inspection of the MAR shows that staff tracked pain using a 1–10 scale in association with administration of Meloxicam, but this was not reflected in the formal care plan or used to update goals. On 08/04/2025 at 12:45 PM, the Social Worker stated that she did not have recollection of any recent updates to the resident's care plan. She stated that she had not communicated with the resident or representatives recently regarding pain management goals. When asked if she knew anything about why he refuses care (appointments/medications/direct care), she stated that there might not be a particular reason so much as the fact that he can be cantankerous and difficult. In an interview on 08/05/2025 at 10:13 AM, the unit nurse stated that from what she knew, the resident’s pain is “sporadic,” and that he often refuses pain medications because of how they make him feel. This was not reflected in the care plan for pain. e) Resident #5 A record review on 08/04/25 at 1:00 PM, revealed an Activity care plan initiated 05/27/2025 for Resident #5 that reads as follows: Focus: Activities. Goal: Will have the opportunity to enjoy activities of choice through the next review date. Interventions: Activities staff to provide in room visits and 1:1 visits. Invite/encourage resident to attend activities daily. Provide resident with a calendar of scheduled activities. Remind resident at least 15 minutes prior to start of activity. Resident requires assistance with mobility to and from activities. Further record review revealed an admission Activity Assessment that has the following marked as interest for Resident #5: crafts, music, being outdoors, watching TV, gardening, puzzles, animals, cooking, baseball games, and Bible study. A review of the Activity Participation Record (APR) for 05/2025 to 08/2025 revealed that Resident #5 had not received any one to one visits. During an interview on 08/04/2025 at 2:50 PM, The State Agency (SA), asked The Activity Director (AD) if he felt that Resident #5's care plan was personalized for activities? The AD replied, No, but I do not do my own care plans. The person that does the MDS does them. The AD confirmed that Resident #5 was not receiving one to one visits as care planned and that her care plan was not individualized to meet her needs. f) Resident #74 A record review on 08/04/25 at 12:30 PM, revealed an Quarterly Activity Progress note that reads as follows: Resident does not attend any activities. Resident is sometimes out in the dining area watching tv or in her room. Activities staff will continue to encourage resident to attend activities of her interest. Activities staff will also continue to complete in room visits once daily for this resident . Activities staff will complete one on ones twice weekly for this resident. Further record review revealed an Activity care plan that reads as follows: Focus: Social isolation r/t inability to makeneeds/wants known she has severe MRwhich limits her attention span. Goals: Needs are met, continue goals.The residents needs will bemet through next review. Interventions: Activities staff to provide in room visits and 1:1. Invite/encourage the resident's family members to attend activities with the resident in order to support participation. Monitor nutritional status. The resident needs, adequate nutritional intake tomaintain normal activity level . Monitor/document for impact of medical problems on activity level. Resident requires assistance with mobility to and from activities. The resident needs assistance/escort activity functions. Further record review revealed that Resident #74 was admitted to the facility in 2016, and no activity assessments could be found. A review of the APR's for 05/2025, 06/2025, and 07/2025 revealed that according to the care plan Resident #74 was scheduled for 26 one to one visits and only received 18. During an interview ON 08/04/25 at 2:40 PM the Activity Director (AD) stated, I do not know why but I could not find an activity assessment on her. There has not been one done. She has been here since 2016, I have been doing this just for a year and I did not catch it. The State Agency (SA) asked the AD why her care plan was not personalized with her interest? The AD replied, I do not know, I do not do my own care plans, the MDS person does them. He confirmed that Resident #5's care plan was not personalized, and that she was not receiving one to one visits as scheduled. g) Resident #83 A record review on 08/05/2025 at 11:30 AM, revealed an Activities care plan for Resident #83 that reads as follows: Focus: Activities. Goal: Will have the opportunity to enjoy activities of choice through the next review date. Interventions: Activities staff to provide in room visits and 1:1. Provide resident with a calendar of scheduled activities. Remind resident at least 15 minutes prior to the start of activities. Resident requires assistance with mobility to and from activities. Further record review revealed an Annual Activities assessment dated [DATE] with current interest indicated as follows: Music, Watching TV, Talking/conversing, and animals. None of the above interests are indicated in the care plan. A review of the APR's for 05/2025, 06/2025, and 07/2025 shows that from 07/11/25 to present Resident #83 had only received (1) one, one to one visit. During an interview on 08/04/2025 at 2:50 PM, The State Agency (SA), asked The Activity Director (AD) if he felt that Resident #s 83's care plan was personalized for activities? The AD replied, No, but I do not do my own care plans. The person that does the MDS does them. The AD confirmed that Resident # 83 was not receiving one to one visits as care planned and that her care plan was not individualized to meet her needs.

