Every finding on record at Riverdale Post Acute

Based on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for two (#3 and #8) of seven residents reviewed for abuse out of 13 sample residents.Resident #4 was admitted to the facility on [DATE] with diagnoses of restlessness and agitation, schizoaffective disorders, paranoid schizophrenia and specified anxiety disorders.On 6/16/26, the staff witnessed Resident #4 hit Resident #8 in the back of the head with a rock, resulting in bruising to the head and a hospital evaluation for Resident #8. The facility determined the altercation was prompted by an earlier visitation from Resident #4's representative. Resident #4 was placed on one-to-one supervision temporarily and 15-minute checks thereafter whenever Resident #4 was visited by his representative. On 7/18/26, Resident #4 grabbed Resident #3's arm and struck her in the face, causing bruising to Resident #3's face, swelling to her eye and a laceration to her lip. Resident #3 required a hospital evaluation and stitches to her lip. Following the incident, Resident #3 said she was fearful of Resident #4. The facility's investigation determined the altercation was not provoked by a visitation from Resident #4's representative and was more likely a concern of impulse control. Following the incident with Resident #3, Resident #4 was placed on perpetual one-on-one supervision due to his unpredictable physical aggression and resident safety.Specifically, the facility failed to protect Resident #8 and Resident #3 from physical abuse by Resident #4, which resulted in bruising to the head of Resident #8 and a bruised eye, bruised arm and a lip laceration requiring stitches for Resident #3.Findings include: I. Facility policy and procedureThe Resident Abuse Prevention policy, undated, was provided by the nursing home administrator (NHA) on 8/13/26 at 12:54 p.m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. II. Incident of physical abuse of Resident #8 by Resident #4 on 6/16/26A. Facility investigationThe facility investigation of the abuse incident between Resident #4 and Resident #8 was provided by the NHA on 8/13/26 at 10:06 a.m.The facility investigation documented Resident #4 hit Resident #8 in the back of the head with a rock in front of the facility on 6/16/26 at 10:45 p.m. Resident #8 was taken to the hospital and sustained bruising to his head. Review of the investigation identified the facility substantiated abuse. B. Resident #8 (victim)1. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses depression, generalized anxiety disorder, and post-traumatic stress disorder. The 8/17/26 minimum data set (MDS) assessment identified Resident #8 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. According to the MDS assessment, he did not have behaviors directed towards himself or others.2. Resident interviewResident #8 was interviewed on 8/12/26 at 6:05 p.m. Resident #8 said he was sitting at the bus stop in front of the facility (on 6/16/26) when Resident #4 walked up to him and asked him if he could have a puff of his cigar. Resident #8 said he told Resident #4 no and Resident #4 picked up a rock and hit him on the back of the head. Resident #8 said there were two nurses that were outside at the time and they saw what happened and called the police. Resident #8 said he was taken to the hospital and pressed charges against Resident #4. He said he had a large bump on his head from the rock. Resident #8 said he recently saw Resident #4 punch Resident #3 in the face (see investigation below) during a smoke break. He said he was worried about Resident #4 in the facility because he never knew when Resident #4 would attack again.3. Record reviewThe psychosocial well-being care plan, initiated 7/31/26, identified Resident #8 had a diagnosis of depression and stage 3 lung cancer. Resident #8 was highly independent with his daily routine and frequently spent time outdoors. According to the care plan, Resident #8's tendency to set firm boundaries and communicate directly, could increase his risk to receive abuse or negative reactions from others. Interventions included acknowledging and respecting Resident #8's communication style while assisting the resident with positive conflict resolution when needed; encouraging him to participate in mental health counseling as ordered and collaborating with the counseling team regarding his needs; encouraging Resident #8 to continue participating in his preferred activities, including spending time outdoors and community outings as tolerated; monitoring the resident for changes in mood, such as withdrawal, hopelessness, or declining interest in preferred activities, and notifying the interdisciplinary team of significant changes; providing him with opportunities to express his feelings related to his cancer diagnosis and his emotional well-being; and respecting Resident #8's independence, choices, and personal boundaries while providing assistance upon request.The 6/16/26 change in condition evaluation documented Resident #8 received trauma. The evaluation documented Resident #8 had a developing lump to the posterior of his right skull due to trauma.The 6/17/26 72-hour charting note documented Resident #8 was being monitored for a resident-to-resident altercation. A second 6/17/26 72-hour charting note documented Resident #8 continued on neurological assessments following a hit to the back of his head with a large rock. C. Resident #4 (assailant) 1. Resident statusResident #4, age less than 65, was admitted on [DATE]. According to the August 2026 CPO, diagnoses included restlessness and agitation, schizoaffective disorders, paranoid schizophrenia and specified anxiety disorders.The 8/7/26 MDS assessment documented Resident #4 had moderate cognitive impairment with a BIMS score of 11 out of 15. According to the MDS assessment, Resident #4 did not have behaviors of verbal or physical aggression directed at others, wandering, rejections of care or other behavioral symptoms not directed at others, but he exhibited hallucinations. 2. ObservationsOn 8/11/26 at 4:07 p.m. certified nurse aide (CNA) #1 sat outside the room of Resident #4. The resident's room door was closed. CNA #1 she said Resident #4 was inside his room but he did not like anyone in his room. On 8/12/26 at approximately 1:50 p.m. Resident #4 was walking back and forth in front of his room with an identified CNA watching him. Resident #4 said pacing was the only way he was getting exercise these days.3. Record reviewResident #4's behavior care, revised 7/30/26, documented Resident #4 exhibited or was at risk for behavioral symptoms related to schizophrenia, including verbal aggression, raised voice, threatening statements, posturing, and physical aggression. The care plan identified Resident #4 could knock over objects or become physically aggressive when he perceived he was being threatened, challenged, or spoken to negatively or disrespected. According to the behavior care plan, Resident #4 could misinterpret statements or interactions due to his delusional thoughts if he perceived the interactions as negative or accusatory, believing that others were talking about him and/or laughing about him. The care plan documented Resident #4 could become verbally aggressive and make threats or accusations when limits were set or redirection was attempted. The care plan identified Resident #4's mental health diagnoses and poor insight to his condition increased his risk of receiving abuse. The intervention, initiated 6/17/26, directed staff to increase the monitoring of Resident #4 and initiate frequent check-in's with the resident after his representative visited the facility.The 6/16/26 change of condition evaluation documented that Resident #4 had physical aggression and was placed on 15-minute checks and kept separated from other residents.The 6/17/26 social services note documented that Resident #4 said he felt Resident #8 was being disrespectful toward him at the time of the 6/16/26 incident. III. Incident of physical abuse of Resident #3 by Resident #4 on 7/18/26A. Facility investigationThe facility investigation of the abuse incident between Resident #3 and Resident #4 was provided by the NHA on 8/11/26 at 4:42 p.m.The facility investigation documented Resident #4 made contact with the face of Resident #3 after a verbal argument during a supervised smoke break in the facility's designated smoking area on 7/18/26. Resident #3 was taken to the hospital for evaluation and sustained bruising to her eye, arm and a laceration to her lip. Review of the investigation identified the facility substantiated abuse. B. Resident #3 (victim)1. Resident statusResident #3, age less than 65, was admitted on [DATE]. According to the August 2026 CPO, diagnoses included major depressive disorder, recurrent, generalized anxiety disorder and anoxic brain damage.The 8/17/26 MDS assessment identified Resident #3 was cognitively intact with a BIMS score of 15 out of 15. According to the MDS assessment, Resident #3 did not have behaviors directed towards herself or others. 2. Resident interview and observationResident #3 was interviewed on 8/11/26 at 3:48 p.m. Resident #3 had a bruised left eye and a faint bruise on her upper left arm. She said Resident #4 hit her on a Saturday (7/18/26) at 9:45 a.m. She said she was outside in the smoking area when he made an obnoxious comment towards her. She said she made a comment back to him. She said he came over to her and grabbed her arm and hit her in the face. She said she was so shocked and did not know what to do. She said CNA #2 got Resident #4 off of her. She said she was now very leery of him. She said she still saw him around the facility and she was afraid that he might hit her again. Resident #3 became tearful and said she did not know what she could do. She said she had not seen the staff do anything to ease her worry about Resident #4. She said this was the first time he hit her, but he had had altercations with other residents before (see investigation above). Resident #3 said residents could go to the smoking area any time, but they could only smoke during the scheduled times. She said she had not seen Resident #4 smoke when she was smoking after the 7/18/26 incident, but he still went out to the smoking area when she was out there. She said since the incident, he would have someone with him when he came outside.3. Record reviewThe 7/18/26 alert note documented Resident #3 was assessed and sent out to the hospital for an evaluation. The 7/18/26 change of condition note documented Resident #3 had a change in skin color or condition. The 7/19/26 72-hour charting note documented Resident #3 was being monitored after she was a recipient of aggression on 7/18/26. The note identified Resident #3's left eye was black and blue and her bottom lip had a small cut on it. The note documented Resident #3 felt unsafe with the aggressor (Resident #4) walking around the facility. The note documented that staff assured the resident they were monitoring the whereabouts of Resident #4 for her safety. The 7/20/26 interdisciplinary team (IDT) note documented Resident #3 had a verbal interaction with another resident (Resident #4) when the other resident came towards Resident #3 and struck her in the face during a smoke break. The residents were immediately separated and Resident #4 was placed on 15-minute checks. Resident #3 was sent to the hospital for an evaluation. According to the note, a referral was sent out for behavioral health counseling for Resident #4. The 7/20/26 72-hour charting note documented Resident #3's left eye remained swollen and black and blue. The note identified Resident #3's lip was slightly swollen after receiving stitches and she had bruising to the left upper arm. According to the note, the resident complained of pain to her eye. The 7/20/26 weekly summary note documented Resident #3 was hit in the face by another resident (Resident #4) the other day (7/18/26) and she was now afraid of the resident. The 7/20/26 social services note documented a mental health counseling referral had been submitted for Resident #3 to provide her with additional support. The note indicated Resident #3 was encouraged to seek assistance from staff if she experienced any more difficulty with peer interactions so staff could intervene and provide her support. The 7/22/26 social services note documented Resident #3 wanted to press charges against Resident #4 after the 7/18/26 altercation. C. Resident #4 (assailant) 1. Record reviewResident #4's behavior care plan, revised 7/30/26, identified new interventions following the 7/18/26 physical altercation with Resident #3. The interventions, initiated 7/18/26, included placing Resident #4 under one-to-one supervision, completing a chart review with the medical director and a pharmacy review of his medications, sending out other facility referrals, and continuing the resident's mental health counseling services. The intervention, initiated 7/20/26, identified Resident #4 was provided with a new smoking schedule that provided individual smoking breaks thirty minutes after other residents' group smoking breaks.The interventions, revised 7/29/26, included administering medication as order, monitoring for side effects, anticipating and promptly meeting Resident #4's needs, documenting and recording behavioral episodes, establishing a rapport with the resident and encouraging him to verbalize his feelings, evaluating and making medication adjustments as needed and maintaining a calm, slow, understandable approach, managing environmental factors to optimize comfort, notifying all necessary parties of episodes of aggression and abusive behaviors, observing and documenting clinical influencing factors, responses to medications and changes in behavior and mood, including frequency of occurrences and potential triggers, offering flavored water packets, space and/or music to help him de-escalate his behaviors. The intervention, initiated 7/29/26, identified Resident #4's new psychotropic medication, Depakote (medication that assists with mood stabilization) would be reviewed by the psychiatric nurse practitioner. According to the intervention, Resident #4's medications would be reviewed in the August 2026 psychiatric pharmacy review. The 7/18/26 nursing note documented Resident #4 was involved in an altercation with another resident (Resident #3) on the morning of 7/18/26. Resident #4 was placed on one-to-one supervision after the altercation and the police were notified. A second 7/18/26 nursing note documented Resident #4 was assessed and had no injuries as a result of the altercation with another resident (Resident #3). Resident #4 was given time to calm down and was redirected to a separate area away from Resident #3. According to the note, the facility staff would continue to monitor Resident #4 closely for any changes in his behavior and implement interventions as needed to help prevent future incidents. Review of Resident #4's August 2026 CPO revealed the following physician's order: One-to-one sitter, ordered 7/18/26. The 7/21/26 psychiatric follow-up note documented Resident #4, with schizoaffective disorder and paranoid schizophrenia, presented a need for an urgent psychiatric evaluation and new mood-stabilizing agent after a physical altercation with another resident. The note documented Resident #4 engaged in the physical assault of another resident (Resident #3). Resident #4 said he struck another resident and gave her a shiner after a verbal provocation. The note documented Resident #4's current psychiatric medications appeared insufficient for impulse control and aggression management and the resident was started on Depakote at 250 milligrams (mg) divided into twice daily dosing for mood stabilization and aggression on 7/21/26. The note documented other interventions included providing Resident #4 with a different smoking time than Resident #3 and he was instructed to go to staff if he felt provoked by another resident rather than engaging in physical altercations. According to the psychiatric note, Resident #4 had had recurrent agitation-related behavioral incidents at the facility. Resident #4 acknowledged the physical altercations but he felt the altercations were a result of the other residents' provocation/initiation and he had minimal self-reflection regarding his own role. According to the note, Resident #4's judgment appeared impaired but he demonstrated some capacity for redirection and acknowledged that he should approach staff when he felt provoked rather than acting out physically.IV. Additional resident interviewsResident #13 was interviewed on 8/12/26 at 6:10 p.m. Resident #13 she was afraid of Resident #4. She said after Resident #4 hit Resident #3, someone was always with him but she tried to stay as far away from Resident #4 as possible.Resident #11 was interviewed on 8/13/26 at 11:25 a.m. Resident #11 said he was concerned about and disliked Resident #4. He said Resident #4 had hit and hurt multiple residents at the facility, including Resident #3 and Resident #8. He said he was worried that Resident #4 might hit someone else. He said he did not feel that Resident #4 should be at the facility. He said the staff now watched Resident #4 every time he left his room or he went outside to smoke. V. Staff interviewsCNA #1 was interviewed on 8/11/26 at 4:10 p.m. CNA #1 said Resident #4 required 24-hour a day supervision and was on 15-min checks. She said she documented that he was in his room every 15 minutes. She said when Resident #4 left the room, she would follow him. She said she tried to keep her distance from the resident,but stayed close enough to stay with him because she had been told that he did not like anyone to get too close to him. CNA #1 said Resident #4 had his own smoking times, separate from other residents and she went with him when he smoked. Licensed practical nurse (LPN) #1 was interviewed on 8/13/26 at 1:13 p.m. LPN #1 said Resident #4 would get upset and exhibit behaviors of throwing items and getting in the face of residents and staff. She said she knew how to handle his behaviors but there were residents that were scared of him. LPN #1 said he was on a 15-minute watch and had one-to-one supervision because the residents did not feel comfortable with him walking around in the facility. The NHA was interviewed on 8/13/26 at 2:26 p.m. The NHA said he was the facility's abuse coordinator. He said staff needed to contact him right away if there was suspected abuse. The NHA said he would report the allegations to the appropriate parties and start his investigation when he received a report of abuse. The NHA said Resident #4 had a history of physical altercations resulting in injury to other residents. The NHA said prior to the incident with Resident #8, Resident #4 had not had a physical altercation with another resident since 2025. The NHA said Resident #8 was sitting outside on a bench the night of 6/16/26. The NHA said Resident #4 approached Resident #8 and Resident #8 told Resident #4 to go away. The NHA said Resident #4 became frustrated and he hit Resident #8 on the head with a rock. He said Resident #8 was taken to the hospital and Resident #4 was placed on one-to-one supervision temporarily. The NHA said through his investigation, he learned that Resident #4 was agitated after a visit with his representative. The NHA said the facility implemented 15-minute checks for Resident #4 on the day of and the day after the resident's representative visited in order to observe if Resident #4 would have any behavior changes or increased agitation. He said Resident #4 was placed on one-to-one supervision for a week or two, following the 6/16/26 incident with Resident #8. He said the staff were first instructed to stay next Resident #4, but their physical closeness increased his agitation. He said the staff were then instructed to keep him in line of sight and intervene when needed during the supervision. He said Resident #4 continued to be on 15-minute checks after his representative visited after the one-to-one supervision was discontinued. The NHA said the most recent physical altercation that Resident #4 had with another resident was on 7/18/26, with Resident #3. The NHA said Resident #3 said something to Resident #4 during a smoke break and he hit her in the face impulsively. He said the incident was witnessed by the staff member supervising the smoking area and the staff member separated the residents immediately. The NHA said Resident #4 was now on one-to-one supervision for the duration of his residency at the facility to keep other residents safe. The NHA said he spoke with Resident #3 after the incident and she said she did not feel safe around Resident #4. The NHA said the altercation between Resident #4 and Resident #3 was not provoked by Resident #4's representative visitation. He said it was determined that the representative was not a factor on 7/18/26 and the NHA felt Resident #4 had impulse issues and his behaviors could not always be predicted. The NHA said he believed that the facility was not a good fit for Resident #4 and a change in environment could help Resident #4's behaviors. NHA said referrals had been sent out to other facilities. The NHA said he (the NHA) had had ongoing communication with Resident #4's representative. The NHA said he substantiated the abuse allegations for Resident #4's altercations with Resident #8 and Resident #3. He said he would have staff remain with Resident #4 to keep the residents at the facility safe.

Based on interviews and record review, the facility failed to ensure residents and/or their representatives had the right to be informed and make treatment decisions for one (#6) of three residents reviewed for diabetic management out of 13 sample residents. Specifically, the facility failed to ensure Resident #6's representative was informed of and educated on the potential side-effects for the use of a glucagon-like peptide-1 (GLP-1) medication for diabetic management.Findings include:I. Facility policy and procedureThe Notification of Changes policy, undated, was provided by the nursing home administrator (NHA) on 8/13/26 at 2:37 p.m. It read in pertinent part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. According to the policy, a new treatment would be a circumstance that required notification. The policy identified if the resident was incapable of making decisions, the representative would make any decisions that needed to be made and the resident should still be told what was happening to them.II. Resident #6A. Resident statusResident #6, age less than 65, was admitted to the facility on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with hyperglycemia, sepsis, specified organism, candidal esophagitis (fungal infection of the esophagus) and dysphagia (swallowing difficulty) following cerebral infection (stroke). The 6/30/26 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of nine out of 15. B. Resident #6's representative interviewResident #6's representative was interviewed on 8/12/26 at 11:46 a.m. Resident #6's representative said Resident #6 was started on a medication (GLP-1) for diabetes management without her permission or knowledge. She said the medication only aggravated his acid reflux and gave the resident a sense of pressure and fullness. She said the medication caused him to lose significant weight. The representative said was not informed of the use of the medication by his physician, the nurses or during the resident's care conferences. The representative said Resident #6 had sepsis and esophagitis caused by the resident often gagging himself and vomiting because he was trying to relieve the pressure in his stomach. She said she was not made aware of the resident's GLP-1 medication use until he went to the hospital on 6/13/26. She said she was told at the hospital that the medication was for diabetic management and the acid reflux and pressure in the resident's stomach could be a related side effect of the medication. She said the hospital took Resident #6 off of the medication. C. Record reviewThe 2/6/26 medication administration note identified Resident #6 was on the medication dulaglutide (a GLP-1) for diabetes. According to the note, the medication was not available on 2/6/26 because there was an insurance issue. The 2/12/26 nurse's note documented Resident #6 would start tirzepatide subcutaneous solution auto-injector (a GLP-1) one time a day every Friday for non-insulin-dependent diabetes mellitus (NIDDM) after the resident's current dulaglutide medication supply ran out, discontinuing the use of dulaglutide. The 2/13/26 medication administration note documented Resident #6's tirzepatide subcutaneous solution auto-injector would start on 2/13/26, when the medication arrived from the pharmacy.The 2/20/26 medication administration note documented dulaglutide subcutaneous solution auto-injector was not available due to the resident's insurance. According to the note, tirzepatide was administered as the replacement for dulaglutide. Review of Resident #6's June 2026 medication CPO revealed the following physician's order:Tirzepatide subcutaneous solution autoinjector 2.5 milligrams (mg)/0.5 milliliters (ml) for NIDDM, ordered date 2/13/26 and discontinued on 6/16/26. Review of Resident #6's weight log identified Resident #6 had a slow trend weight loss that resulted in a significant weight loss of 8% in three months on 5/8/26. A review of Resident #6's electronic medical record (EMR) did not identify that the resident or his representative were notified of the GLP-1 medication use for treatment of diabetes or that they were educated on the medication's potential side effects. review of Resident #6's progress notes revealed Resident #6 had a history of nausea and vomiting and behaviors of placing his fingers in his mouth to make himself gag and vomit. The 6/13/26 eInteract summary for providers note identified Resident #6 had a change of condition related to chest pain with emesis. The physician was notified and Resident #6 was sent to the emergency room for an evaluation and treatment.The 6/16/26 hospital discharge summary note identified Resident #6 was seen at the hospital for multiple diagnoses, including sepsis, inflammation of the esophagus and an esophageal yeast infection. According to the discharge summary, recommendations to the facility's primary care physician included discontinuing the resident's Mounjaro (tirzepatide) due to nausea, which caused the resident to make himself gag. The summary note indicated Mounjaro could be a contributing factor to the resident's nausea, especially if he had some degree of gastroparesis (slow digestion).III. Staff interviewsThe interim director on nursing (DON) was interviewed on 8/12/26 at 3:23 p.m. The interim DON said the use of a GLP-1 medication required a consultation with a physician and an indication for its use. She said there should be communication and a discussion with the resident/resident's representative for the medication. The interim DON said she did not find documentation of communication/discussion of a GLP-1 with Resident #6 or his representative in the resident's EMR. She said she would contact the resident's physician/primary care physician to see if he had any additional information. The interim DON and the regional clinic resource were interviewed together on 8/13/26 at 11:35 a.m. The interim DON and the regional clinic resource said the use of a GLP-1 medication for diabetic management should be assessed and monitored for side effects such as nausea, vomiting, stomachache and bloating. The interim DON said a GLP-1 medication decreased a person's appetite and provided them with a feeling of fullness.A voice message from Resident #6's primary care physician (when the resident resided at the the facility) was received on 8/13/26 at 1:29 p.m. The primary care physician said it was not standard for him to go over all side effects of a medication with a resident or a resident's representative in a long-term care setting due to the time he had available, but he said the risk and benefits of each medication were weighed out in his mind during the decision-making process. He said when there was an adverse outcome related to a medication, plans would be changed and the medication would be discontinued. He said Resident #6 was no longer on tirzepatide.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#7) of four residents reviewed for quality of care out of 13 sample residents.Specifically, the facility failed to respond in a timely manner to a change of condition for Resident #7.Findings include:I. Facility policy and procedureThe Provision of Quality Care policy, undated, was provided by the nursing home administrator (NHA) on [DATE] at 2:37 p.m. It read in pertinent part, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices.II. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included cerebral infarction (stroke) due to occlusion or stenosis of small artery, Parkinson's disease with dyskinesia (movement disorder) with fluctuations, dysphagia (swallowing difficulty) and vascular dementia, moderate with mood disturbance.The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. According to the MDS, the resident was dependent on staff for most of his activities of daily living (ADL). B. Resident representative interviewResident #7's representative was interviewed on [DATE] at 11:00 a.m. Resident #7's representative said she was contacted by the facility on [DATE]. She said she was told Resident #7 was unresponsive and not doing well. She said she drove to the facility and saw Resident #7 in a fetal position, grunting in pain and he had diarrhea. She said she asked the nurse if the facility had called for an ambulance and the nurse told her no because the resident had a DNR (do not resuscitate) status. The representative said the nurse told her they laid Resident #7 in bed and made him comfortable. She said she told the nurse that Resident #7's DNR status was for no CPR (cardiopulmonary resuscitation) or a ventilator. The representative said she told the nurse to call for an ambulance right away and he was sent to the hospital. She said Resident #7 was admitted to the hospital with pneumonia, sepsis, and his kidneys were not functioning well. She said she was told by a nurse at the hospital that going to the hospital saved Resident #7's life.C. Record reviewThe [DATE] advanced directive care plan, initiated [DATE], documented Resident #7 had a Physician Order For Life-Sustaining Treatment (POLST) with his DNR status. According to the care plan, the POLST for Resident #7's DNR status would be kept in his medical records at all times, staff would recognize Resident #7's wishes and follow as indicated and staff would notify the hospital/clinic/ambulance of the resident's wishes as indicated within HIPAA (Health Insurance Portability and Accountability Act) policy and procedures.The Medical Orders for Scope of Treatment (MOST) form, signed by Resident #7 on [DATE], documented that the resident did not want CPR, but indicated he wanted the medical interventions of selective treatment if he was breathing and had a pulse. According to the MOST form, the resident's selective treatment wishes included a hospital transfer if indicated. Review of Resident #7's [DATE] CPO revealed the following physician's order: DNR (do not resuscitate), no directions specified for the order, revised [DATE].-The physician's order did not indicate that the resident did not want to be transferred to the hospital if needed.The [DATE] nursing note documented a certified nurse aide (CNA) came to the nurse at 11:15 a.m. and told her Resident #7 was breathing, but he was not responding when he was called by his name. The note documented the nurse conducted an external rub on the resident's chest and there was no response. Resident #7's vital signs were taken, and his blood pressure was noted to be 103/65 mmHg (millimeters of mercury); his pulse was 76 beats per minute (bpm); his respiratory rate was 12 breaths per minute; his body temperature was 95.9 degrees Fahrenheit (F); his oxygen saturation levels (level of oxygen in the blood) were 93% on room air; and his blood sugar was 230 milligrams per deciliter (mg/dl). According to the progress note, the CNAs laid Resident #7 down in his bed and made him comfortable. The nurse spoke with the on-call physician who told the nurse to keep Resident #7 comfortable and conduct 15-minute checks on him. The note identified Resident #7's representative was notified and came to the facility. The note documentative the resident's representative saw Resident #7 and requested that he be sent to the emergency room. Resident #7 was transported by the paramedics to the hospital at 12:20 p.m. (on [DATE]) and the on-call physician was notified of the hospital transport. The note identified the resident's representatives and the director of nursing (DON) went to the hospital with Resident #7. -The review of the resident's electronic medical record (EMR) did not indicate treatment was provided to Resident #7 after he had a change in condition or his advance directive was initiated when the Resident #7 was identified to be unresponsive but breathing.The [DATE] hospital emergency department provider notes documented Resident #7 was sent the the emergency department from his facility for hypotension and altered mental status. The note documented the resident was hypotensive to the 70's systolic and had an improvement with his blood pressure and mentation with 500 milliliters (ml) bolus injection in route to the hospital. The note identified Resident #7 arrived at the hospital groaning, grimacing and unable to communicate with coherent speech or able to follow commands. The note indicated the resident was tachycardic, hypotension and had an altered mental status leading to concerns for sepsis etiology. The note documented the emergency department's provider's clinical impression was Resident #7 had sepsis, due to an unspecified organism, acute cystitis without hematuria (bladder infection) and altered mental status. The note documented the resident was critically ill due to his high probability of imminent deterioration in his condition. The [DATE] hospital inpatient provider note documented Resident #7 had severe sepsis on admission to the hospital with tachycardia (increased heart rate) and leukocytosis (high white blood cell count). The provider note summary documented Resident #7 had identified severe sepsis due to aspiration pneumonia. The note documented the resident's leukocytosis resolved, he was no longer having fevers and had completed his antibiotics. The [DATE] social services note documented Resident #7 did not want to return to the facility and transferred to another facility. III. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on [DATE] at 11:03 a.m. LPN #2 said if a resident had a change of condition, she would notify the physician, the director of nursing (DON) and the resident's representative. LPN #2 said a resident's MOST form informs the facility if the resident wanted CPR or not. She said a resident would not have CPR if the resident had a DNR code status and had no pulse. She said if the resident had selective treatment wishes on their MOST form and was actively breathing, she would send the resident to the hospital and notify the physician and the resident's representative. LPN #1 was interviewed on [DATE] at 1:13 p.m. LPN #1 said she was Resident #7's nurse on [DATE]. She said the resident had some breakfast in the morning and later that morning, a CNA found Resident #7 in the dining room slumped over in his wheelchair, at approximately 10:45 a.m. LPN #1 said the resident had a history of sleeping in his wheelchair. She said she determined he was not sleeping and was unresponsive instead. LPN #1 said Resident #7 was not making any noise but was moving around a bit. She said the staff placed him in bed and took his vital signs and made him comfortable. She said nothing was overly concerning with his vital signs, but she and two other nurses thought he was actively dying. She said said called the on-call physician and informed the physician of Resident #7's condition and that he was a DNR code status. LPN #1 said residents with a DNR code status should be kept comfortable and provided with any needed medications. She said residents with a full code status (yes for CPR) or selective treatment should go to the hospital. She said when a resident was unresponsive, she would look in the MOST form binder to confirm the resident's code status. LPN #1 said she looked in the MOST form binder on [DATE], but for some reason, Resident #7's MOST form was not in the binder with the other ones. LPN #1 said she started to panic because she could not find the resident's MOST form. She said by the time Resident #7's representative arrived at the facility, she was still looking for it. She said the representative said she wanted Resident #7 to go to the hospital so the paramedics were called and the resident was sent out to the hospital. LPN #1 said she found an older MOST form in Resident #7's electronic medical record (EMR) and printed it off to send with the resident to the hospital. She said she did not remember if the MOST form identified if the resident wanted selective treatment or not. LPN #1 said if she had seen the MOST form first and it indicated the resident wanted selective treatment, she would have had him go to hospital prior to his representative's request to send him out. The NHA was interviewed on [DATE] at 2:26 p.m. The NHA said Resident #7 had a change in condition on [DATE] and the facility called the on-call physician. He said the on-call physician told the nurse not to send Resident #7 to the hospital because of his DNR code status. The NHA said when the resident's representative arrived at the facility, she wanted him sent out to the hospital so the facility sent him to the hospital. The interim director of nursing (DON) was interviewed on [DATE] at 2:40 p.m. The interim DON said residents' MOST forms were reviewed on admission and quarterly to make sure the MOST form matched the physician's orders and effectively communicated the resident's wishes. The interim DON said the nurses' station had the hard copies of the MOST forms of each resident for quick reference and so the forms could be readily available to be sent out with the resident if the resident went to the hospital. The interim DON and the regional clinical resource were interviewed together on [DATE] at 3:23 p.m. The regional clinical resource said the treatment provided when Resident #7 had a change of condition/unresponsiveness was to make the resident comfortable, take his vital signs and call the physician. She said the physician told the nurse to monitor Resident #7. The regional clinical resource said monitoring could be a form of treatment. The regional clinical resource said LPN #1 felt Resident #7 was fine, based on his vital signs and she was monitoring him. The regional clinical resource said on paper, the resident looked stable. She said if a nurse saw more of a decline with a resident, the nurse would need to assess the resident, provide communication to the physician and notify the resident's representative. She said if a resident had selective treatment wishes, the nurse would offer to send the resident to the hospital unless there was prior documentation stating otherwise. The regional clinical resource said if a nurse was in a panic and did not check a resident's EMR for his selective treatment status and if she felt as though the resident was actively dying, the nurse would require additional education. A voice message from Resident #7's primary care physician (when the resident resided in the facility) was received on [DATE] at 5:51 p.m. The primary care physician said he was aware that Resident #7 became suddenly ill (on [DATE]) and then went to the hospital. The physician said he saw Resident #7 a week prior to his hospitalization and Resident #7 was doing quite well. He said overall, Resident #7 was very frail, had difficulty with secretions, had Parkinson's disease and may have aspirated. He said from what he understood, the nurse assessed him and called the on-call physician, who told the nurse to keep an eye on him. The primary care physician said the resident's representative later arrived at the facility and wanted the resident sent out to the hospital. The primary care physician said that was what he would have done as well. The primary care physician said Resident #7 could have had a change of condition and his condition deteriorated fast.