Based on record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow appropriate infection control practices during medication administration. The facility also failed to follow enhanced barrier precautions. These were random opportunities for discovery. Resident Identifiers: #27 and #6. Facility Census: 91.Findings included:a) Resident #27 The facility's policy titled Medication Administration, with no date of implementation or revision documented, gave instructions to take care not to touch medications with bare hands while removing the medications from their source. On 07/31/2025 at 9:23 AM, Registered Nurse (RN) #33 was observed administering medications to Resident #27. The medications were contained in blister packs. Each dose was individually sealed within the pack and needed to be pushed through the package by the nurse. When two (2) of the resident's medications, clonazepam and sertraline, were removed from the blister packaging, they fell onto the uncovered medication cart. RN #33 then used her bare fingers to put the medications in the medication cup to be administered to the resident. On 07/31/25 at 8:45 AM, the Director of Nursing (DON) stated medications dropped on the top of the medication cart should be discarded and bare hands should not be used to touch medications. No further information was provided through the completion of the survey. b) Resident #6 The facility's policy titled Enhance [sic] Barrier Precautions, with no implementation or revision dates given, stated enhanced barrier precautions (EBP) would be followed for residents with indwelling medical devices. The policy also stated that gown and gloves would be worn during high-contact resident care for residents in EBP. Feeding tube care or use was included in the list of high-contact resident care activities. Review of Resident #6's physician's orders showed an order written on 05/13/25 for enhanced barrier precautions to be maintained at all times for wounds and gastroscopy tube.On the door to Resident #6's room was a sign stating, Enhanced Barrier PrecautionsEveryone Must:Clean their hands, including before entering and when leaving the room.Providers and staff must also:Wear gloves and a gown for the following High-Contact Resident Care Activities.DressingBathing/ShoweringTransferringChanging LinensProviding Hygiene Changing briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing On 08/04/2025 at 12:18 PM, Licensed Practical Nurse (LPN) #5 was observed flushing Resident #6's gastroscopy tube and connecting a bag of enteral feeding to infuse over one (1) hour. To provide the treatment, LPN #5 wore gloves but did not wear a gown. On 08/04/2025 at 12:26 PM, the Director of Nursing confirmed gowns should be worn by staff performing enteral flushes and feeding. No further information was provided through the completion of the survey process.

Based on policy review, record review and staff interview, the facility failed to provide specialized rehabilitation services for speech therapy. This failed practice was found to be true for two (2) of two (2) residents during the annual survey process and had the potential to affect a limited number of residents. Resident Identifiers: #6 and #84. Facility Census: 91. a) Resident #84 A record review on 08/04/25 at 11:45 AM, revealed that Resident #84 was ordered a regular diet, regular texture, thin liquids diet on 02/07/25. The diet was changed on 07/25/25 to a regular diet, puree texture, thin liquids. A record review of Resident #84's weights shows that her actual admission weight, taken the day after admission was 116.4 pounds (lbs.) and her current weight taken on 07/07/25 was 110 lbs. Further record review revealed that Resident #84 had ordered supplements throughout the weight loss but had not had any Speech Therapy Consults before her diet was downgraded to the puree texture. During a telephone interview on 08/04/25 at 12:58 PM, The Registered Dietician (RD) stated, I would agree that it is a big downgrade in diet to go from regular texture to puree without a speech consult first. During an interview on 08/04/2025 at 3:20 PM, The Director of Nursing (DON) stated, I just started education with my staff saying that they cannot downgrade a diet that far without a speech consult. That there are steps that need to be followed. b) Resident #6 On 07/30/25 at 9:55 AM, the state surveyor interviewed Resident 6 as part of the annual survey process. The resident stated he could not eat anymore because he aspirates and gets pneumonia. The resident reported he had not had any Speech Therapy (ST) for swallowing difficulties. The resident's diet order was noted as follows :NPO diet, NPO texture, NPO (nothing by Mouth) consistency. The State Surveyor interviewed the Director of Nursing (DON) on 07/31/25 at 11:30 AM. The DON reported the Speech-Language Pathologist (SLP) had retired and speech therapy services were provided via Telehealth pending the results of a resident's Modified Barium Swallow Study (MBSS). The DON reported Resident #6's last MBSS was in 2016. The resident's last SLP Evaluation was completed on 02/01/23. The resident was discharged from speech therapy services for dysphagia on 02/13/23. Diet recommendations included: Solids: - Any/all solids/liquids and Liquids-Thin cup/IDDSI 0, Thin Straw/IDDSI 0. Progress Note dated 05/12/25 stated, Pt. seen by telehealth to assess if appropriate to have chewing gum following MD request. Pt. is currently NPO receiving g-tube feedings as primary source of nutrition/hydration. Pt. presents with reduced alertness, poor positioning and currently on ABT for PNA. Pt. is not appropriate for gum/anything by mouth at this time 2'2 high risk of aspiration. Pt. agreeable. Continue Oral care and elevated HOB during g-tube feedings. Reconsult SLP if change in status. The resident was screened quarterly on 04/24/25 and 06/12/25 with no ST services indicated at this time. The resident received Physical Therapy (PT) services during the 06/12/25 quarterly screen. The facility's screening Policy Statement stated, Therapy Services will perform for needed services for all new admissions and readmissions to the facility. The patient has had several hospitalizations with Admitting and Discharge Diagnoses of Recurrent aspiration pneumonia . On 03/12/24, the resident's admitting diagnosis from (name of local hospital) was acute on chronic hypoxemic: respiratory failure Recurrent aspiration. On 06/08/24, the resident's admitting and discharge diagnosis from (name of local hospital) was Aspiration pneumonia. On 06/24/24, DMC Discharge summary stated, This gentleman is