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#1) of three residents reviewed for accident hazards out of nine sample residents.Specifically, the facility failed to ensure neurological assessments were completed after Resident #1's unwitnessed fall, which resulted in a head injury.Findings include:I. Facility policy and procedureThe Head Injury policy, revised October 2025, was provided by the nursing home administrator (NHA) on 6/16/26 at 4:15 p.m. It read in pertinent part, It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury. Assess residents following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: vital signs, general condition and appearance, neurological evaluation for changes in physical functioning, behavior, cognition, level of consciousness, dizziness, nausea, irritability, slurred speech or slow to answer questions, evaluation of the head, eyes, ears, and nose for significant changes in vision hearing, smell or bleeding, any injuries to head, neck, eyes, or face including lacerations, abrasions or bruising, pain assessment. Perform neurological checks as indicated or as specified by the physician.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included dementia, heart disease, malnutrition and dysphagia (difficulty swallowing).The 4/1/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required supervision from staff for eating, walking at least 10 feet and transfers and moderate assistance for hygiene, showering and dressing. B. Resident interview and observationOn 6/15/26 at 1:30 p.m. Resident #1 was walking in the hallway immediately outside of her room. Resident #1's skin had large yellow areas (bruises) on both of her cheeks and forehead, each at least three centimeters (cm) to four cm wide by three cm to four cm long. In the center of both yellow areas on each cheek was a small purple one cm by one cm area. Resident #1 said she could not remember well, but she said she had fallen one night. Resident #1 said she hurt her head and had head pain after she fell. C. Record reviewA nursing progress note, dated 5/23/26 at 3:09 a.m., documented that at 2:00 a.m., staff members heard a loud noise from Resident #1's room and found the resident lying on the floor next to her bed. It documented Resident #1 said when she stood up from bed, she lost her balance and fell. It documented a four cm by four cm hematoma (a collection of blood from an injury) with a small abrasion on the right side of her forehead. A document for Resident #1 titled Neurological Record was provided by the NHA on 6/16/26 at 12:45 p.m. The document revealed the following instructions: document the date and time of each assessment, including level of consciousness, pupil response, motor functions and hand grasps, extremities, pain response and vital signs. It documented the initial assessment was to be completed in the resident's electronic medical record (EMR), and then written (hard copy/paper) documentation every 15 minutes for one hour, every 30 minutes for two hours, every hour for two hours and then every shift for 72 hours. Initial assessments were documented on the form.Review of the Neurological Record for Resident #1 revealed complete written documentation of the neurological shift assessments was missing at the following times following the resident's fall on 5/23/25:-On 5/24/26, the day shift and evening shift assessments did not include documentation for Resident #1's level of consciousness , pupil response, hand grasps, motor response and pain response and it was not signed by the nurse.-On 5/24/26, the night shift assessment documented Resident #1 refused pupil response and motor assessments, however, there was no documentation in the EMR that the physician was notified of Resident #1's refusal of these assessments.-On 5/25/26, the day shift and evening shift assessments did not include documentation for Resident #1's level of consciousness, pupil response, hand grasps, motor response and pain response.-On 5/25/26, the night shift assessment documented Resident #1 refused pupil response and motor assessments, however, there was no documentation in the EMR that the physician was notified of Resident #1's refusal of these assessments. -On 5/26/26, the day shift assessment did not include documentation for Resident #1's level of consciousness, pupil response, hand grasps, motor response and pain response.A nursing progress note, dated 5/26/26 at 2:05 p.m., documented Resident #1 had worsening confusion, inability to walk, headache and dizziness and was unable to lay flat. It documented that she was responsive to questions. Physician's orders were received and Resident #1 was transferred to the hospital.III. Staff interviewsThe director of nursing (DON) was interviewed on 6/16/26 at 2:50 p.m. The DON said the physician was notified of Resident #1's fall on 5/23/26. The DON said after Resident #1 was transferred to the hospital on 5/26/26, she (the DON) reviewed the documentation for Resident #1's neurological assessments and found there was missing documentation of the assessments. The DON said each scheduled neurological assessment should have been completed and the physician notified if Resident #1 refused assessments at any time. The DON said she had not met with licensed practical nurse (LPN) #2 to review the missed documentation of Resident #1's neurological assessment. The DON said she reviewed the missed documentation and provided education to RN #1 and certified nurse aide with medication authority (CNA-Med) #1. The DON said education was provided to all nursing staff to ensure neurological assessments were completed and documented, however, she had not reinforced education for contacting the physician if residents refused any part of the neurological assessments.Registered nurse (RN) #2 was interviewed on 6/16/26 at 6:20 p.m. RN #2 said he was Resident #1's nurse on the night she fell (on 5/23/26). RN #2 said after the fall, Resident #1 had a large hematoma on the right side of her head. RN #2 said Resident #1 told him that she stood up and her legs gave out. RN #2 said he contacted the physician and began neurological checks per the facility's protocol.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to serve the residents meals at appropriate temperatures. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/28/26. It revealed in pertinent part, Time/Temperature control for safety food shall be maintained at 135 degrees F (Fahrenheit) or above and 41 degrees F or less. (3-501.16 ) II. Facility policy and procedureThe Food Preparation and Service policy, revised November 2022, was provided by the nursing home administrator (NHA) on 4/22/26 at 6:11 p.m. The policy read in pertinent part, When verifying food temperatures, staff use a thermometer which is both clean, sanitized, and calibrated to ensure accuracy. The danger zone for food temperatures is above 41 degrees F and below 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous food (PHF) must be maintained at or below 41 degrees F or at or above 135 degrees F. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after four hours. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff.III. ObservationsDuring a continuous observation of the lunch meal service on 4/22/26, beginning at 10:45 a.m. and ending at 12:01 p.m., the following was observed:At 10:48 a.m. four plates were already assembled with salad chicken and hawaiian roll each ready to be placed on the meal cart.At 10:49 a.m. the dietary manager (DM) started checking temperatures of food lined up on the steam table ready for the meal service. The following temperatures were recorded:-The chicken salad was 55 degrees F-The soft and bite chicken salad was 55 degrees F-The pureed chicken salad was 45 degrees FAt 10:53 a.m. cook (CK) #1 placed the four plates assembled onto the meal cart.At 10:54 a.m. CK #1 resumed assembling meal plates with wedge chicken salad and a hawaiian roll.-CK #1 continued assembling meal plates with wedge chicken salad at an inappropriate holding temperature. IV. Resident interviewResident #1 was interviewed on 4/22/26 at 9:45 a.m. Resident #1 said he ate his meals in his room and they were always cold when delivered. Resident #1 said he did not eat them and tried to buy food from outside of the facility.V. Record reviewReview of the April 2026 food temperature log revealed the following;-Temperatures were not documented during breakfast service on 4/1/26, 4/2/26, 4/3/26, 4/4/26, 4/5/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/18/26 and 4/19/26-Temperatures were not documented during lunch service on 4/1/26, 4/2/26, 4/3/26, 4/4/26, 4/5/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/18/26 and 4/19/26-Temperatures were not documented during dinner service on 4/5/26, 4/6/26, 4/7/26, 4/12/26, 4/13/26, 4/14/26 and 4/19/26.VI. Staff interviewsCK #1 was interviewed on 4/22/26 at 3:55 p.m. CK #1 said she checked the food temperatures after cooking. She said she verified the temperatures on the steam table prior to meal service to ensure the food remained at proper holding temperatures. CK #1 said she documented the temperature checks in the food temperature log. She said the holding temperature should be 38 degrees F or lower for cold food and 165 degrees F or higher for hot food. CK #1 said if the food was not the proper temperature, she would reheat the hot food and put the cold food in the fridge. She said to maintain proper holding temperatures at the steam table, she ensured there was enough ice in the pan for cold food. For hot food, she ensured the water level was properly maintained so the pan remained submerged in water. CK #1 said she should not have served the wedge chicken salad at a holding temperature of 55 degrees F due to the potential risk of foodborne illness to residents. She said she placed ice in the pan but the room was very hot without adequate ventilation.The DM was interviewed on 4/22/26 at 4:05 p.m. The DM said the cook checked the food temperatures after removal from the oven and prior to the meal service. He said hot food such as chicken and turkey should be held at 165 degrees F or higher, and beef at 155 degrees F or higher. The DM said cold food should be held at 40 degrees F or below. He said the wedge chicken salad should not have a holding temperature of 55 degrees F. The DM said the April 2026 food temperature log was not consistently completed correctly as cooks sometimes forgot to fill it out. The DM said he had provided education to the cooks regarding proper temperature monitoring and documentation.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to:-Contact the physician for clarification on what type of precaution Resident #3 needed; and,-Communicate the precautions to the staff clarify and communicate Resident #3's isolation precautions. I. Facility policy and procedure The Multidrug-Resistant Organisms policy, dated December 2024, was received from the nursing home administrator (NHA) on 4/22/26 at 6:11 p.m. It read in pertinent part, Multidrug-resistant organisms (MDROs) are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs. Infection means the organism is present and is causing illness. Colonization means that the organism is present in or on the body but is not causing illness. The following strategies are based on current recommendations for MDRO prevention and control: Implement systems to designate residents known to be colonized or infected with a targeted MDRO and to notify receiving healthcare facilities or personnel prior to transfer of such residents within or between facilities. Implement Contact Precautions (CP) routinely for all residents colonized or infected with a targeted MDRO. When active surveillance cultures are obtained as part of an intensified MDRO control program, implement contact precautions until the surveillance culture is reported negative for the targeted MDRO. Implement Enhanced Barrier Precautions for certain MDRO-colonized/infected residents whose site of colonization or infection can be appropriately contained and who can observe good hand hygiene practices.II. Record reviewReview of Resident #3's April 2026 computerized physician orders (CPO) revealed the following physician's orders:-Isolation Precautions: Isolation with: Contact precautions related to MDRO (GI), ordered on 3/23/36.-Enhanced Barrier Precautions (EBP): Gown and Glove use during all high-contact resident care or activities due to MDRO, ordered 3/26/26. Review of Resident #3's comprehensive care plan did not reveal what type of isolation precautions the resident was on. The communication note, documented on 4/22/26 at 6:14 p.m. revealed the director of nursing (DON) contacted the physician. The note revealed Resident #3 had a history of respiratory MDRO and the physician said enhanced barrier precautions (EBP) were sufficient at that time.-The facility failed to contact the physician for clarification on what type of precaution the resident needed when there were two different physician ordered precautions and failed to communicate the precautions to the staff.III. ObservationsOn 4/22/26 at 2:26 p.m. Resident #3's room was observed. There was not an EBP or contact precaution signs on the door or surrounding area.On 4/22/26 at 4:29 p.m. Resident #3's room was observed. There was not an EBP or contact precaution signs on the door or surrounding area. -Interviews revealed it was the facility's process to place a sign on the resident's door to indicate what precautions the resident was on (see interviews below)IV. Staff interviewsCNA #2 was interviewed on 4/22/26 at 1:56 p.m. CNA #2 said the staff used to have to wear a gown and gloves in Resident #3's room. She said Resident bt #2 did not have MDRO anymore, so the staff did not need to wear PPE. CNA #2 said staff were told they only had to worry when Resident #2 had a cold. CNA #2 said a previous nurse, who was no longer at the facility, said the MDRO was in Resident #3's feces and urine. -However, Resident #3 still required EBP.Licensed practical nurse (LPN) #1 was interviewed on 4/22/26 at 2:19 p.m. LPN #1 said it was not required to wear PPE when providing care to Resident #3. LPN #1 said she was not aware of any infection he had. LPN #1 said if residents required contact precautions, there would be an order for it in the system.CNA #1 was interviewed on 4/22/26 at 4:42 p.m. CNA #1 said Resident #3 moved rooms at some point. CNA #1 said earlier that day (4/22/26), Resident #3 was then moved back to his original room. CNA #1 said that when Resident #3 first got to the facility, he had isolation precautions and PPE hanging on the outside of his door for staff to put on before going into the room. CNA #1 said once Resident #3 moved to his new room, she did not know what happened to the signs and PPE that he previously had on his door. CNA #1 said she did not know whether or not Resident #3 had contact or EBP precautions signs or PPE on his door at the time of the interview. CNA #1 said she thought Resident #1 had MDRO in his urine. CNA #1 said she wore a gown and gloves when assisting Resident #3 in the bathroom.LPN #1 was interviewed again on 4/22/26 at 4:22 p.m. LPN #1 said she looked at the order and saw there were two orders which showed both EBP and contact precautions. LPN #1 said normally the medication administration record (MAR) or treatment administration record (TAR), would alert nurses if residents should have been on precautions. LPN #1 said nothing popped up on the MAR or TAR to notify her that Resident #3 had isolation precautions so she was not aware he needed them. LPN #1 said no one told her about required precautions in morning report. LPN #1 used the computer and navigated to Resident #3's orders. LPN #1 said there were two orders for isolation precautions. She said the order directed staff to utilize EBPs and one called for contact precautions related to MDRO (GI). LPN #1 said she did not know which to use so she would follow up with the director of nursing (DON) and physician to figure out what to do. LPN #1 said she was not sure who implemented precautions at the facility. LPN #1 said she had not reached out to the physician or the DON at that point.The DON and regional clinical resource were interviewed together on 4/22/26 at 6:20 p.m. The DON said the housekeeping director was responsible for placing isolation signage and PPE equipment on resident's doors. The DON said once the housekeeping director was made aware of a new admission who required PPE, they would place signage and PPE on the resident's door to be used. The DON said if a resident had isolation precautions, there should be a care plan related to that topic. The DON said if the resident moved rooms, the signage and PPE equipment should still be implemented at the new room. The DON said in order for precautions to be discontinued, there would need to be a physician's note indicating that the resident no longer had symptoms or required isolation precautions. The DON said negative lab results would also be needed to discontinue precautions.The DON said the electronic medical record indicated Resident #3 had MDRO in the sputum. The DON said staff should have been wearing PPE during cares for Resident #3. The DON said CNAs were informed about precautions through shift change and reports to one another. The DON said nurses were made aware of precautions through doctor's orders. The regional clinical resource said nurses also received reports from one another and the MAR also alerted nurses of precautions.The DON said she clarified with the medical director and concluded that Resident #3 should be on EBP precautions. The DON said the contact precautions order was discontinued. The DON said they checked to see what precautions were on Resident #3's door and said unfortunately there was no PPE or signage indicating Resident #3 was on precautions. The DON said there should have been signs on the door and that is how the facility identified isolation precautions. The DON said staff would immediately implement EBPs. The DON said the facility would also create a care plan related to Resident #3's MDRO and EBPs.

Based on observations, record review and interviews, the facility failed to ensure two (#5, and #8) of six residents reviewed out of 13 sample residents were kept free from resident-to-resident physical abuse.Specifically the facility failed to: -Protect Resident #8 from physical abuse by Resident #14; and, -Protect Resident #5 from physical abuse by Resident #9. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and Procedure, revised April 2021, was provided by the nursing home administrator (NHA) via email on 2/19/26 at 2:15 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff; other residents; consultants; volunteers; staff from other agencies; family members; legal representatives; friends; visitors; and/or any other individual. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities; provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; instruct staff regarding appropriate ways to address interpersonal conflicts; and help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.II. Incident of physical abuse by Resident #14 towards Resident #8 on 1/31/26A. Facility investigationThe facility abuse investigation report was provided by the NHA on 2/17/26 at 5:15 p.m.The investigation documented the date of the incident as 1/31/26 at 11:00 p.m.The investigation revealed that Resident #14 made contact with Resident #8 with a coke can to the side of Resident #8's face. This took place in the men's secured unit dining area. The residents were separated and placed on frequent monitoring by the facility. The police, the physician and all appropriate parties were notified.The investigation documented Resident #8 had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. Resident #8 had a history of behavioral issues related to dementia . The investigation documented Resident #14 was cognitively intact with a BIMS score of 14 out of 15 and had a history of behavioral issues related to dementia. The incident was not witnessed by staff. The victim (Resident #8) was evaluated for changes in condition and assessed by a nurse on 2/1/26. Resident #8 sustained a skin tear to the left corner of the eye and was treated. The physician recommended to monitor the laceration and bruising to the left eye area every shift for three days. The investigation documented Resident #8 was interviewed and said Resident #14 did not like him doing the trash, so Resident #14 hit him in the face. The investigation documented the facility attempted to interview Resident #14 twice, but the resident refused to talk or engage. Resident #14 stated he would not talk about it.The investigation documented abuse questionnaires were completed for other residents stating they felt safe in the facility.The investigation documented Resident #8 was placed on 15-minute checks and was offered psychosocial support.The investigation documented Resident #14 was placed on 15-minute checks. The resident's care plan was reviewed by the interdisciplinary (IDT) team. The resident was offered psychosocial support. The resident's medication regimen was to be reviewed for any potential changes.-However there were no updates to Resident #14's behavioral care plan to prevent further recurrence (see record review below). The investigation documented the incident was to be discussed in QAPI (quality assurance and performance improvement) to identify potential changes that could have been implemented to prevent a recurrence.The investigation documented contact was made between the residents and the abuse allegation was substantiated. B. Resident #14 (assailant) 1. Resident statusResident #14, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, type 1 diabetes mellitus, anxiety disorder and heart failure.The 12/17/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required supervision or touching assistance for toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, rolling left and right, sitting to lying, sitting to stand, chair to bed transfers, toilet transfers, and walking. He required setup or clean up assistance with eating. The assessment revealed he had potential indicators of psychosis, including delusions. He had behavioral symptoms including physical behavioral symptoms directed toward others four to six days per week, verbal behaviors one to three days per week, and other behavioral symptoms not directed toward others one to three days per week. He had rejection of care behaviors one to three days per week.2. Record reviewResident #14's behavioral care plan, revised 1/31/26, revealed the resident was involved in an altercation on 1/31/26. The care plan documented the residents were separated and assessed for acute injury. Interventions included the staff de-escalated Resident #14's aggressive mood by returning with him to his room, initiated 1/31/26. -However there were no preventative interventions to prevent a recurrence. The 1/31/26 at 11:30 p.m. IDT behavior note, documented as a late entry, revealed Resident #14 was found in the dining room with a crushed soda can in his hand. The note documented he stated he had hit Resident #8 for trying to take it from him. The note documented the residents were separated and assessed for acute injury. The staff de-escalated Resident #14's aggressive mood by returning with him to his room. The physician, power of attorney (POA) and leadership were notified. The note documented the risk factors included dementia, history of aggression and medications.C. Resident #8 (victim)1. Resident statusResident #8, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2026 CPO, diagnoses included dementia with behavioral disturbance, anxiety disorder, chronic obstructive pulmonary disease (COPD) and congestive heart failure. The 2/4/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. He required setup or clean-up assistance with eating, toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, rolling left and right, sit to stand transfers, bed to chair transfers, and use of manual wheelchair.The assessment revealed he had potential indicators of psychosis including delusions. He had no behavioral symptoms, rejection of care or wandering according to the assessment.2. Record reviewResident #8's behavioral care plan, revised 4/7/23, revealed he had behavioral issues related to his dementia. Pertinent interventions included providing the opportunity for positive interaction and attention by stopping and talking with him as passing by, monitoring behavior episodes and attempting to determine the underlying cause, considering the location, time of day, persons involved, and situations, documenting behavior and potential causes and the residents feelings and reported concerns.The 1/31/26 at 11:30 p.m. IDT note, documented as a late entry, revealed Resident #8 was struck in the left eye with a soda can by another resident who thought that Resident #8 was trying to take his soda. Interventions included the residents were separated and assessed for acute injury. Resident #8 had a small cut to the left outside corner of his eye; the wound was cleaned and patted dry. The POA and administration were notified. The note documented risk factors included Resident #8 said he was not trying to take the soda can and did not know why he was struck.D. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/19/26 at 10:15 a.m. CNA #1 said she worked on the men's secured unit, where Resident # 8 and Resident #14 resided. CNA #1 said she was informed about the altercation between Resident #8 and Resident #14 and that Resident #14 had smashed his soda into the face of Resident #8 unprovoked. CNA #1 said the staff had not been provided with any new prevention techniques or interventions to apply to Resident #14's behaviors to prevent a recurrence.CNA #2 was interviewed on 2/19/26 at 10:25 a.m. CNA #2 said she worked on the men's secured unit. CNA #2 said she was told about the altercation between Resident #8 and Resident #14, so that she could be aware to keep them separated. CNA #2 said that Resident #14 had hit Resident #8 with a soda can in his face. CNA #2 said the only prevention she could think of was to try to keep the two residents separated and she had not been told of anything else. III. Incident of physical abuse by Resident #9 towards Resident #5 on 2/10/26A. Facility investigationThe facility abuse investigation report was provided by the NHA on 2/17/26 at 5:15 p.m.The investigation documented the date of the incident as 2/10/26 at 3:30 p.m.The investigation revealed that at approximately 3:00 p.m. Resident #9 was wandering/walking past Resident #5's room in the hallway of the men's secured unit. At this point, the residents both got verbally aggressive with each other. This led to Resident #9 making contact with Resident #5's head. The residents were immediately separated from each other during the course of the investigation. The residents were placed on frequent monitoring. Both residents were evaluated for any changes in condition from the altercation. The police, the physician and all appropriate parties were notified. -However there were no updated interventions to prevent further recurrence. Resident #5's BIMS score was a 13 out of 15 and the resident had no history of behaviors.Resident #9 had severe cognitive impairments and had a history of behaviors. The investigation documented the resident had a history of verbal aggression toward staff and may become resistant to cares. The investigation documented the behaviors may be triggered by feeling rushed, loss of control, unfamiliar staff, changes in routine, or unmet needs. The investigation documented without appropriate interventions, behaviors may escalate and place Resident #9 and others at risk.The investigation documented the incident was not witnessed by staff. Resident #5 was evaluated for changes in condition and assessed by a nurse immediately. There were no signs or symptoms of injury noted, no redness, bruising, or skin injury. Resident #5 denied pain. Resident #5 appeared well and at baseline.Resident #5 was interviewed outside his room in the hallway. He said Resident #9 cussed at him. Resident #5 said he told Resident #9 not to speak to him that way and he had never done anything to him. Then Resident #9 hit Resident #5, causing Resident #9 to fall. Resident #5 said he called out for help and the staff was there immediately to help separate them. Resident #5 said he knew that Resident #9 just needed help and was not angry with him. Resident #5 said he felt safe and well cared for and supported. Resident #9 was interviewed and was unable to answer questions. The investigation documented the resident appeared to be confused. Resident #9 was provided with psychosocial support, and physical assessment with no injuries noted.The investigation documented abuse questionnaires were completed for other residents stating they felt safe in the facility.The investigation documented Resident #5 was placed on 15-minute checks and was offered psychosocial support.The investigation documented Resident #9 was placed on 15-minute checks. The resident's care plan was reviewed by the IDT team. The resident offered psychosocial support. The investigation documented the resident's medication regimen to be reviewed for any potential changes.-However there were no updates to Resident #9's behavioral care plan to prevent further recurrence. The investigation documented the incident to be discussed in QAPI to identify potential changes that could have been implemented to prevent a recurrence.The investigation documented the facility determined that contact was made between the residents.B. Resident #9 (assailant) 1. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included vascular dementia, severe, with behavioral disturbance, insomnia and pulmonary embolism. The 1/21/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. He required substantial/maximal assistance with shower/bathing. He required partial/moderate assistance with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. He required supervision or touching assistance with rolling left and right, sitting to lying, sitting to standing, chair to bed transfers, toilet transfers, eating, and walking.The assessment revealed he had potential indicators of psychosis including delusions. He had no behavioral symptoms, rejection of care or wandering according to the assessment.2. Record reviewReview of Resident #9's behavior toward staff care plan, revised 1/8/26, revealed the resident had a history of physical and verbal aggression toward staff and may become resistant to care. The care plan documented without appropriate interventions, behaviors may escalate and place Resident #9 and others at risk. Pertinent interventions included care in pairs. If resistant to care, ensure his safety and approach at a later time. Request sent for psychiatric medication review to psychiatric nurse practitioner (NP) and psychiatrist, initiated 2/17/26 (during survey).-Review of the comprehensive care plan did not reveal a care plan focus for the resident's behaviors directed towards other residents. The 2/10/26 at 3:49 p.m. IDT behavior note, documented as a late entry, revealed Resident #9 was hit by another resident (Resident #5) in the hallway. The note documented the nurse checked on both resident's right away and staff members had already separated both of the residents. The note documented the interventions documented vital signs were initiated and within normal baseline limits and a neurological assessment was done with no abnormal findings noted at this time. The resident's emergency contact, the physician and the NHA were notified. The note documented the risk factors included a history of aggressive behavior, medications and dementia diagnosis.The 2/10/26 at 7:12 p.m. nurse note revealed that at 3:30 p.m. the nurse was notified by the certified nurse aide with medication authority (CNA-Med) that this resident was hit by another resident in the hallway. The nurse went to check on both residents right away and staff members had already separated both residents. Resident #9 refused to answer any questions. The nurse assessed the resident for injuries and notified the director of nursing (DON) for a head to toe assessment, vital signs were initiated and within normal baseline, a neurological assessment was done with no abnormality noted at this time. The resident's emergency contact was notified, and the physician and NHA were notified.The 2/11/26 at 4:33 p.m. nurse note revealed the resident received physical aggression. Staff were monitoring the resident's vital signs and neurological assessments were within normal baseline limits. The resident denied pain.-Resident #9's progress notes indicated that Resident #9 was hit by Resident #5. However, the facility investigation indicated that only Resident #5 was hit.C. Resident #5 (victim)1. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included fracture of left forearm, type 2 diabetes mellitus, dementia with behavioral disturbance and bipolar disorder. The 1/16/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. He was dependent for lower body dressing. He required substantial/maximal assistance for toilet transfers, shower transfers, shower/bathing, toileting hygiene, upper body dressing and for wheeling manual wheelchair. He required partial/moderate assistance with oral hygiene and personal hygiene. He required supervision/touching assistance for sit to stand transfers and chair to bed transfers. The assessment documented he had no behavioral symptoms, rejection of care or wandering according to the assessment.2. Record reviewResident #5's behavioral care plan, initiated 2/17/26 (during the survey), revealed the resident exhibited and was at risk for behavioral symptoms due to bipolar disorder and dementia with behavioral disturbance. Pertinent interventions included providing activities assessment for diversional activities, anticipating the resident's needs and meeting promptly, documenting and recording behavioral episodes, encouraging the resident to verbalize his feelings, obtaining psychiatric consultation as indicated, sending a referral for counseling services. The 2/10/26 at 6:44 p.m. nurse note revealed that at 3:30 p.m. the nurse was notified by the CNA-Med that this resident was hitting another resident (Resident #5) in the hallway. The nurse went to check on both residents right away and staff members had already separated them. When the resident was asked, he said the other resident cursed bad words to him and he hit him on his face. The writer assessed the resident for injuries and notified the DON for a head to toe assessment, vital signs were initiated and within normal baseline limits, a neurological assessment was done with no abnormality noted. The resident's emergency contact, physician and the NHA were notified.The 2/11/26 at 10:01 a.m. IDT behavioral note, documented as a late entry, revealed Resident #9 was wandering past Resident #5's room and they were verbally aggressive with each other, causing Resident #9 to strike out at Resident #5 and making contact with his head. The note documented the residents were separated, assessed and placed on 15-minute checks. Resident #9 was assisted to his room. D. Staff interviewsCNA #1 was interviewed on 2/19/26 at 10:17 a.m. CNA #1 said of all the residents in the men's secured unit, Resident # 9 was very mean and she was a little scared of him. CNA #1 she was told about the altercation between Resident #5 and Resident #9. CNA #1 said she did not know if both residents were hit or just Resident #5 but that Resident #9 ended up on the floor. CNA #2 was interviewed on 2/19/26 at 10:28 a.m. CNA #2 said she was told about the altercation between Resident #9 and Resident #5 and that Resident #9 had hit Resident #5 in the face. CNA #2 said she was not sure how Resident #9 ended up on the floor. CNA #2 said she was not given any techniques to prevent a further recurrence other than to watch and keep them separated. IV. Additional staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 2/19/26 at 10:32 a.m. LPN #1 said she had not worked on the men's unit for a while so she had not been informed about any of the resident-to-resident altercations that had occurred recently. LPN #1 said it probably would be a good idea to know so that she could watch out and keep certain residents apart or be aware of any interventions.The NHA, the DON and the social services assistant (SSA) were interviewed together on 2/19/26 at 12:15 p.m. The NHA said a QAPI meeting was held on 2/10/26 and the next one would be held on 3/10/26. The NHA said the facility normally went through all reportable incidents and discussed them at the QAPI meetings. The NHA said they had not discussed the 2/10/26 incident in QAPI yet between Resident #5 and Resident #9 but would do so at the 3/10/26 meeting. The NHA said the process for an abuse investigation consisted of reporting to him (the abuse coordinator), he would report to the State agency, and then begin an investigation. The NHA said the facility had a risk management report that the nurse completed and then it was discussed with IDT. The DON said she filled out the IDT notes but she did not not understand the intervention section and had thought it was for immediate intervention and not done to prevent a recurrence. The NHA said in January 2026 the facility did a root cause analysis for the men's unit to try to decrease incidents and decided to make more space in the hallways. The DON said there was no root cause analysis section on each individual IDT note, so no root cause analysis was being done after each incident to determine the preventative intervention. The DON said the care plans could be updated from the IDT notes, but since the IDT notes only documented the immediate interventions, the care plans were not being updated with interventions to prevent a recurrence. The DON said it would be better to determine a preventative intervention based on a root cause and then she could get appropriate interventions that matched and then evaluate the effectiveness of the interventions. The NHA said there should be updates added to the care plan after each incident to help prevent a recurrence of abuse at least within five days, or sooner to prevent a recurrence.The NHA said with the incident between Resident #5 and Resident #9, Resident #9 had wandered through the hallway and passed Resident #5's room and started arguing with him, Resident #9 made contact with Resident #5 and then Resident #9 lost his balance and fell. The NHA said following this incident, Resident #9's care plan should have had an updated approach to prevent recurrence and protect the residents, but acknowledged it had not been done. The NHA said the social services department would be responsible for updating the care plans after an incident. The NHA and the DON said they were not aware that Resident #9's behavioral care plan was only for behaviors toward staff and that there should be a care plan added that would address physical and verbal aggression toward residents. The DON said for the incidents with Resident #8 and Resident #14, she had only put in the immediate interventions on the IDT note, which included that the residents were separated and assessed for acute injury and staff de-escalated Resident #14's aggressive mood by returning him to his room. The DON said no further abuse prevention interventions were added to Resident #14's care plan because she did not know she needed to add anything other than the immediate actions taken. The NHA said that Resident #14 had hit Resident #8 in the head with a soda can. The NHA said the facility would do a lot better at making sure interventions were specific to the residents in preventing a recurrence beyond the immediate deescalation. The DON said she would make the time to get to the risk management reports sooner and complete the IDT notes to get the interventions in place to prevent a recurrence and also educate the staff as well to check the care plan to prevent further occurrences. The NHA said the facility would do an audit from all the incident cases from January 2026 and February 2026 and add late interventions to prevent further occurrences. The NHA said the social services department would be responsible for adding all of the preventative interventions.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards. Specifically, the facility failed to:-Ensure medication and treatment carts was kept locked when not being monitored by nursing staff;-Ensure residents' medications were stored in a locked cabinet when not being monitored by the medication administration nurse; and,-Ensure residents' medications were not prepoured into medication cups, stacked on top of one another on the medication cart and left unattended in a common area of the facility.Findings include:I. Facility policy and procedureThe facility policy for medication storage was requested on 1/22/26 at 3:48 p.m., however, the policy was not provided by the end of the survey on 1/22/26. II. ObservationsOn 1/20/26, from 1:00 p.m. to 2:00 p.m., and again on 1/21/26, from 9:48 a.m. to 11:20 a.m., the treatment cart closest to the front entrance was observed to be unlocked and unmonitored by nursing staff.On 1/22/26, from 12:15 p.m. to 12:30 p.m., the medication cart was observed to be unlocked. The assigned medication nurse, registered nurse (RN) #1, was not in sight of the medication cart. On top of the medication cart was a prefilled insulin syringe and several paper medication cups labeled with different residents' names. Each of the medication cups contained residents' medication. Each paper medication cup was stacked on top of each other so that the bottom of the cup was touching the surface of another resident's medication. In addition, there was a plastic medication cup containing an unknown medication at the top of the stack of prepoured medication cups. The director of nursing (DON) was notified of the concern when the medication administration nurse did not return to the cart for an extended period of time. The DON immediately called for RN #1 to return to the medication cart and educated RN #1 on proper medication administration and storage. The DON talked to RN #1 regarding unattended medications and RN #1 was brought to the medication cart and shown the unsecured medications. RN #1 said she had just left the cart unattended to go into the supply room. The DON informed RN #1 that leaving medications on top of a medication cart was unacceptable.On 1/22/26 at 2:55 p.m. the treatment cart closest to the front entrance was observed to be unlocked and unmonitored by RN #1.III. Staff InterviewsLicensed practical nurse (LPN) #2 was interviewed on 1/22/26 at 3:00 p.m. LPN #2 said both the treatment and the medication carts should be kept locked when not being monitored by the floor nurse. He showed the contents of the treatment cart, which included wound care supplies and prescription medications. LPN #2 said he had the keys to the cart if he needed something out of it and then locked the cart and said it was to be locked at all times. The DON was interviewed on 1/22/26 at 1:35 p.m. The DON said the expectation was for the nurses to keep the medication and treatment carts locked when not being accessed by the nurse. The DON said prepouring of medications was not allowed. The DON said all nursing staff would receive education on the expectation for proper medication storage.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection.Specifically, the facility failed to follow proper infection control practices during wound care for Resident #4.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Guideline For Hand Hygiene In Health Care Settings, (2/27/24) retrieved on 2/3/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety, Efficacy of Promotion and Impact of Improved Hand Hygiene: evidence supports the belief that improved hand hygiene can reduce health-care-associated infection rates. Failure to perform appropriate hand hygiene is considered the leading cause of health-care-associated infections and spread of multiresistant organisms and has been recognized as a substantial contributor to outbreaks.II. ObservationsOn 1/22/26 at 10:00 a.m. licensed practical nurse (LPN) #1 was observed performing wound care for Resident #4. The following was observed: LPN #1 gathered and brought all wound care supplies and the physician's order for wound care from the resident's chart into Resident #4's room. -LPN #1 did not perform hand hygiene before opening the facility's treatment cart, touching the treatment supplies and bringing the wound care supplies to the resident's room. LPN #1 placed the wound care supplies on top of Resident #4's bedside table. -LPN #1 did not sanitize the table's surface prior to laying out and setting up the wound care treatment supplies on top of the table. -LPN #1 placed the wound care scissors obtained from the wound care cart on Resident #4's bedside table without sanitizing the wound care scissors LPN#1 proceeded to put on gloves without performing hand hygiene and removed Resident #4's wound dressing. The wound dressing was slightly soiled with yellow discharge from the wound. After removing Resident #4's old wound dressing, LPN#1 opened a bottle of sterile saline with the same soiled gloves she removed the old dressing with and set the bottle on the unclean bedside table. -LPN #1 did not perform hand hygiene prior to opening the bottle of saline. After handling the saline bottle, LPN #1 removed her soiled gloves, but did not perform hand hygiene. LPN #1 proceeded to reach into the box of clean unused gloves (without performing hand hygiene) and pulled out a new pair of gloves. LPN #1 put on the new pair of gloves without performing hand hygiene.After putting on the new pair of gloves, LPN #1 proceeded to pour saline on a clean gauze pad to clean Resident #4's open wound. LPN #1 picked up the wound care scissors from the resident's soiled bedside table and used the scissors to cut an antimicrobial dressing material that she then placed onto Resident #4's open wound. -LPN #1 did not sanitize the wound care scissors prior to cutting the antimicrobial dressing and putting it onto the resident's wound.LPN #1 next applied an ointment to Resident #4's wound and covered the wound with a foam covered bandage, an ace wrap and a hard plastic brace. LPN#1 proceeded to wrap the brace and the resident's arm with another ace bandage and cut off the velcro with the unsanitized scissors. III. Staff interviewsThe director of nursing (DON) was interviewed on 1/22/26 at 1:35 p.m. The DON said poor wound care practices were not acceptable and she would educate the nursing staff on proper infection control practices when performing wound care.