well known to our service and has had multiple admissions over the last 12 months, requiring HPNC to bipap and intubation. He has been deemed to have capacity, is known to aspirate, he does not wish to change his diet, nor does he want a feeding tube. On 07/20/2024. The resident's discharge summary stated: Recurrent Aspiration pneumonia and regular diet. On 03/06/25 the resident was hospitalized at (name of local hospital) with an admitting dx of Sepsis due to left lower lobe aspiration type pneumonia. Discharge summary stated, mechanical soft diet. Discharge from (name of local hospital) dated 03/28/25 had an admitting and discharge diagnosis of Aspiration pneumonia. Discharge summary dated [DATE], had a discharge diagnosis with Dysphagia with recurrent aspiration. Informed Decision to Refuse to Follow Physician's Dietary Orders and Release of Liability were completed on the following dates: - 01/24/2016 1500 cal diet - 02/22/2016 Nectar thick liquids - 11/10/2021 Nectar thickened liquids Dietary order changes were as follows: Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 12/27/2021 Regular diet, Regular texture, Regular consistencylow residue diet x3 days the resume previous dietDiet Completed 07/27/2022 Regular diet, Regular texture, Regular consistencyregular thin liquidsDiet Discontinued 02/1/2023 Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 04/12/2023 Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 10/24/2023 Regular diet, Chopped texture, Thin Liquids consistencyDiet Discontinued 01/21/2023 Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 12/03/2023 Regular diet, Chopped texture, Thin Liquids consistencyDiet Discontinued 12/16/2023 Regular diet, Pureed texture, Thin Liquids consistencyDiet Completed 12/28/2023 Regular diet, Chopped texture, Thin Liquids consistencyDiet Discontinued 12/31/2023 Regular diet, Chopped texture, Thin Liquids consistencyDiet Discontinued 02/01/2024 Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 03/13/2024 Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 03/27/2024 Regular diet, Pureed texture, Nectar Thickened Liquids consistency(No salt packet)Diet Discontinued 03/27/2024 Regular diet, Pureed texture, Nectar Thickened Liquids consistency(No salt packet)Diet Discontinued 06/08/2024 Regular diet, Pureed texture, Nectar Thickened Liquids consistencyDiet Discontinued 06/24/2024 NPO diet, NPO textureDiet Discontinued 07/20/2024 Regular diet, Regular texture, Regular consistencyfor diet changeDiet Discontinued 11/11/2024 Regular diet, Regular texture, Regular consistencyfor diet changeDiet Discontinued 11/20/2024 Regular diet, Chopped texture, Regular consistencyfor diet changeDiet Discontinued 03/06/2025 Regular diet, Regular texture, Regular consistencyfor diet changeDiet Discontinued 03/07/2025 NPO diet, NPO texture, NPO (Nothing by Mouth) consistencyDiet Active 05/07/2025 On 08/04/2025 at 10:06 AM, the Regional Rehab Manager was interviewed via phone. The Director of Rehab (DOR) was on vacation. The Regional Rehab Manager reported that the previous SLP had retired in October of 2024. Speech therapy services are contracted with hospitals for outpatient speech therapy services. A telehealth evaluation is completed via telehealth and if therapy is recommended, they go to (name of hospital) for outpatient therapy services. The Regional Rehab Manager reported the screening process as follows: -Screening Procedure - nursing referral to rehab via Point Click Care, based on hospital discharge paperwork. -Quarterly Long Term Care (LTC screenings) are interdisciplinary - refer if a change. -DOR tracks screens for significant change and quarterly for LTC residents. -DOR attends Interdisciplinary Meetings (IDT)meetings and Care Plan Meetings. -Protocol for change in diet or swallowing difficulty - notified by nursing or updated during meetings - daily or as scheduled. On 08/05/2025 at 8:52 AM, the DON reported the staff meet every morning to discuss changes, incidents/accidents and significant changes and that there was no actual IDT meetings. On 08/05/2025 at 3:34 PM - Resident #6 was interviewed by the State Surveyor and the resident reported he would like to eat and stated, I'd like to, but I know I can't. He reported it had been three (3) months since he had something to eat by mouth. The patient reported he had not had swallowing therapy or exercises, no swallowing x-rays, or any tests to check to see if he could eat.

Based upon record review and staff interview, the facility failed to provide medically-related social services to assist the resident in attaining or maintaining their mental and psychosocial health. This was found to be true to one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #9. Facility census: 91. Findings included:a) Resident #9Upon admission to the facility on [DATE], the Resident had a diagnosis of Post Traumatic Stress Disorder (PTSD), Anxiety and Major Depressive Disorder, Recurrent and Severe. The diagnosis for PTSD was also found on her Pre-admission Screening and Resident Review Assessment. A review of her medical record documents revealed, a Social Service Assessment, was performed by the Director of Social Services on 06/20/24. Section G of this document consisted of a Trauma Screen. The resident responded No to all the questions, thus scoring negative for trauma. Resident #9's care plan document stated she had a communiction problem related to choosing not to speak at times. Her score on her Brief Interview for Mental Status (BIMS) at the time of admission was nine (9). There were no indications that the Social Services Assessment was completed with the resident's representative's input. The Social Services Assessment completed on the resident failed to probe for any PTSD triggers. Further, there was no referral for psychological evaluation, or psychological services offered. The Director of Social Service's notes and assessment do not address PTSD at all. There were no attempts to determine triggers for PTSD.An interview with the DON on 08/04/2025 1:00 PM reviewed MDS, Care Plan, PASARR, Social Worker notes, no referral for psych. She acknowledged they were missing.On 08/04/2025 at approximately 1:40 PM, an interview was completed with the Director of Social Services. When she was asked why the resident did not have care plan goals or interventions for depression or PTSD, psychological referral for evaluation and treatment or behavioral services offered, the Director of Social Services stated she did not feel it was necessary because the resident had responded no to all the questions under the Trauma Screening.