Based on record review and interviews, the facility failed to ensure seven (#16, #17, #19, #8, #4, #18 and #11) of 17 residents reviewed for abuse out of 18 sample residents were kept free from abuse.Specifically, the facility failed to:-Ensure Resident #16 and Resident #17 were kept free from physical abuse toward each other on 6/7/25;-Ensure Resident #17 was kept free from physical abuse by Resident #19 on 7/29/25;-Ensure Resident #8 was kept free from physical abuse by Resident #17 on 8/14/25;-Ensure Resident #17 was kept free from physical abuse by Resident #19 on 8/31/25;-Ensure Resident #19 and Resident #17 were kept free from physical abuse toward each other on 9/17/25;-Ensure Resident #4 was kept free from physical abuse by Resident #5 on 6/18/25;-Ensure Resident #18 was kept free from physical abuse by Resident #5 on 8/10/25; and,-Ensure Resident #11 was kept free from physical abuse by Resident #12 on 7/9/25.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention policy, revised 4/1/25, was provided by the nursing home administrator (NHA) on 10/2/25 at 3:57 p.m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff, other residents, friends, any other individuals, legal representatives and visitors. Develop and Implement policies and protocols to prevent and identify abuse or mistreatment of residence. Ensure adequate staffing and oversight to prevent burnout, stress working situations and high turnover rates. Identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of Resident property.I. Incidents of physical abuse involving Resident #17A. Incident of physical abuse between Resident #16 and Resident #17 on 6/7/251. Facility investigationThe facility investigation, dated 6/7/25, was provided by the nursing home administrator (NHA) on 9/30/25 at 4:30 p.m. The investigation revealed the following:On 6/7/25 Resident #17 wandered into Resident #16's room, at which point the residents began arguing with each other. Resident #17 struck Resident #16 in the chest. Resident #16 then threw his coffee cup at Resident #17 which struck him in the face. The residents were separated and placed on frequent checks. Staff were educated to watch for wandering from Resident #17. Both residents were assessed for a change in condition and for any injuries. Residents from the unit were interviewed to see if there were any unreported incidents which needed to be reported. Staff on the unit were interviewed to see if there was any additional information regarding the incident.The investigation indicated Resident #17 had a history of physical and verbal aggression to other residents and staff. Resident #17's care plan documented interventions including providing positive interactions and attention, monitoring medication, providing staff intervention when aggression was initiated and keeping the resident within line of sight as much as possible. The investigation indicated Resident #16 did not have a history of behaviors and had not been involved in any other incidents in the 12 months prior.The facility concluded the allegation of physical abuse was unsubstantiated since the incident of aggression occurred between both residents.-However, physical abuse occurred due to Resident #17 hitting Resident #16 in the chest and Resident #16 throwing a coffee cup at Resident #17's face.2. Resident #17a. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the September 2025 computerizedphysician orders (CPO), diagnoses included dementia with behavioral disturbance, adult failure to thrive and senile degeneration of the brain.The 8/29/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident needed substantial assistance to dependence on staff for most activities of daily living (ADL).The MDS assessment documented the resident did not have physical or verbal behaviors directedat others or other behavioral symptoms not directed toward others during the assessment period.b. Record reviewThe antipsychotic care plan, revised 6/14/22, revealed Resident #17 was at risk for complications related to using antipsychotic medications to treat his insomnia and dementia with behavioral disturbance. Pertinent interventions included reviewing behaviors and interventions and their effectiveness, keeping the resident in the nursing staff's line of sight, and encouraging the resident to stay clear of doorways.The behavior care plan, revised 4/9/24, revealed Resident #17 had a behavior problem which included the resident becoming aggressive toward peers and staff due to his dementia with behavioral disturbance. Resident #17's triggers included reacting to how others were speaking to or about him and reacting when approached or touched from the back or side. Pertinent interventions included frequent checks; providing opportunities for positive reaction; scratching the resident's back and calling him gorgeous; offering snacks and fluids and ensuring the resident sat with his back against the wall.The physical aggression care plan, revised 7/27/23, revealed Resident #17 had the potential to be physically aggressive towards others due to his poor safety awareness and impulse control. Resident #17's triggers included his peers walking up behind him and vulgar language. Resident #17's behaviors were de-escalated by sitting him with his back against the wall and offering him fluids and snacks of his liking. Pertinent interventions included analyzing the time of day, places, circumstances and triggers of an incident; and documenting, assessing and anticipating Resident #17's needs.-The most recent intervention added to Resident #17's care plan was on 1/14/25 related to his exit-seeking behaviors.A progress note, dated 5/25/25 at 10:06 a.m., revealed Resident #17 was being monitored for a decrease in Zyprexa (an antipsychotic medication primarily used to treat schizophrenia and bipolar disorder) dosage. The note documented Resident #17 did not have any change in behaviors. Resident #17 continued to try to leave the building and was kicking and pounding on the exit doors.A progress note, dated 6/13/25 at 5:28 p.m., revealed Resident #17 grabbed another resident (Resident #19) by the arm and pulled. Resident #17 and Resident #19 were immediately separated. The residents were assessed and did not sustain any injuries. The residents' representatives, the DON, the NHA and the residents' physicians were notified.c. Resident #17's representative interviewResident #17's representative was interviewed on 9/30/25 at 12:12 p.m. The resident's representative said Resident #17 had lived at several facilities over the past few years, and the current facility was the only facility that would take Resident #17 due to his behavioral and medical concerns. The resident's representative said he was notified whenever Resident #17 had any incidents with any other residents. He said Resident #17 had issues dealing with his dementia and general decline. The resident's representative said Resident #17 was previously receiving hospice care and without the additional support of the hospice staff, it seemed Resident #17's level of required care was beyond what the facility could provide with their staffing. The resident's representative said Resident #17 had a previous traumatic brain injury which resulted in the resident having impulse control issues. The resident's representative said he and the facility tried to manage Resident #17's conditions with behavioral medications. The resident's representative said Resident #17's issues with impulsivity made him hard to control, as he did not have any decision-making abilities. He said Resident #17's behavioral problems had previously resulted in him being discharged from other facilities. The resident's representative said Resident #17 did not like when people came up behind him, and the facility staff were aware of the resident's quirks and triggers. He said staff members at the facility had tried to adjust Resident #17's care plans and medications, but there was nothing they could do to help him. The resident's representative said the biggest challenge Resident #17 faced was continuity of care and issues with having enough staff to keep an eye on all of the residents in the unit. The resident's representative said Resident #17 was a high-risk individual and could easily get hurt, but also got irritated and thought he could get into fights and defend himself.3. Resident #16a. Resident statusResident #16, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, diagnoses included alcohol-induced persisting dementia, traumatic subdural hemorrhage (bleeding in the brain) and mood disorder.The 9/10/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. The resident required supervision or touching assistance from staff for most ADLs.The MDS assessment documented the resident did not have physical behaviors directed at others or other behavioral symptoms not directed toward others. The assessment documented the resident had verbal behavioral symptoms directed toward others occurring on one to three days of the seven-day assessment look-back period.b. Resident #16's interviewResident #16 was interviewed on 10/1/25 at 1:56 p.m. Resident #16 said he did not like a lot of the other residents that lived on the unit with him. Resident #16 said he did not like to talk to people. c. Record reviewThe behavior care plan, revised 7/1/25, revealed Resident #16 had a behavioral problem when he wanted to be left alone. Resident #16 had the potential to be physically or verbally aggressive toward his roommates or others. Pertinent interventions included providing opportunities for positive interactions and when agitated, intervening before the agitation escalated, guiding him away from the source of distress and engaging calmly in conversation.The antidepressant medication care plan, revised 12/30/24, revealed Resident #16 was prescribed an antidepressant medication related to his mood disorder, depression, persistent anger with himself or others and reduced social interactions. Pertinent interventions included observing Resident #16's mood and response to the medication and observing and recording the effectiveness of the drug regimen.A progress note, dated 6/7/25 at 4:13 p.m., revealed at 12:30 p.m. that afternoon (on 6/7/25), a member of the nursing staff saw Resident #17 sitting in the doorway of Resident #16's room. Resident #16 started to yell at Resident #17 to get him out of his room. Due to increased behaviors and wandering behavior, Resident #17 became agitated and swung his arm at Resident #16, making physical contact with Resident #16's chest. In response, Resident #16 threw his cup of coffee at Resident #17 which hit him in the face. Two nursing staff members separated the residents, contacted their representatives and left a message for the residents' physician.B. Incident of physical abuse between Resident #19 and Resident #17 on 7/29/251. Facility investigationThe facility investigation, dated 7/29/25, was provided by the NHA on 9/30/25 at 4:30 p.m. The investigation revealed the following:On 7/29/25 at 2:35 p.m. Resident #17 wandered into Resident #19's room. Resident #19 reacted to Resident #17 entering his room by pushing over Resident #17's wheelchair, resulting in Resident #17 falling. Resident #17 was found in Resident #19's room on his back with his knees bent and his wheelchair tipped over, while Resident #19 was sitting in his recliner. The residents were separated, assessed and put on frequent checks. The investigation indicated Resident #17 had a history of physical and verbal aggression to other residents and staff. Resident #17's care plan documented interventions including providing positive interactions and attention, monitoring medication, providing staff intervention when aggression was initiated and keeping the resident within line of sight as much as possible. The investigation indicated Resident #19 had a history of aggression toward staff, poor impulse control, and had been involved in other incidents of physical abuse within the previous 12 months.The facility concluded the allegation of physical abuse was unsubstantiated since Resident #19 reacted to Resident #17 wandering into his room, causing the fall and the resident's intent was reactionary, and due to Resident #17 not having any physical or emotional harm from the event.-However, physical abuse occurred due to Resident #19 tipping Resident #17 out of his wheelchair, resulting in a fall.2. Resident #19a. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia with behavioral disturbance.The 7/23/25 MDS assessment revealed the resident had severe cognitive impaired with a BIMS score of zero out of 15. The resident required supervision to substantial assistance for all ADLs.The MDS assessment documented the resident had physical and verbal behaviors directedat others on one to three days of the seven day assessment period.b. Resident representative interviewResident #19's representative was interviewed on 9/30/25 at 1:35 p.m. The resident's representative said she felt the facility was not well staffed and she did not think there were enough staff members to supervise the residents on the secured unit. She said Resident #19 had previously had issues with other residents. The resident's representative said there had been a lot of resident-to- resident incidents involving Resident #19 in the last few months She said she felt the incidents happened because there were not enough staff members in the secured unit and the staff members did not watch Resident #19 as much as they used to. The resident's representative said she was aware another resident hit Resident #19 recently. The resident's representative said Resident #19 was very private and tended to become very upset when other residents walked into his room, which had been an issue in the past. c. Record reviewThe behavioral care plan, revised 8/8/25, revealed Resident #19 had a history of physical and verbal aggression towards staff. Pertinent interventions included administering medications as ordered, assessing and anticipating the resident's needs, performing frequent checks, analyzing the resident's triggers, determining what de-escalated the resident and documenting the findings.-The behavioral care plan did not document the resident's identified trigger of physical aggression when other residents entered his room (see above interview with the resident's representative).The antipsychotic medication care plan, revised 8/5/24, revealed Resident #19 received an antipsychotic medication for behavioral management due to his potential for injury to himself or others, as he had a history of choking a staff member at a previous facility. Interventions included administering medications as ordered, monitoring for target behaviors, and psychiatry to review medications after a recent physical altercation (initiated 9/2/25).C. Incident of physical abuse between Resident #8 and Resident #17 on 8/14/251. Facility investigationThe facility investigation, dated 8/15/25, was provided by the NHA on 9/30/25 at 4:30 p.m. The investigation revealed the following:On 8/14/25 at 2:25 p.m. Resident #8 was wandering through the hall and ran into Resident #17's wheelchair. Resident #17 reacted and hit Resident #8 in the face. The incident was witnessed by a member of the nursing staff. The residents were separated, assessed and put on frequent checks. The investigation indicated Resident #17 had a history of physical and verbal aggression toward other residents and staff. Resident #17's care plan documented interventions including providing positive interactions and attention, monitoring medication, providing staff intervention when aggression was initiated, and keeping the resident within line of sight as much as possible. The investigation indicated Resident #8 had a history of behaviors, including throwing objects when he was upset and initiating aggression towards another resident. The resident had not been involved in any other incidents in the 12 months prior. Resident #8's care plan included interventions such as anticipating the resident's needs, providing quiet areas for him to calm down, and to be non-confrontational when approaching him.The facility concluded the allegation of physical abuse was unsubstantiated since the incident between Resident #8 and Resident #17 did not result in any physical or emotional harm.