Based on record review, resident interview and staff interview, the facility failed to provide appropriate treatment and services to restore a resident's normal eating skills. This failed practice was found to be true for Resident #6 during the annual survey process and had the potential to affect a limited number of residents. Resident Identifier: #6. Facility Census: 91. Findings included: a) Resident #6 On 07/30/25 at 9:55 AM, the state surveyor interviewed Resident 6 as part of the annual survey process. The resident stated he could not eat anymore because he aspirates and gets pneumonia. The resident reported he had not had any Speech Therapy (ST) for swallowing difficulties. The resident's diet order was noted as follows :NPO diet, NPO texture, NPO (nothing by Mouth) consistency. The State Surveyor interviewed the Director of Nursing (DON) on 07/31/25 at 11:30 AM. The DON reported the Speech-Language Pathologist (SLP) had retired and speech therapy services were provided via Telehealth pending the results of a resident's Modified Barium Swallow Study (MBSS). The DON reported Resident #6's last MBSS was in 2016. The resident's last SLP Evaluation was completed on 02/01/23. The resident was discharged from speech therapy services for dysphagia on 02/13/23. Diet recommendations included: Solids: - Any/all solids/liquids and Liquids-Thin cup/IDDSI 0, Thin Straw/IDDSI 0. Progress Note dated 05/12/25 stated, Pt. seen by telehealth to assess if appropriate to have chewing gum following MD request. Pt. is currently NPO receiving g-tube feedings as primary source of nutrition/hydration. Pt. presents with reduced alertness, poor positioning and currently on ABT for PNA. Pt. is not appropriate for gum/anything by mouth at this time 2'2 high risk of aspiration. Pt. agreeable. Continue Oral care and elevated HOB during g-tube feedings. Reconsult SLP if change in status. The resident was screened quarterly on 04/24/25 and 06/12/25 with no ST services indicated at this time. The resident received Physical Therapy (PT) services during the 06/12/25 quarterly screen. The facility's screening Policy Statement stated, Therapy Services will perform for needed services for all new admissions and readmissions to the facility. The patient has had several hospitalizations with Admitting and Discharge Diagnoses of Recurrent aspiration pneumonia . On 03/12/24, the resident's admitting diagnosis from (name of local hospital) was acute on chronic hypoxemic: respiratory failure Recurrent aspiration. On 06/08/24, the resident's admitting and discharge diagnosis from (name of local hospital) was Aspiration pneumonia. On 06/24/24, DMC Discharge summary stated, This gentleman is well known to our service and has had multiple admissions over the last 12 months, requiring HPNC to bipap and intubation. He has been deemed to have capacity, is known to aspirate, he does not wish to change his diet, nor does he want a feeding tube. On 07/20/2024. The resident's discharge summary stated: Recurrent Aspiration pneumonia and regular diet. On 03/06/25 the resident was hospitalized at (name of local hospital) with an admitting dx of Sepsis due to left lower lobe aspiration type pneumonia. Discharge summary stated, mechanical soft diet. Discharge from (name of local hospital) dated 03/28/25 had an admitting and discharge diagnosis of Aspiration pneumonia. Discharge summary dated [DATE], had a discharge diagnosis with Dysphagia with recurrent aspiration. Informed Decision to Refuse to Follow Physician's Dietary Orders and Release of Liability were completed on the following dates:- 01/24/2016 1500 cal diet- 02/22/2016 Nectar thick liquids- 11/10/2021 Nectar thickened liquids Dietary order changes were as follows: Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 12/27/2021 Regular diet, Regular texture, Regular consistencylow residue diet x3 days the resume previous dietDiet Completed 07/27/2022Regular diet, Regular texture, Regular consistencyregular thin liquidsDiet Discontinued 02/1/2023 Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 04/12/2023 Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 10/24/2023 Regular diet, Chopped texture, Thin Liquids consistencyDiet Discontinued 01/21/2023 Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 12/03/2023 Regular diet, Chopped texture, Thin Liquids consistencyDiet Discontinued 12/16/2023 Regular diet, Pureed texture, Thin Liquids consistencyDiet Completed 12/28/2023 Regular diet, Chopped texture, Thin Liquids consistencyDiet Discontinued 12/31/2023 Regular diet, Chopped texture, Thin Liquids consistencyDiet Discontinued 02/01/2024Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 03/13/2024 Regular diet, Regular texture, Nectar Thickened Liquids consistency(Mildly thicken Liquid) Free water protocolDiet Discontinued 03/27/2024 Regular diet, Pureed texture, Nectar Thickened Liquids consistency(No salt packet)Diet Discontinued 03/27/2024 Regular diet, Pureed texture, Nectar Thickened Liquids consistency(No salt packet)Diet Discontinued 06/08/2024 Regular diet, Pureed texture, Nectar Thickened Liquids consistencyDiet Discontinued 06/24/2024 NPO diet, NPO textureDiet Discontinued 07/20/2024 Regular diet, Regular texture, Regular consistencyfor diet changeDiet Discontinued 11/11/2024 Regular diet, Regular texture, Regular consistencyfor diet changeDiet Discontinued 11/20/2024 Regular diet, Chopped texture, Regular consistencyfor diet changeDiet Discontinued 03/06/2025 Regular diet, Regular texture, Regular consistencyfor diet changeDiet Discontinued 03/07/2025 NPO diet, NPO texture, NPO (Nothing by Mouth) consistencyDiet Active 05/07/2025 On 08/04/2025 at 10:06 AM, the Regional Rehab Manager was interviewed via phone. The Director of Rehab (DOR) was on vacation. The Regional Rehab Manager reported that the previous SLP had retired in October of 2024. Speech therapy services are contracted with hospitals for outpatient speech therapy services. A telehealth evaluation is completed via telehealth and if therapy is recommended, they go to (name of hospital) for outpatient therapy services. The Regional Rehab Manager reported the screening process as follows:-Screening Procedure - nursing referral to rehab via Point Click Care, based on hospital discharge paperwork. -Quarterly Long Term Care (LTC screenings) are interdisciplinary - refer if a change.-DOR tracks screens for significant change and quarterly for LTC residents.-DOR attends Interdisciplinary Meetings (IDT)meetings and Care Plan Meetings.-Protocol for change in diet or swallowing difficulty - notified by nursing or updated during meetings - daily or as scheduled. On 08/05/2025 at 8:52 AM, the DON reported the staff meet every morning to discuss changes, incidents/accidents and significant changes and that there was no actual IDT meetings. On 08/05/2025 at 3:34 PM - Resident #6 was interviewed by the State Surveyor and the resident reported he would like to eat and stated, I'd like to, but I know I can't. He reported it had been three (3) months since he had something to eat by mouth. The patient reported he had not had swallowing therapy or exercises, no swallowing x-rays, or any tests to check to see if he could eat.

Based upon record review and staff interviews, the facility failed to update the Pre-admission Screening and Resident Review (PASARR) when new diagnoses were given. This was found to be true for two (2) of eight (8) residents reviewed during the annual survey process. Resident identifiers: #9, #42. Facility census: 91. Findings included: a) Resident #9 A review of the electronic health record reflected the Resident had the following diagnoses related to mental health:ANXIETY DISORDER, UNSPECIFIED 6/17/2024MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 6/17/2024POST-TRAUMATIC STRESS DISORDER, UNSPECIFIED 6/17/2024 The resident's most recent Pre-admission Screening and Resident Review (PASARR) was completed on 09/25/24 by the facility. Under the section III, MI/MR, Current Diagnosis, None was marked. There is a box for Major Depression, but it was not selected. There is also a selection for Other Relation Conditions, and it was not marked. Post Traumatic Stress Disorder (PTSD) and Anxiety could have been specified in that section. The resident's Medical Diagnostic Screening (MDS) assessment was last completed on 06/26/25. Under Section I Active Diagnoses, Psychiatric/Mood Disorder question, Post Traumatic Stress Disorder (PTSD) is marked. But, Anxiety Disorder is not marked, and Depression is not marked. Comparing the MDS and the PASARR, the diagnoses do not agree. Nor, do the diagnoses in the resident's electronic health record (EHR) agree with either the MDS or the PASARR. This was reviewed with the Director of Nursing (DON) on 08/04/25 at 1:00 PM. Comparing the documents, the DON agreed the diagnoses in the electronic health record were accurate, and the MDS and PASARR diagnoses were not coordinated. b) Resident #42 On 08/04/25 at 01:02 PM, Resident #42's PASARR and Diagnosis List were reviewed. A diagnosis of Post-Traumatic Stress Disorder was listed, but was not on the resident's PASARR. On 08/04/2025 at 01:27 PM, the Director of Nursing and Social Worker confirmed the PTSD diagnosis was not on the resident's PASARR.

Based upon record review and staff interview, the facility failed to accurately reflect the resident's diagnoses in the assessment. This was found to be true for one (1) of twenty-seven (27) residents reviewed during the annual survey process. Resident identifier: #9. Facility census: 91.Findings included: a) Resident #9 A review of the electronic health record reflects the Resident has the following diagnoses related to mental health:ANXIETY DISORDER, UNSPECIFIED 6/17/2024MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 6/17/2024POST-TRAUMATIC STRESS DISORDER, UNSPECIFIED 6/17/2024 The most recent Minimum Data Set (MDS) assessment was completed on 06/26/25. Under Section I: Active Diagnoses, Psychiatric/Mood Disorder, the facility only marked Post Traumatic Stress Disorder. Anxiety disorder or depression were not marked. These findings were reviewed with the Director of Nursing (DON) on 08/04/25 at 1:00 PM. The DON acknowledged the error.

Based on record review and staff interview, the facility failed to ensure documentation that required transfer information was provided to the receiving hospital. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for care area of hospitalization. Resident identifier: #21. Facility census: 91. Findings included:a) Resident #21 Review of Resident #21's electronic medical records showed the resident was transferred to the hospital on [DATE] due to a fall, altered mental status, and an elevated blood glucose level. Further review of Resident #21's electronic medical records did not reveal documentation regarding what information was sent to the hospital to which the resident was transferred. On 08/04/2025 at 3:07 PM, the Director of Nursing (DON) provided a document titled Acute Care Transfer Document Checklist. The document had Resident #21's name written on it, along with the date 07/13/25. The document gave the following instructions: Copies sent with resident, check all apply. The document contained two (2) lists with boxes to be checked. The first list stated, These documents should ALWAYS accompany patient and included a universal transfer form, face sheet, current medication list or current medication administration record, advance directives or Physician's Orders for Scope of Treatment form, facility capabilities list, transfer notification, bed hold policy and notification, and immunization record. The bottom of the form stated, By signing you agree that the above has been provided to the resident upon transfer to the hospital. The form was signed by the nurse and by the ambulance staff accepting the envelope of documents. The second list stated, Send these documents as INDICATED and included acute change in condition/nurse's progress note, most recent history and physical and any recent hospital discharge summary, recent physician, nurse practitioner, or physician's assistant orders related to acute condition, relevant lab results, and personal belongings sent with the resident. None of the items on the checklist had been checked to indicate the information was sent to the hospital with Resident #21 on 07/13/25. The Director of Nursing confirmed this checklist was the only document available regarding the information sent to the hospital with Resident #21 on 07/13/25. No further information was provided through the completion of the survey process.

Based on observation and staff interview the facility failed to provide a clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents during the Long-Term Care Survey Process. Facility Census: 91. Findings include: a) room [ROOM NUMBER]-B The initial observation on 07/30/25 at 11:16 AM, revealed in the bathroom of room [ROOM NUMBER]-B, around the entire base of the toilet was a dried orange, yellow and brown substance. The floor was sticky, and the bathroom had a strong urine odor. During an interview on 07/31/25 at 12:28 PM, The Housekeeping Supervisor (HS) confirmed that the bathroom was dirty, and stated, I will get that cleaned up.