-However, physical abuse occurred due to Resident #17 hitting Resident #8 in the face.The facility follow-up actions included reviewing both residents' care plans for potential additions, and reviewing the incident in their IDT team meeting to see what potential interventions could be used. -However, Resident #17's care plan was not updated following this resident-to-resident altercation.2. Resident #8a. Resident statusResident #8, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia with behavioral disturbance, impulse disorder and depression.The 6/18/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of nine out of 15. The resident was dependent on staff assistance for most ADLs.The MDS assessment documented the resident did not have physical or verbal behavioral symptoms directed towards others during the assessment period.b. Record reviewThe behavioral care plan, revised 7/1/25, revealed Resident #8 displayed frequent wandering behaviors, threw objects when he was upset and had a history of physical aggression towards other residents. Pertinent interventions included attempting to keep Resident #8 in a daily routine, anticipating and meeting his needs, conducting frequent checks as needed, redirecting the resident from inappropriate behaviors, staying an arm's length away from the resident and reducing stimuli so the resident was able to calm down and regain control.The antipsychotic medication care plan, revised 6/25/25, revealed Resident #8 received an antipsychotic medication to treat his traumatic brain injury with behaviors. Resident #8's behaviors included inappropriate sexual behavior, physical abuse, including attempting to hit, kick, or throw things at others, and verbal abuse. Pertinent interventions included observing the resident's mood and response to medications and attempting nonpharmacological interventions when possible.A progress note, dated 7/14/25 at 10:50 p.m., revealed Resident #8 was running into members of the nursing staff repeatedly. Resident #8 was redirected multiple times, and raised his fist at the nursing staff.A progress note, dated 7/23/25 at 12:41 a.m., revealed Resident #8 was running into staff members with his wheelchair. Staff attempted to educate and redirect Resident #8, and the resident struck out at the staff with his fist. Resident #8 was combative with staff during ADL care.A progress note, dated 8/14/25 at 4:02 p.m., revealed Resident #8's face was assessed after a resident-to-resident altercation. Resident #8 did not have any bruising, redness, or swelling. Resident #8 did not complain of any pain. The residents involved in the incident were separated and were placed on frequent checks.An IDT note, dated 8/15/25 at 10:50 a.m., revealed that on 8/14/25 another resident hit Resident #8 on the right side of his face. The other resident (Resident #17) was upset that Resident #8 bumped into him with his wheelchair. The residents were immediately separated, frequent checks initiated, and the resident was redirected if he was in the hallway or in crowded areas to avoid bumping into other residents. Risk factors included impaired safety awareness and impulsivity.D. Incident of physical abuse between Resident #19 and Resident #17 on 8/31/251. Facility investigationThe facility investigation, dated 8/31/25, was provided by the NHA on 9/30/25 at 4:30 p.m. The investigation revealed the following:On 8/31/25 at 7:20 p.m. a nursing staff member saw Resident #17 and Resident #19 engaged in a physical altercation. Resident #19 was holding Resident #17's legs and pulling them. Nursing staff members immediately separated the residents and attempted to assess them. Resident #17 was placed near the nurse's station for close observation. Resident #17 told a member of the nursing staff that Resident #19 had hit him in the face. No injuries were noted to either resident at the time.Interviews with the nursing staff after the incident on 9/2/25 revealed Resident #17 was kicking his legs at Resident #19 when Resident #19 grabbed his legs.The facility did not submit a formal investigation of the allegation to the state survey agency (SSA). Cross-reference F609 for failure to report an allegation of abuse.E. Incident of physical abuse between Resident #19 and Resident #17 on 9/17/251. Facility investigationThe facility investigation, dated 9/18/25, was provided by the NHA on 9/30/25 at 4:30 p.m. The investigation revealed the following:On 9/17/25 at 6:40 p.m. Resident #19 hit Resident #17 in the head. Resident #17 was wearing a protective hat at the time. Resident #17 reached back and struck Resident #19 in the chest. The incident was witnessed by a nursing staff member. The residents were separated, assessed and put on frequent checks.The staff member who witnessed the incident said the incident occurred when she was assisting Resident #17 out of his room in his wheelchair. The staff member said while she was trying to redirect Resident #19, Resident #17 reached around and made contact with Resident #19.The investigation indicated Resident #17 had a history of physical and verbal aggression to other residents and staff. Resident #17's care plan interventions included providing positive interactions and attention, monitoring medication, staff intervention when aggression was initiated, and keeping the resident within line of sight as much as possible. The investigation indicated Resident #19 had a history of aggression toward staff and poor impulse control, and had been involved in other incidents of physical abuse within the previous 12 months.The facility concluded the allegation of physical abuse was unsubstantiated since, while both residents made physical contact with each other, the incident between Resident #19 and Resident #17 did not result in any physical or emotional harm.-However, physical abuse occurred due to Resident #17 and Resident #19 hitting and making physical contact with each other.The facility follow-up actions included reviewing the incident in their IDT team meeting to see what potential interventions could be used to prevent the situation from reoccurring. -However, Resident #17's care plan was not updated following this resident-to-resident altercation.F. Staff interviewsCNA #1 was interviewed on 10/1/25 at 1:20 p.m. CNA #1 said there were residents on the secured unit that picked on and went after each other. CNA #1 said Resident #16 threw coffee at Resident #17 the other day, so she now knew to serve him last at meals. CNA #1 said she was very scared for Resident #17 after that day. CNA #1 said watching over the secured unit felt like keeping pitbulls with chickens. CNA #1 said some residents, such as Resident #17, did not know where they were or if they were in someone else's way, so the staff all stepped in to make sure no one was picking on another resident and ensure no one fell. CNA #1 said it was her job to keep everyone on the unit safe.CNA #1 was interviewed again on 10/1/25 at 2:00 p.m. CNA #1 said Resident #17 was the aggressor sometimes, but it depended on the situation and his mood. CNA #1 said Resident #17 was very defensive when people pulled or bumped into his wheelchair or when people came up behind him. CNA #1 said she thought Resident #17 felt the other residents were there to beat him up. CNA #1 said Resident #19 and Resident #17 were both unpredictable and could become mad quickly. CNA #1 said she felt stressed out because of how draining it was to keep everyone on the secured unit settled down.CNA #1 said she tried to dance with Resident #19 and talk with him to de-escalate him, but sometimes his mood was aggressive and she had to leave and reapproach him later. CNA #1 said Resident #17 should be approached from the front of his wheelchair. CNA #1 said Resident #17 liked snacks, but since he was on a pureed diet, they did not always have any pureed textured snacks to give him. CNA #1 said there were interventions in Resident #19 and Resident #17's care plans for their behaviors, but sometimes the interventions did not work because they were too old. CNA #1 said she thought the residents' care plans did not get updated often enough, and she was not sure who was responsible for updating them.Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 10/1/25 at 3:00 p.m. CNA-Med #1 said Resident #17 did not typically pick fights and mostly kept to himself. She said Resident #17 had swung at her a few times when he was pulling on the exit doors to get out of the unit, but he was usually otherwise neutral. She said Resident #17 escalated quickly from verbal aggression to physical aggression when people got into arguments with him. CNA-Med #1 said Resident #17 was usually able to be redirected with sodas and talking with him. CNA-Med #1 said she knew of one instance in which Resident #17 wandered into Resident #19's room when Resident #19 was in a bad mood, and Resident #19 dumped Resident #17 out of his wheelchair. CNA-Med #1 said Resident #19 was not able to be redirected when he was in a bad mood, and it was best to just leave him alone. She said the residents' behavioral interventions were documented in their care plans. CNA-Med #1 said the care plans were updated with new interventions after any incidents. CNA-Med #1 said she did not know who updated the residents' care plans.The NHA, the SSD and the DON were all interviewed together on 10/1/25 at 4:05 p.m. The NHA said abuse was defined as physical harm, mental anguish or physical anguish. The SSD said the facility initiated an investigation whenever there was an incident of alleged abuse. The NHA said the SSD said they interviewed residents on the neighborhoods where the incidents occurred, including any witnesses if the incident was witnessed when completing the abuse investigation. The NHA said if there was suspected abuse, the staff completed a change of condition report to determine if affected residents sustained any pain or anguish to determine if harm occurred. The NHA said the facility staff relied heavily on the change of condition reporting for their abuse investigations. The DON said the facility staff notified the physician and the resident's responsible party, and documented their follow-up and monitoring of the resident for the next 72 hours. The DON said the nursing staff documented if the resident voiced any fear, new details or had any changes in mentation or behaviors. The DON said a skin assessment was performed if new skin changes were noted. The DON said the nursing staff performed behavior monitoring to watch for any tearfulness, frustration, or other behaviors outside the resident's normal demeanor. The DON said this was documented in the resident's progress notes. The DON said every risk management assessment was reviewed by the IDT team, during which time the residents' care plans were reviewed and new interventions added as needed. The DON said the residents' previous interventions were assessed to determine effectiveness and removed any ineffective interventions. The DON said assessments and care plan updates were important to perform so the facility staff members would know how to effectively care for the residents in the facility.The DON said the IDT examined the root cause of the incidents to determine why the resident-to-resident incident occurred, and assessed for interventions to put into place to prevent further incidents. The DON said this analysis was completed during every abuse investigation.The NHA, the SSD and the DON were interviewed together again on 10/1/25 at 5:14 p.m. The NHA said Resident #17 was a former prison guard and was very reactionary.The SSD said the staff's interventions to calm Resident #17 included distracting him with movies, his television, taking him for a walk and talking about his son or his past. The SSD said Resident #17 did not like to be approached from behind. The SSD said Resident #17 was very social. The NHA said the facility was struggling to find different effective interventions for Resident #17. The SSD said Resident #17 struggled in group activities and was placed on a one-to-one activity program. The SSD said the facility had tried different medication adjustments for Resident #17 as wellThe DON said Resident #17's care plan was updated to include his triggers. The DON said she thought this was done recently, but upon review of Resident #17's care plan she said it was not completed. The SSD said keeping Resident #17 within line of sight, having a staff member in the dining room with him whenever he was there, keeping him occupied, or setting the resident up in his room were recent interventions that were added to his plan of care. The NHA said Resident #17's room was right next to the nurses' station. The NHA said he did not know if there were any specific interventions to help prevent Resident #17 from reacting to someone walking up behind him, which was why the facility moved his room to the nurses' station so the staff could keep an eye on him and intervene.The SSD said during the one-to-one activity program, the activities staff tried to take Resident #17off the unit as much as possible and take him to group activities.The DON said a specific person at the facility was not assigned to add care plan interventions. The DON said a staff member took notes during their IDT meetings and someone else added the care plan interventions afterwards. The DON said her goal was to put in a new intervention into the residents' care plans after each incident.The NHA said the facility staff had made updating the residents' care plans after each incident a goal, but their documentation was not there. The NHA said he, the DON and the SSD should be responsible for ensuring the residents' care plans were updated after each incident.II. Incidents of physical abuse involving Resident #5A. Incident of physical abuse of Resident #4 by Resident #5 on 6/18/251. Facility investigationThe facility investigation, dated 6/19/25, was provided by the NHA on 9/30/25 at 3:20 p.m. The investigation revealed the following:On 6/18/25 at 6:00 p.m. during a scheduled smoking time, Resident #4 was upset with another resident when Resident #5 approached her and scratched her arm. The residents were separated, assessed and put on frequent checks. Resident #4 sustained scratch marks down both forearms.The investigation documented Resident #4 had a history of behaviors, including self-destructive behaviors and a history of not taking her medications or eating meals. The behavioral care plan included interventions such as reminding the resident to choose positive behaviors and encouraging the resident to take her medications. Resident #4 had not been involved in any other incidents in the previous 12 months.The investigation documented Resident #5 did not have a history of behaviors, and did not indicate if Resident #5 had been involved in any other incidents in the previous 12 months.-However, Resident #5 had been involved in a physical altercation two months prior to the 6/18/25 incident with Resident #4.The facility substantiated physical abuse as contact was made from the assailant to the vi

Based on record review and interviews, the facility failed to report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for two (#6 and #17) of 17 residents reviewed for abuse out of 18 sample residents.Specifically, the facility failed to ensure incidents of alleged physical abuse involving Resident #6 and Resident #17 were reported to the State Survey Agency (SSA). Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, dated September 2022, was provided by the nursing home administrator (NHA) on 10/1/25 at 6:31 p.m. It read in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy interpretation and implementation: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; adult protective services (where state law provides jurisdiction in long-term care); law enforcement officials; the resident's attending physician; and the facility medical director. All allegations are thoroughly investigated. The administrator initiates investigations. II. Resident #6 A. Allegation of abuse on 9/9/25 between Resident #6 and Resident #21 The facility abuse investigation was provided by the NHA on 9/30/25 at 3:45 p.m. The abuse investigation included an interview with Resident #21, dated 9/10/25, completed by social services assistant #1. The interview documented Resident #6 got mad at Resident #21 (who was his roommate) for leaving the bathroom door open. He said both he and Resident #6 were lying in bed, awake. He said Resident #6 began yelling and threatened to punch him in the face. Resident #21 said certified nurse aide (CNA) #2 entered the room just as Resident #6 was getting ready to throw the rolling bedside table at him. Resident #21 said he witnessed verbal aggression between residents every day. The 9/9/25 nursing progress note, documented at 6:30 a.m., revealed the nurse heard yelling coming from Resident #6 and Resident #21's room. When the nurse entered the room, the nurse witnessed Resident #21 sitting quietly on the side of his bed while his roommate (Resident #6) was yelling at him. Two CNAs were standing in front of Resident #6. The nurse immediately removed the resident from the room into the dining room. An assessment was completed with no injuries noted and the resident denied pain. The incident was under investigation. The 9/9/25 change of condition form for Resident #6 revealed behavioral changes with physical aggression. The behavioral changes were documented as yelling at his roommate, throwing things, pushing the resident's end table into Resident #21, which hit Resident #21's right arm. Resident #6 continued to be agitated after the incident and was provided a quiet environment. The 9/10/25 interdisciplinary team (IDT) behavior note revealed that on 9/9/25 at 6:30 a.m., Resident #6 had thrown several items on the floor and was yelling at Resident #21. Resident #6 had pushed the bedside table at Resident #21. The NHA, the physician and the resident's guardian were notified. -The facility was unable to provide documentation the allegation of abuse was reported to the SSA. B. Staff interviews The NHA, the director of nursing (DON), and the social services director (SSD) were interviewed together on 10/1/25 at 4:06 p.m. The NHA said he was responsible for reporting allegations of abuse to the SSA. The NHA said the allegation of physical abuse on 9/9/25 between Resident #6 and Resident #21 was not reported to him and therefore was not reported to the SSA. -However, the change of condition assessment documented the NHA was notified of the incident between Resident #6 and Resident #21. The NHA said all allegations of abuse should be reported to the SSA. III. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, adult failure to thrive and senile degeneration of the brain. The 8/29/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident required substantial assistance from staff for most activities of daily living (ADL). The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others during the assessment period. B. Record review A progress note, dated 8/31/25 at 7:20 p.m., revealed a nurse was standing at her cart when she looked down the hall and observed Resident #17 attempting to kick another resident (Resident #19). Resident #19 was holding Resident #17's legs and pulling at them. The nurse ran down the hall and immediately separated the residents with assistance from another staff member. Neither resident had any apparent signs of injury. Resident #17 refused to take off his coat so the nurse could perform a skin assessment. Resident #17 was assisted to a position near the nurse's cart for close observation. The facility investigation, dated 8/31/25, was provided by the NHA on 9/30/25 at 4:30 p.m. The investigation revealed the following: On 8/31/25 at 7:20 p.m. a nursing staff member saw Resident #17 and Resident #19 engaging in a physical altercation. Resident #19 was holding Resident #17's legs and pulling them. Nursing staff members immediately separated the residents and attempted to assess them. Resident #17 was placed near the nurses' station for close observation. Resident #17 told a member of the nursing staff that Resident #19 had hit him in the face. No injuries were noted to either resident at the time. The NHA, the physician, the on-call nurse, and the residents' representative were all notified within three hours of the incident on 8/31/25. Interviews with the nursing staff, after the incident on 9/2/25, revealed Resident #17 was kicking his legs at Resident #19 when Resident #19 grabbed his legs. -However, the facility failed to provide documentation to indicate the incident on 8/31/25 was reported to the SSA. C. Staff interviews The NHA was interviewed on 10/1/25 at 5:14 p.m. The NHA said he was the abuse coordinator for the facility. He said he was responsible for reporting incidents of alleged abuse to the SSA The NHA said incidents of potential abuse should be reported to him within 24 hours of the incident occurring so he was able to report the incident to the SSA. The NHA said the facility's management team evaluated each allegation of abuse to determine if it met the requirements to be reported to the SSA. -However, the facility abuse investigation documented the NHA was notified regarding the incident on 8/31/25 and failed to report it to the SSA.