Based on observation, resident interviews and staff interviews, the facility failed to ensure resident room temperatures were maintained between 71 to 81 degrees Fahrenheit (F). This failed practice has the potential to affect more than a limited number of residents. Facility census: 87. Findings include: An unannounced complaint investigation was conducted. Upon entering the building, an interview was conducted with Registered Nurse (RN) # 42 at 9:20 AM. When asked if the building was hot on 06/29/24. RN # 42 answered it was hot especially on B side of the building. I understand parts have been ordered. After meeting with the Nursing Home Administrator (NHA) and providing a request of documents and electronic medical record access, a tour was conducted on the A Hall at 12:22 PM. The outside temperature was 77 degrees F at the time. Observations of the resident rooms on the A Hall found the following concerns: 110 No air conditioning (AC) 104 Resident #49 complained the room was too hot and the AC unit was not blowing any air and the switch could not be moved to turn on AC. Reported to the Maintenance Director on 07/02/24 at 1:48 PM. room [ROOM NUMBER] little air coming from AC unit. room [ROOM NUMBER] Air not cool. room [ROOM NUMBER] No fan on on AC unit Resident #9 said the room was hot. room [ROOM NUMBER] Fan turned off and no air moving. room [ROOM NUMBER] Resident #50 stated that the unit had been leaking into the floor from the time she was admitted which was about a year. Stated, they put towels around it because the water runs down the floor. The unit filter was partially pulled out and was wet. Fan would not turn on. NHA was told about leak at 1:40 PM on 07/02/24. NHA stated he would have the Maintenance Director take care of the leak. At 12:49 PM the outdoor temperature had risen to 78 degrees F. At 12:58 PM, found the room hot and found Resident #72 naked in bed in room [ROOM NUMBER] A. An interview with Nurse Aide (NA) #44 found this resident sleeps naked at all times and has all of her life. The room mate was fully clothed and the door to the room was closed and the curtain pulled between the residents. On 07/02/24 at 1:15 PM the outdoor temperature was 79 degrees F. All rooms on the B hall were toured with the Maintenance Director and found the temperatures ranged from 71.2 degrees F to 79.4 degrees F in room [ROOM NUMBER]. Resident #20 in room B115 stated the room was hot but she knows they are trying to get this fixed. At 4:24 PM, room [ROOM NUMBER] temperature was rechecked and found to be 83 degrees F. This was reported immediately to the NHA. He stated he would take care of it. In addition he stated the room air conditioners were being picked up and would be installed once they arrived. In addition he stated, an AC company had inspected the AC unit on 06/27/24 and were to replace several parts in each room unit. He further stated they were awaiting the estimate approval from corporate. On 07/03/24 at approximately 9:00 AM, found both residents in room [ROOM NUMBER] had been moved to another room and room [ROOM NUMBER] had no residents in the room. An interview with Resident #20 stated, she was glad they were moved and this room was more comfortable.

Based on observation, resident interview and staff interview, the facility failed to maintain a functioning room air conditioner when water was leaking from the air conditioning unit in room [ROOM NUMBER] on A Hall. Facility census: 87. Findings include: a) room [ROOM NUMBER] On 07/02/24 at 12:46 PM Resident #50 stated, the air conditioning unit had been leaking into the floor from the time she was admitted which was about a year ago. She stated, they put towels around it because the water runs down the floor. Resident #50 stated, she was afraid she could fall with the water in the floor. An observation of the unit found the filter was partially pulled out and was wet. The unit fan would not turn on. NHA was told about the leak at 1:40 PM on 07/02/24. An interview with the Maintenance Director on 07/03/24 at approximately 9:30 AM confirmed he didn't have a work order regarding the unit leaking. He stated, the drain tube was plugged up and had been opened. An additional observation found the floor dry and the filter had been replaced and was dry.

Based on resident interview, record review, and staff interview, the facility failed to ensure residents were free from sexually aggressive behavior (such as making sexually explicit comments and forced observation of masturbation and exposure ) from Resident #59. The lack of action from the facility to address and protect the other residents resulted in an immediate jeopardy situation for more than an isolated number of residents. The facility was notified of the immediate jeopardy on 11/07/23 at 5:01 PM. The plan of correction, as follows, was accepted at 6:57 PM on 11/07/23: -Resident #59 will be placed on 24 hour, one on one supervision effective 5:00 pm on November 7, 2023, to protect all residents. Documentation will be done q (every) 15 minutes as to what the resident is doing, and log will be maintained. (Log attached) -An immediate report will be submitted to OHFLAC, APS, and the Regional Ombudsman on November 7, 2023. -Resident #132 will be moved over to B-Side of facility at his request. This will be done November 7, 2023. -Referral will be made for geriatric psych placement and evaluation and treatment. Upon acceptance at geriatric psych facility, Resident #59 will be admitted . -Resident #59 will not be given a roommate for a minimum of 90 days pending geriatric psych admission, pending their acceptance of resident and their recommendations. -Resident #59 will be seen by (Name of Telepsych) for medication review and recommendations. Resident is already established with (Name of Telepsych company) at Nella's at [NAME] Lake Healthcare. -Resident #59 ' s behaviors will be documented on q shift, for the next 90 days, by licensed nursing staff and will be reviewed at monthly QAPI meetings. The Immediate Jeopardy was abated on 11/08/23 at 10:41 AM. The deficient practice remained a scope and severity of G, for Resident #132 who suffered emotional harm and concern that Resident #59 would return to his room as Resident #59 remained near this resident. Resident identifiers: #59 and #132. Facility census: 79. Findings included: a) Resident #132 Review of the facility's narrative of complaints filed in the last six (6) months on the morning of 11/7/23, provided to the survey team by the Social Worker (SW) #2 found the summary dated 11/04/23: (Typed as written) (Name of Resident #132) reported that his roommate (Resident #59) asked him if he could F*** him in the a**. This resident was immediately moved to another room; he had concerns that he was still in the same hallway near (Resident #59.) Plans are being made to move (Name of Resident) to the other side of the building. Staff confirmed with (Name of Resident) and his mother that (Name of Resident #59) only made inappropriate remarks but never tried to touch (Name of Resident #59.) On 11/07/23 at 12:05 PM, the surveyor asked Resident #132 how he was. The resident stated, I'm madder than hell. When asked why, he stated, My roommate made some derogatory sexual comments to me over the weekend and now I am across the hall from him. I still have to look at him. I want moved as far away from him as I can. I want moved to the other side of the building. He can still see me, and I can still see him. He can come into my room at any time, he can walk right over to my room. The resident said when he told the staff about the incident, he was moved out of his room to a room directly across the hallway from Resident #59. Resident #132 said he called the police and wanted Resident #59 arrested. He said he was told Resident #59 had Dementia and cannot be arrested. Resident #132 said Resident #59 knows exactly what he is doing. He keeps coming to his doorway and staring at me. The resident said he was unable to get out of bed by himself and that once staff got him up in his wheelchair he was mobile. Resident #132 said if Resident #59 would get close enough to him he could hit him. He said he feared what he might do to Resident #59 if he could. Record review found Resident #132 was admitted to the facility on [DATE]. The Resident was placed in a room with Resident #59. Review of Resident #132's medical record found a nurse's note, dated 11/04/23 noting the Resident had made multiple calls to 911 for the alleged incident that occurred with the previous roommate. This nurse spoke with emergency services to let them know the Resident was not in harm. On 11/04/23 at 11:10 AM, the resident's mother wanted information regarding her son's previous hospital visits. The nurse noted his mother was not on the list of family members to have information about the resident. The nurse allowed the resident to grant permission for his mother to have information. There was no indication that the resident lacked capacity at this time. The Medical Record contained a capacity statement noting the resident had capacity to make medical decisions from a previous admission to the facility. Record review found Resident #132 was sent to the local hospital on 11/04/23, after the resident and his mother insisted, he be sent to the hospital. The resident left for the emergency room in the afternoon and was in the building around 4:30 PM on the same day. On 11/07/23 at 1:31 PM, the Social Worker (SW) #2 was asked if she was aware of the incident. She stated she was and provided witness statements. SW #2 said the incident was not reported to the proper State authorities. She said she did not know why but Resident #59 hadn't done anything else. The SW provided a copy of a Complaint, Comment Concern Resolution, dated 11/04/23: The form noted Resident #132 reported his roommate (Resident #59) asked him if he could F*** him in the A**. Resident #132 was immediately moved to another room. When Resident #132 was still concerned because he was only moved across the hall, Resident #132 was moved to the other side of the building. The follow up resolution was: Resident #132 was satisfied with the resolution of moving him to the other side of the building. The form was signed by the administrator, Director of Nursing (DON) and the Social Worker on 11/06/23. Observation on 11/07/23 during the morning, found the Resident had never been moved to the other side of the building. On the morning of 11/07/23 the Resident was observed by the survey team to be directly across the hallway from his old roommate, Resident #59. Statements attached to the complaint included: A statement from a Licensed Practical Nurse (LPN) #36, dated 11/04/23 at 1:52 PM, Revealed the LPN received a telephone call from the Resident's sister stating she wanted to report a sexual assault against her brother. The sister was at the hospital with Resident #132 when the call was made to the facility. The LPN spoke to the sister and the resident who related the same story regarding Resident #59. Resident #132 denied being physically touched by Resident #59. The LPN said she would tell the social worker and the administrator about the situation. A second statement from Nurse Aide (NA) #23 revealed the resident had reported the incident to her and said Resident #59 was whispering things to him in the night saying he wanted to F*** him in the A**. Then his mother came in and they started the process of sending him to the hospital. She stated she reported it the first chance she had because of everything going on. The statement was signed by NA #23 but was not dated. A statement dated 11/4/23 from the activity assistant (AA) #28 documented she was also aware of the situation after the Resident told her what the roommate #59 said. Resident #59 asked if he could F*** him in the A**. At 9:40 AM on 11/08/23, LPN #36 said she became aware of the situation after Resident #132's sister called her on the telephone when the Resident was in the emergency room . She said she called the administrator to let him know. She said she did not report the incident because no one told her to. At 9:44 AM on 11/08/23, NA #23 said she became aware of the situation around breakfast on the morning of 11/04/23 when Resident #132 told her what happened. She said it was a busy morning and she forgot to tell the nurse about it. It was a busy morning, because Resident #132 wanted to go to the hospital because he said he needed to get the fluid drawn off of him. I was trying to get him ready to go out. At 8:06 AM on 11/08/23, Resident #132 said, I feel like I have no rights, they are supposed to listen to me, I know I have rights. b) Resident #59 Record review found the Resident was admitted to the facility on [DATE]. Review of the Resident's most recent Minimum Data Set (MDS) a quarterly, with an Assessment Reference Date (ARD) of 10/29/23 found this resident is ambulatory and transfers are independent, and no staff assistance is required. Review of daily progress notes found no notes were written on 11/04/23 regarding the alleged incident in this Resident's record. No notes of any kind were written about this Resident on 11/04/23. Review of the progress notes for this Resident from 02/01/23 to present found the following documented behaviors: The Resident's responsible party was notified on 02/28/23, by the SW that he was being admitted for a psychiatric stay due to recent inappropriate sexual behaviors. The behaviors leading up to the hospitalization