Based on observations, record review and interviews, the facility failed to ensure three (#97, #37 and #47) of eight residents reviewed for accident hazards out of 36 sample residents remained as free from accidents as possible. Resident #97, who was known to be at risk for falls, was admitted on [DATE] with diagnoses of dementia, hearing impairment, unsteady and shuffling gait, and right sided weakness. The facility initiated a fall care plan which included interventions of anticipating and meeting the resident's needs, encouraging rest periods when signs of fatigue were noted, ensuring that the resident wore appropriate footwear when ambulating and keeping the resident in line of sight as needed. Resident #97 sustained falls with injury on 12/30/24 (abrasion to the right side of his head), 1/12/25 (laceration to his head) and 1/19/25 (abrasion to the back of his head). Resident #97 was sent to the emergency department (ED) for evaluation and treatment after each of the three falls. However, the facility failed to implement new fall interventions until 1/22/25 (after the third fall), when an intervention of a soft helmet for the resident to wear while awake was initiated. On 2/22/25 Resident #97 experienced another fall while ambulating in the hallway which resulted in a laceration to the back of his head and required the resident to again be sent to the ED for evaluation and treatment of a subarachnoid hemorrhage (bleeding into the space between the brain and the arachnoid membrane, one of the protective layers covering the brain). The facility failed to implement any new fall interventions upon the resident's return to the facility on [DATE]. On 2/24/25 Resident #97 experienced another fall on 2/24/25 that resulted in a large amount of bleeding to the resident's head in the same area as the resident's laceration that resulted from his fall on 2/22/25. The resident still had staples in his head from the previous fall on 2/22/25. The resident was again sent to the ED where he received six additional sutures for treatment of the laceration. The resident returned to the facility on [DATE] and the facility ordered a medical grade ribcap helmet (a medical grade helmet which offers 360 degree protection to the head). Staff interviews during the survey (see interviews below) revealed Resident #97 was not wearing the soft helmet initiated on 1/22/25 when he fell on [DATE] and 2/24/25 and the facility failed to ensure Resident #97 was encouraged to wear his safety helmet prior to his falls on 2/22/25 and 2/24/25. Due to the facility's failure to implement timely and effective interventions following each of Resident #97's falls, and the facility's failure to ensure care planned interventions were followed, the resident sustained head injuries, which required transfer to and treatment in the ED, from multiple falls. Additionally, the facility failed to ensure staff transferred Resident #37 and Resident #47 appropriately, according to their documented transfer status. Findings include: I. Facility policy and procedure The Fall and Fall Risk, Managing policy, revised March 2018, was provided by the nursing home administrator (NHA) on 3/25/25 at 3:25 p.m. It read in pertinent part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Environmental risk factors that contribute to the risk of falls include wet floors, poor lighting, incorrect bed height or width, obstacles in the footpath, improperly fitted or maintained wheelchairs and footwear that is unsafe or absent. Resident conditions that may contribute to the risk of falls include fever, infection, delirium and cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypertension, functional impairments, visual deficits and incontinence. Medical factors that contribute to the risk of falls include arthritis, heart failure, anemia, neurological disorders and balance and gait disorders. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not have been previously identified. II. Resident #97 A. Resident status Resident #97, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, chronic kidney disease, hearing loss, repeated falls and encephalopathy (medical conditions affecting brain function). The 2/6/25 minimum data set (MDS) assessment revealed Resident #97 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He needed substantial assistance with transfers, used a walker and needed supervision or touching assistance with ambulation. B. Record review Resident #97's fall care plan, initiated 11/22/22, documented he was at risk for injury related to falls, a diagnosis of dementia, hearing impairment, unsteady and shuffling gait and right sided weakness. Pertinent interventions included anticipating and meeting the resident's needs (initiated 11/22/22), encouraging rest periods when signs of fatigue were noted (initiated 11/22/22), ensuring that the resident wore appropriate footwear when ambulating, (initiated 11/22/22), educating the resident, family and caregivers about safety reminders and what to do if a fall occurred (initiated 7/7/23), resident to be in line of sight as needed (initiated 3/6/24), soft helmet while awake (initiated 1/22/25), staff to ensure the resident was not too close to others while walking in the hallway (initiated 1/22/25) and medical-grade helmet (initiated 2/24/25). A review of Resident #97's electronic medical record (EMR) revealed the following progress notes: A 12/30/24 charting note, documented at 8:00 p.m,. revealed that Resident #97 had a fall. The resident was using a walker, going too fast and lost his balance. The resident was wearing non-skid socks on both feet and his walker was in front of him. The resident hit his head, either on the dresser or the night stand, and had an abrasion to the right side of his head and an egg-sized lump. The resident was not taking any anti-coagulant medications (blood thinners). The resident had major difficulty attempting to walk to his bed and kept holding his head at the site of impact. The resident was sent out to the ED for evaluation. A 12/31/24 charting note, documented at 11:15 p.m., revealed that Resident #97 returned from the hospital at 11:15 p.m. The resident had another fall while in the hospital. -The facility failed to initiate any new fall interventions following the resident's 12/30/24 fall (see care plan above). A 1/3/25 weekly summary note, documented at 9:55 a.m., indicated that Resident #97 had no falls or injuries the previous week. -However, the resident progress notes documented the resident had a fall on 12/30/24 that resulted in an abrasion to the right side of his head and an egg-sized lump. A 1/10/25 progress note, documented at 11:36 a.m., revealed that the floor staff observed Resident #97 with worsened balance, leaning to the right side, and staff had to watch the resident closely and provide physical support when walking at times with a walker. A 1/13/25 interdisciplinary team (IDT) note, documented at 9:41 a.m., revealed that on 1/12/25 at 2:00 a.m., Resident #97 was seen sliding to the floor by a certified nurse aide (CNA). Resident #97 hit the back of his head and sustained a laceration to the head without a change of consciousness. The resident was sent to the ED for evaluation. -The facility failed to initiate any new fall interventions following the resident's 1/12/25 fall (see care plan above). A 1/19/25 charting note, documented at 6:45 p.m., revealed that Resident #97 had a fall in the hallway while other residents were gathering for a cigarette break. The resident hit his head multiple times on the wall when he fell . Neurological assessments and frequent checks were initiated and the resident was found to have an abrasion to the back of his head approximately three centimeters (cm) in diameter. The nurse on the unit notified the physician and the resident was sent to the ED for further evaluation. A 1/24/25 note, documented at 11:40 a.m., revealed that Resident #97 continued on therapy services three times a week for a fall and decreased strength. The resident continued to use a four-wheeled walker for ambulation and did very well unless he was tired. Staff encouraged the resident to rest between meals and when he was noticeably becoming unstable, as evidenced by the resident beginning to [NAME] to the right and run into walls. The resident could be difficult to redirect due to a language barrier and dementia diagnosis. A 2/21/25 progress note, documented at 6:43 p.m. revealed that Resident #97 continued to use a walker to ambulate in the hallways. He was encouraged to wear a helmet and to take rest breaks through the day, but was resistant to this guidance. -However, the resident's fall care plan failed to indicate the resident refused to wear his helmet or take rest breaks (see care plan above). A 2/22/25 progress note, documented at 3:15 a.m., revealed that Resident #97 was walking in the hallway with a walker and fell on his back, resulting in a laceration to the back of his head. Pressure was applied to stop the bleeding. The resident was able to squeeze a staff member's hand and sit upright on his own. A registered nurse (RN) was notified. The resident was sent to the hospital for treatment and evaluation. -The progress note failed to document if Resident #97 was wearing a protective soft helmet, per the care planned interventions on 1/22/25 (see care plan above). -The facility failed to document refusals by Resident #97 to wear the care planned soft helmet or attempts by staff to encourage the resident to wear it. -The facility failed to initiate any new fall interventions following the resident's 2/22/25 fall (see care plan above). A 2/23/25 progress note, documented at 12:04 p.m., revealed that Resident #97 was readmitted to the facility, was confused and wandering frequently between hallways and his room. The resident required frequent staff monitoring for high risk of falling. A 2/23/25 progress note, documented at 4:10 p.m., revealed that Resident #97 returned to the facility from the hospital for treatment of a subarachnoid hemorrhage following a fall at the facility. The resident had sutures on the back of his head. A 2/24/25 progress note, documented at 6:50 p.m., revealed that a staff member was called to come and help with Resident #97 due to a fall and a large amount of bleeding to the resident's head. The resident still had staples in his head from his previous fall on 2/22/25. Staff applied pressure to the resident's wound and the resident was sent out to the ED for further evaluation. A 2/24/25 progress note, documented at 11:43 p.m., revealed that Resident #97 returned to the facility with a head laceration that was repaired with six additional sutures. The resident had a 10 cm laceration to the back of his head and returned to the facility at 10:05 p.m. -The progress note failed to document if Resident #97 was wearing a protective soft helmet, per the care planned interventions on 1/22/25. -The facility failed to document refusals by Resident #97 to wear the care planned soft helmet or attempts by staff to encourage the resident to wear it. A 2/25/25 nurse's note, documented at 4:07 p.m., revealed that a ribcap helmet was ordered for Resident #97and staff were to encourage the resident to wear the helmet, and the resident's care plan was updated. The resident was to have a one-to-one sitter until the helmet was received. A 2/28/25 progress note documented, at 9:31 a.m., revealed that Resident #97's therapy for fall risk had been discontinued. The resident had fallen in the past week with head injuries and had been under one-to-one staff supervision. According to the hospital physician, the resident had a history of stroke which caused him to walk with weight on his heels and he was prone to falling backward. Review of Resident #97's post-fall assessments revealed the following: A 12/30/24 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had multiple falls the last six months and strayed off the straight path of walking but failed to document the resident used a walker. A 1/15/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk and strayed off the straight path of walking. However, the post-fall assessment documented the resident had one to two falls in the last six months, contrary to the previous assessment on 12/30/24 that documented he had multiple falls in the same time frame. The 1/15/25 assessment additionally failed to document the resident used a walker. A 1/20/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had multiple falls in the last six months and strayed off the straight path of walking. However, the resident's use of psychotropic medications and laxatives were not documented on the assessment and the assessment failed to document that the resident used a walker. A 2/25/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had one to two falls in the last six months and the resident's use of psychotropic medications and laxatives were not indicated on the assessment. The assessment documented the resident used a walker. -However, the resident had five falls in the last 60 days (see above) and was ordered risperidone starting 1/30/25, neither of which was indicated on the assessment. The assessment additionally failed to document the resident strayed off the straight path of walking as indicated on the previous post fall assessments (12/30/24, 1/15/25, 1/20/25). The fall investigations for Resident #97's falls on 2/22/25 and 2/24/25 were provided by the NHA on 3/24/25 at 3:23 p.m. -The fall investigations failed to document if Resident #97 was wearing a soft helmet as a fall prevention. C. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 3/25/25 at 2:55 p.m. LPN #4 said Resident #97's fall on 2/22/25 occurred near the end of her shift. LPN #4 said the resident would walk around with a walker several times during the course of the night. LPN #4 said he would take his walker and follow around the edge of the wall, catching the wheel of his walker on the wall, and he would do that several times during the night. LPN #4 said she told the CNAs to keep an eye on Resident #97 and that the resident had a history of falling backwards. LPN #4 said when Resident #97's fall occurred on 2/22/25, she was at the medication cart and passing medications. She said the resident was bleeding a lot from his head and was sent to the hospital. LPN #4 said there was a physician's order for the resident to wear a helmet from a previous fall, but the helmet did not fit and the resident would not wear it. LPN #4 said the order was discontinued and he did not have a current order for a helmet. LPN #4 said she had the CNAs check the room for a helmet but they were unable to locate one. CNA #8 was interviewed on 3/25/25 at 3:00 p.m. CNA #8 said when Resident #97 fell on [DATE], staff were getting a group of residents together to smoke and Resident #97 was ambulating with a walker. CNA #8 said Resident #97 was supposed to have a special helmet but the resident took the helmet off. CNA #8 said the resident was on every 15-minute checks and was supposed to be getting a hard helmet. CNA #8 said the resident did wear the grippy socks. She said he was not wearing a helmet when he fell a second time on 2/24/25. The director of nursing (DON) and the NHA were interviewed together on 3/26/25 at 10:20 a.m. The DON said the facility had a soft shell to fit inside the normal hat Resident #97 wore regularly. The DON said it was care planned to encourage Resident #97 throughout the shift to wear his protective helmet and there was no set amount of times to remind him. -However, the care plan did not indicate staff were to encourage the resident to wear his protective helmet (see care plan above). The DON said staff tried to anticipate Resident #97's behavior. The DON said a soft shell helmet would benefit Resident #97 more when he was ambulating. The DON said the resident did not wear the rib cap helmet in the bed due to skin breakdown. The DON said Resident #97 swatted at his hand when he had tried to put the helmet on him. The NHA said Resident #97 was not wearing his helmet when he fell on [DATE]. III. Resident #37 A. Resident status Resident #37, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke), type 2 diabetes mellitus, dementia, anxiety, difficulty walking and heart failure. The 12/31/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. The resident was dependent on care for all activities of daily living (ADL) except eating, where she needed set up assistance. The MDS assessment did not document use of a mechanical lift or prior falls. B. Record review Resident #37's fall care plan, revised 11/6/24, documented she was at high risk for falls due to incontinence, paralysis, psychoactive drug use, was unaware of safety needs and declined therapy. Pertinent interventions, revised 4/1/24, included to anticipate and meet Resident #37's needs. A fall mat intervention was initiated 10/11/24. Resident #37's ADL care plan, revised 7/16/24, documented she had a self care performance deficit due to hemiplegia and dementia. Pertinent interventions, initiated 7/16/24, included that Resident #37 was totally dependent on staff for repositioning and turning in bed and required a hoyer lift (mechanical lift) with two staff members for transfers. A 3/23/25 nursing progress note, documented at 7:30 p.m., revealed that a CNA was transferring Resident #37 into bed. The CNA then came out of the room and said the resident was on the floor. The CNA said that she lowered the resident to the floor. Resident #37's 3/23/25 fall investigation was provided by the NHA on 3/24/25 at 3:23 p.m. The fall investigation documented Resident #37's fall happened during a transfer and the CNA said the resident tripped over oxygen tubing and the floor mat was also in the way during the transfer. -However, per Resident #37's ADL care plan, the resident was supposed to be a two-person transfer with a hoyer lift (see care plan above). Resident #37's 3/24/25 post-fall assessment documented the resident's gait analysis as unable to independently come to a standing position. C. Staff interviews CNA #3 was interviewed on 3/25/25 at approximately 3:00 p.m. CNA #3 said Resident #37 needed a mechanical lift for transfers and the assistance of two staff members to transfer. CNA #3 said she was aware Resident #37 had fallen previously. CNA #3 said Resident #37 could transfer while standing from her bed to her chair but needed to have two staff members assist her closely and she usually used the mechanical lift for transfers. The DON was interviewed on 3/26/25 at 10:20 a.m. The DON said Resident #37's care plan indicated the mechanical lift was to be used to transfer Resident #37. The DON said it was against company policy to transfer Resident #37 without the mechanical lift. The DON said the facility staff directly transferred the resident to her bed without the mechanical lift on 3/23/25 and one CNA was present in the room at the time instead of two. 50219 IV. Resident #47 A. Resident status Resident #47, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included multiple sclerosis (a disease that causes breakdown of the protective covering of nerves), history of traumatic brain injury, epilepsy and encephalopathy (a medical condition that affects brain function). The 2/13/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS assessment score of 12 out of 15. The resident was dependent on staff for most ADLs. The assessment documented the resident was dependent on staff for all transfers. B. Record review The functional abilities care plan, revised 8/1/24, revealed Resident #47 required staff assistance with ADLs due to his multiple sclerosis and history of traumatic brain injury. Pertinent interventions included Resident #47 requiring extensive total assistance with bathing and showering and requiring a hoyer lift with two staff members for transfers, revised 10/18/24. The fall care plan, initiated 12/16/24 and revised 2/12/25, revealed Resident #47 was at risk for falls due to altered balance while standing, a history of falls and an unsteady gait. Pertinent interventions included having two staff members to assist with transfers with a hoyer lift (initiated 4/29/24), engaging with Resident #47 and reminding him to stay seated until the hoyer lift transfer was complete (initiated 6/30/24) and only using the hoyer lift for transfers (initiated 2/6/25). -However, the resident had already had an intervention for transfers with two people and a hoyer lift which was initiated on 4/29/24, 10 months prior to the hoyer lift intervention implemented on 2/6/25. The facility fall report, dated 12/31/24 at 10:45 a.m., revealed Resident #47 was receiving a shower when he fell . An unidentified CNA was transferring Resident #47 to a chair when the resident slipped, the CNA was unable to hold him and the resident fell . According to the CNA, Resident #47 hit his head on the wall. No injuries or bruises were observed during the nurse's assessment and Resident #47's range of motion and behavior were at baseline. The RN was notified. The report documented physiological factors contributing to the fall included weakness. A change in condition form, dated 12/31/24 at 11:57 a.m., revealed Resident #47 fell in the shower room. Resident #47 slipped during a transfer and fell down. Resident #47 hit his head on the wall during the fall. Resident #47 was not in distress and his vital signs were within normal limits. A post-fall rehabilitation screening, dated 12/31/24 at 1:55 p.m., revealed Resident #47 fell during an assisted transfer. Resident #47 was dependent for transfers, and the physical therapist recommended using a mechanical lift and rolling shower chair for showers. -However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above). An interdisciplinary team (IDT) note, dated 1/2/25 at 9:32 a.m., revealed that on 12/31/24 at approximately 10:45 a.m., Resident #47 was in the shower room with a shower aide and slipped on the floor. The CNA reported Resident #47 hit his head. Risk factors included the lift protocol was not followed and Resident #47 was impulsive and had poor safety awareness. Prior interventions included having physical therapy evaluate Resident #47, a floor mat by Resident #47's bedside and his bed in the lowest position. Interventions put into place included re-educating staff on the facility's lift policy. The facility fall report, dated 2/6/25 at 6:43 p.m., revealed Resident #47 had a witnessed fall. The report documented an unidentified CNA called the nurse into Resident #47's room around 4:30 p.m. to assist the resident on the floor in his room. The nurse entered Resident #47's room and observed him lying down on the floor. The RN in the building was called to assess Resident #47. No physical injuries were noted at the time and Resident #47 said he was tired and wanted to stay in bed. Resident #47 was assisted by four staff members back into bed, his vital signs were taken and a neurological assessment was performed. An IDT note, dated 2/7/25 at 10:32 a.m., revealed that on 2/6/25 at 6:43 p.m., Resident #47 was assisted to the floor by a CNA during a transfer due to weakness. No pain or injuries were identified. Resident #47 was assisted back into his bed per his request by four staff members. Resident #47 stated he was tired. Risk factors included weakness, dementia and a history of falls. Prior interventions included having physical therapy evaluate and treat Resident #47, a floor mat on Resident #47's bedside and his bed in lowest position, and re-educating the staff on the facility lift policy. Interventions initiated included only using a hoyer lift for transfers. -However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above). A post-fall rehabilitation screening, dated 2/7/25 at 1:49 p.m., revealed Resident #47 was attempting to transfer during the fall. The physical therapist recommended using a mechanical lift for improved safety with transfers. -However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above). C. Staff interviews CNA #5 was interviewed on 3/26/25 at 9:30 a.m. CNA #5 said Resident #47 needed to be transferred using a hoyer lift. CNA #5 said Resident #47 could stand with two staff members assisting him early in the mornings, and mainly needed to use the hoyer lift after lunch. -However, according to the resident's care plan, the resident was to be a hoyer lift for all transfers (see care plan above). CNA #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said Resident #47 usually needed to use a hoyer lift to transfer. CNA #2 said in the mornings, if Resident #47 felt good he could stand, but he generally needed to use the hoyer lift. CNA #2 said they would often only have one CNA to operate a hoyer lift rather than two, but over the last two months they had enough staff to have two staff members operating the hoyer lifts. LPN #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #47 needed to transfer with the hoyer lift, but sometimes had good days where he did not need to use the lift. LPN #1 said Resident #47 needed to use the hoyer lift since he had a decline the month prior. -However, according to the resident's care plan, the resident had been care planned to use a hoyer lift for transfers since 4/29/24 (see care plan above). The director of rehabilitation (DOR) was interviewed on 3/26/25 at 12:56 p.m. The DOR said Resident #47 needed to be transferred with a hoyer lift at all times. The MDS coordinator (MDSC) was interviewed on 3/26/25 at 3:36 p.m. The MDSC said Resident #47 needed to be transferred using the hoyer lift exclusively. The MDSC said Resident #47 had multiple sclerosis and was wheelchair-bound when he was admitted but had experienced a continuous decline in mobility. The MDSC said Resident #47 used to transfer by stand and pivot method but had a few falls in which his legs buckled under him. The MDSC said Resident #47's fall in February 2025 was related to a transfer during which he tried to self-transfer and was caught by the facility staff. The MDSC said Resident #47's fall in December 2024 occurred as a CNA was transferring him in the shower room and he fell . The DON was interviewed on 3/26/25 at 4:40 p.m. The DON said Resident #47 needed to be transferred with a hoyer lift at all times. The DON said Resident #47 used to transfer via stand and pivot a year prior (2024). The DON said Resident #47's fall on 12/31/24 went directly against the facility's no-lift policy. The DON said Resident #47 was a known hoyer lift user and the resident could not coordinate balancing weight on his legs. The DON said the CNA was trying to transfer Resident #47 to his wheelchair when he fell on [DATE]. The DON said Resident #47's fall on 2/6/25 was unwitnessed. The DON said Resident #47 had rolled out of bed and onto the floor. -However, the facility fall report documented Resident #47's fall as witnessed, and the IDT note on 2/7/25 documented the fall occurred during a transfer and the CNA lowered the resident to the floor due to weakness (see record review above).