included: 2/2/2023 03:11 General Nurses Note Note Text: Aid reported to nurse that while showering him he asked if she wanted to play with this while holding his penis in his hand. Aid explained to him that that was inappropriate. While aid was helping resident to dry off and get dressed he again while holding his penis asked her if she would play with it. Aid again explained that that was inappropriate and that he needed to stop. A note dated, 02/06/23 at 5:30 PM, General Nurses Note At approximately 5:30 CNA (Certified Nurse Aide) approached undersigned and another nurse and stated that this male resident had exposed himself to a female resident in B side dining room. CNA informed that female was immediately escorted from dining room and taken to her room. A note dated 2/23/2023, 00:09 General Nurses Note Note Text: Resident was seen multiple times by staff member with private areas exposed in the common area in front of a female resident trying to get her touch him inappropriately. Resident was redirected each time. (This incident was reported to the proper State Authorities.) The Resident was sent to the psychiatric facility on 02/28/23 and returned to the facility on [DATE]. Progress notes indicated the Resident's behaviors continued after his return to the facility: 3/28/2023 01:33 General Nurses Note Note Text: Resident was found playing with penis in hallway while female residents were in hallway multiple times during the shift. This nurse has made multiple attempts to keep residents in room. Resident becomes aggressive when room door is shut. Attempted to redirect with snacks/drink and conversation no effect. Resident at this time is sitting at bedside. Call light within reach. 3/30/2023 02:05 General Nurses Note Note Text: resident was in his room standing in front of door holding his penis in his hand, CNA asked him to shut door if he was going to do that. Resident redirected. 5/5/2023 05:31 General Nurses Note Note Text: while CNA'S doing rounds noted resident standing in doorway with his pants pulled down, holding his penis in his hands looking into the ladies that live across the hall's room. Redirected resident, he became slightly upset but pulled his pants up and laid down on his bed. 6/13/2023 02:00 General Nurses Note Note Text: CNA doing rounds, saw this resident in room [ROOM NUMBER]. hiding between the bed and sink asked resident what he was doing. He stated 'she waved her hand for me to come over there.' Explained to resident that was a males room and he is sleeping. Assisted resident back to his room. Explained to him if he needed anything to ring his call bell. 7/26/2023 02:51 General Nurses Note Note Text: resident up sitting in dining room when Resident #21 went by him he took his penis out of his pants and was trying to show it to her. Resident was educated to how inappropriate that was and assisted back to his room. 7/27/2023 02:38 General Nurses Note Note Text: Resident ambulating throughout facility grabbing at groin. Resident was redirected to room. Resident sitting on side of bed. Denies any pain or discomfort at this time. 7/31/2023 03:45 General Nurses Note Note Text: This nurse was walking down hallway when passed residents room when he was playing with self in doorway with door open. Attempted to close door when resident became agitated grabbing at door. This nurse redirected resident to laying down in bed. Call light within reach. Review of the care plan found the following: The resident has a behavior problem r/t (Related to) sexually inappropriate behaviors, exposing self to others. Date Initiated: 02/06/2023. Revision on: 02/28/2023 No changes noted, continue goals. Date Initiated: 04/27/2023 The goal associated with the problem: Behaviors have lessened since last review. Continuing goals. Date Initiated: 07/28/2023. Revision on: 11/01/2023 Target Date: 01/28/2024 The resident will have fewer episodes of sexually inappropriate behaviors weekly by review date. Date Initiated: 02/06/2023 Revision on: 11/01/2023 Target Date: 01/28/2024 No behaviors noted. Continue goals. Date Initiated: 11/01/2023 Interventions included: Anticipate and meet the resident's needs. Date Initiated: 02/06/23 Revision on: 02/06/23 Attempt to redirect resident when behaviors occur. Date Initiated: 02/06/23 If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Date Initiated: 02/06/23 Revision on: 02/06/23 Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 02/06/23. Revision on: 02/06/23 Notify Social Worker as needed. Date Initiated: 02/06/2023. Psych eval and inpatient if needed. Date Initiated: 02/24/2023. At 3:38 PM on 11/07/23, the administrator and the Director of Nursing reviewed the care plan and were asked: How does the facility monitor the Resident's behaviors and how is the cause of the behaviors determined as indicated in the care plan? In addition, the administrator and DON were asked: Who are the other residents involved in the nursing notes in Resident #59's chart? Were incident reports completed? Were any of the incidents reported to the proper State authorities? How are the other residents being protected from Resident #59's behaviors? The DON said the Resident saw a tele-med psychiatrist. Review of the tele-med psychiatrist notes with the DON, found the resident had a visit on 03/30/23 and the psychiatrist noted, .Resident has had no further behaviors . Yet behaviors were recorded on 03/28/23, when the resident was found playing with his penis in the hallway while female residents were present. The attempts at redirection were unsuccessful. The next tele- med visit was on 06/08/23 again the psychiatrist documented no behaviors. The resident did have behaviors on 05/05/23. On 08/25/23, the psychiatrist documented the resident had no behaviors, yet behaviors were documented on 07/26/23, 07/27/23 and 07/31/23. The DON had no answer as to why the psychiatrist did not know about the behaviors. The DON was asked if the facility should be responsible for telling the psychiatrist about the Resident's behaviors? She said yes but could not explain how the psychiatrist did not know about the behaviors. On 11/08/23 10:09 AM, the DON identified Resident #21 from Resident #59's 07/26/23 progress note. A review of Resident #21's progress notes found no notes were written in her medical record regarding the incident on 07/26/23. At the close of the survey no further information was provided regarding how Resident #59's behaviors affected other residents. No information was provided to indicate the facility provided daily monitoring of Resident #59 before the alleged incident on 11/04/23. No information was provided to verify the facility reported the alleged incidents involving other residents after the 02/23/23 reporting.