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement contained the required components. Specifically, the facility failed to: -Ensure the arbitration agreement presented to residents contained language that provided for the selection of a venue that was convenient to both parties; and, -Provide for the selection of a neutral arbitrator agreed upon by both parties. Findings include: I. Facility policy and procedure The Binding Arbitration Agreement policy, dated November 2023, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. The policy read in pertinent part, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about the important aspects of their health, welfare and safety. Arbitration agreements provide for the selection of a neutral arbitrator, which is agreed upon by both parties. A neutral arbitrator is an impartial, unbiased party decision maker, without the appearance of any conflicts of interest, contracted with and agreed to by both parties to resolve their dispute. Residents (or representatives) are given the opportunity to suggest an arbitrator and venue. If the facility disagrees with the resident's suggested arbitrator(s) and/or venue, the facility will document the reason and provide that documentation to the resident (or representative). Arbitration agreements provide for the selection of a venue that is both convenient to and suitably meets the needs of both parties. The venue will be agreed upon by both parties. When selecting a venue for consideration, ' convenience' for the resident (or representative) may be determined by his or her ability to get to the venue. II. Facility's binding arbitration agreement A copy of the facility's binding arbitration agreement was provided by the NHA on 3/23/55 at 10:55 a.m. The agreement read in pertinent part, The arbitration shall be administered and conducted by a contracted provider in accordance with its comprehensive arbitrations rules and procedures. Within 15 days after a claim for arbitration is made, the demand shall be filed by the contracted provider (dispute resolution specialist) and a single arbitrator will be selected from a list provided by the named provider pursuant to its rules to conduct the arbitrations. The arbitrator shall have the jurisdiction to decide whether the claims may be arbitrated pursuant to this agreement. The hearing arising under this voluntary arbitration agreement shall be held in the county where the facility is located. -The facility's binding arbitration agreement failed to include the selection of a neutral arbitrator agreed upon by both parties and failed to contain language that provided for the selection of a venue that was convenient to both parties. III. Staff interviews The admission coordinator (AC) was interviewed on 3/26/25 at 12:20 p.m. The AC said the facility's arbitration agreement did not include information indicating a resident could speak with federal, state, local, surveyors or ombudsman. She said the information was included in the facility's admission agreement (a separate document) instead. The AC said there was no language in the facility's arbitration agreement regarding a selection of venue by both parties.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in three of three unit nourishment refrigerators. Specifically the facility failed to: -Ensured the nourishment room refrigerators were maintained at a safe temperature; -Ensure health shakes were labeled in the unit nourishment refrigerators; and, -Ensure the floor, walls and ice machine in the main kitchen were maintained in a clean and sanitary condition. Findings include: I. Ensure safe cold food holding temperatures were maintained and health shakes were labeled in the nourishment refrigerators A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, ([DATE]), retrieved on [DATE], read in pertinent part, Except during preparation, cooking, or cooling, or when time is used as the public health control time/temperature control for safety food shall be maintained at 135 degrees fahrenheit (F) or above at 41 F or less. (,d+[DATE].16) B. Observations On [DATE] at 10:30 a.m. the following was observed in a south unit nourishment refrigerator and freezer: -Six health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed health shakes; -There was brown liquid splattered on the sides and spilled on the bottom of the freezer and inside the door shelf; and, -A box of turkey pot pie was in the freezer with an expiration date of [DATE] with a name written on the box. On [DATE] at 2:25 p.m. the following was observed in the south unit nourishment refrigerator: -There was brown liquid splattered on the sides and spilled on the bottom of the freezer and inside the door shelf; -A box of turkey pot pie in the freezer with an expiration date of [DATE]; and, -Nine health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed health shakes. The [DATE] ([DATE] to [DATE]) temperature log for the south unit nourishment refrigerator was reviewed. The temperatures were recorded as follows: -On [DATE] the temperature was 42 F. -On [DATE] the temperature was 46 F. -On [DATE] the temperature was 42 F. -On [DATE] the temperature was 45 F. -On [DATE] the temperature was 48 F. -On [DATE] the temperature was 45 F. -On [DATE] the temperature was 43 F. -The recorded refrigerator temperatures were above the acceptable cold holding temperature of 41 F and there was no evidence to indicate the temperature was corrected (see professional reference above). An unidentified certified nurse aide (CNA) looked at the frozen turkey pot pie with the expiration date of [DATE] and said the resident whose name was written on the box was no longer at the facility and placed the expired product back in the freezer. On [DATE] at 2:40 p.m. the following was observed in the men's secured unit nourishment refrigerator: -Three health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed healthsakes. On [DATE] at 2:45 p.m. the following was observed in the Aspen unit nourishment refrigerator : -Seven health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed healthsakes. The [DATE] ([DATE] to [DATE]) temperature log for the aspen unit nourishment refrigerator was reviewed. The temperatures were recorded as follows: -On [DATE] the temperature was 42F. -On [DATE] the temperature was 42 F. -On [DATE] the temperature was 42 F. -On [DATE] the temperature was 48 F. -On [DATE] the temperature was 46 F. -The recorded refrigerator temperatures were above the acceptable cold holding temperature of 41 F and there was no evidence to indicate the temperature was corrected (see professional reference above). C. Staff interviews The director of nursing (DON) was interviewed on [DATE] at approximately 3:25 p.m. The DON said the dietary staff managed the unit nourishment refrigerators. CNA #2 was interviewed on [DATE] at approximately 2:30 p.m. CNA #2 said the overnight nursing staff checked the nourishment refrigerator temperatures and removed expired products. Certified nurse aide with medication aide (CNA-Med) #1 said the night shift usually checked the nourishment refrigerator temperatures and she said she would check the temperatures of the nourishment refrigerators again for accuracy. The dietary director (DD) and the nursing home administrator (NHA) were interviewed together on [DATE] at 12:00 p.m. The NHA said the dietary department was responsible for recording the nourishment refrigerators temperatures and checking for expired products. The NHA said the nourishment refrigerator in the south unit was running a high temperature (out of range) because the thermometer was in the door but they moved the thermometer back inside the refrigerator. She said when they moved the thermometer the temperature was reading within normal limits. The DD said that unit refrigerator temperatures and maintenance of the product would be corrected. The DD said since the refrigerator temperatures were running high, the staff should take the temperature of the food in the refrigerator to ensure it was a safe temperature, and if the food was not a safe temperature after 30 minutes the food would be discarded. The DD said he was going to go through the product in the unit refrigerators and clean them out. The NHA said he was not sure if the facility provided education to the CNAs on refrigerator temperature maintenance so they would notice if the temperature was out of range during their use of the refrigerators. II. Maintain a clean and sanitary kitchen environment A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, ([DATE]), retrieved [DATE] read in pertinent part, Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where food establishment operations are conducted; and nonabsorbent for areas subject to moisture such as food preparation areas, walk-in refrigerators, warewashing areas, and areas subject to flushing or spray cleaning methods. (,d+[DATE].11) B. Facility policy and procedure The Sanitization policy, revised [DATE], was provided by the NHA on [DATE] at 11:32 a.m. It read in pertinent part, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris and protected from rodents and insects. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Ice machines and ice storage containers are drained,cleaned and sanitized per manufactures instructions. C. Observations The initial kitchen tour was conducted on [DATE] at 9:10 a.m. The following was observed: -Approximately ten missing coving tiles (a curved tile that transitions the floor to the wall) behind the ice machine extending under the clean side of the dish machine table. The pipe extending from the back of the ice machine was dripping onto the floor instead of the drain and created standing water that pooled into the grout between the existing floor tiles. Four coving tiles were damaged and separated from the wall. The wall behind the ice machine was bowed out into the kitchen; -The aluminum filter on the back of the ice machine was caked with brown debris; and, -A large section extending approximately ten feet long and a foot wide revealed an exposed, uneven and rough concrete floor that was missing kitchen floor tiles. A kitchen walk through was conducted in the main kitchen on [DATE] from 11:10 a.m. through 1:30 p.m. The following was observed: -Approximately ten missing coving tiles behind the ice machine and extending under the clean side of the dish machine table (a curved tile that transitions the floor to the wall) were missing. The pipe extending from the back of the ice machine was dripping onto the floor instead of the drain and created standing water that pooled into the grout between the existing floor tiles. Four coving tiles behind the ice machine were damaged and separated from the wall. The wall behind the ice machine was bowed out into the kitchen; -The aluminum filter on the back of the ice machine was caked with brown debris; and, -A large section extending approximately ten feet long and a foot wide revealed an exposed, uneven and rough concrete floor that was missing kitchen floor tiles. D. Staff interviews The NHA was interviewed on [DATE] at approximately 3:30 p.m. The NHA said he was not aware that the filter on the back of the ice machine had not been cleaned and had not seen the tiles behind the dish machine. He said he was not aware the ice machine was dripping onto the floor. The NHA said the kitchen floor was missing tiles because a broken pipe had been repaired and the facility would repair the floor in house. The DON was interviewed on [DATE] at approximately 3:30 p.m. The DON said it looked like the ice machine had been moved from where it usually sat The DD and the NHA were interviewed together on [DATE] at 12:00 p.m. The NHA said he was not sure if the ice machine filter had been assigned to anyone to clean. He said it was possible the ice machine filter should have been cleaned as part of the regular clean performed by their contacted vendor. E. Facility follow up On [DATE] at 11:32 a.m. the NHA provided documentation that the facility reached out to a local vendor on [DATE] for a quote on epoxy chip coating (seamless) the kitchen floor. No further documentation was provided if the local vendor provided the quote.

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet orders of puree and mechanical soft as indicated on their meal tray cards. Findings include: I. Facility policy and procedure The Therapeutic Diets policy, undated, was provided by the nursing home administrator (NHA) on 3/26/25 at 11:32 a.m. It read in pertinent part, Diet orders should match the terminology used by the food and nutrition services department. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. II. Record review The menu extensions and modifications for modified texture diets were provided by the dietary director (DD) on 3/26/25 at 5:00 p.m. The menu extensions documented the following modifications for the mechanically altered food items served during lunch meal service on 3/25/25: -The regular diet included beef tostadas, shredded lettuce and tomato, ground green chili stew and fruit crisp. -The mechanically altered diet included puree beef tostadas, no lettuce and tomato, ground green chili stew and sliced peaches. -However, the modified texture diet menu extensions did not specifically state a mechanical soft altered diet as listed on the resident's meal tickets, but listed a mech altered diet. The extensions also included IDDSI mince and moist level five and soft and bite size level six which the facility had not yet transitioned to use (see the interviews below). III. Meal service observation and test tray During a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen: The posted menu was beef tostada with shredded lettuce and tomato and fruit crisp. At 11:21 a.m. a resident's lunch plate was assembled by cook (CK) #1 with a crisp, fried tostada shell topped with ground beef and a fruit crisp was placed on the tray by dietary aide (DA) #1. The meal ticket on the tray documented a mechanical soft-ground texture and the tray was placed in a cart for delivery. -However, according to the meal extensions, the resident should have received a pureed beef tostada. (see meal extensions above) All 11:22 a.m. a residents meal tray was assembled by CK #1. DA #1 placed a fruit crisp on the tray. The meal ticket on the tray documented a mechanical soft-ground texture and the tray was placed in a cart for delivery. -However, according to the meal extensions, the resident should have received peach slices, not fruit crisp (see meal extensions above). At 11:33 a.m. a resident's lunch plate was assembled by CK #1 with a crisp, fried tostada shell topped with ground beef. The meal ticket on the tray documented a mechanical soft-ground texture. -However, according to the meal extensions, the resident should have received a pureed beef tostada. (see meal extensions above) At 12:00 p.m. a puree plate was prepared and served to a resident. The plate consisted of puree meat, mashed potatoes and a puree green vegetable. The resident's meal ticket documented a puree diet texture. -The puree vegetable served to the resident included peas which should not have been pureed (see interview below). At 12:16 p.m. the DD said to CK #1 that the fried tostada shells were a choking hazard. At 12:20 p.m. the DD removed the puree meat from the steam table and placed the puree meat in a food processor to blend the food. The DD said he wanted to make sure the food was the right consistency. The puree meat was placed back in the steam table for meal service. At 12:00 p.m. a puree plate was prepared and served to a resident. The plate consisted of puree meat, mashed potatoes and a puree green vegetable. -The puree vegetable served to the resident included peas which should not have been pureed (see interview below). At 12:31 p.m. The DD said to CK #1 that for a mechanical soft diet texture the tortilla should always be bite size and soft while he cut a soft flour tortilla and placed the pieces on a plate. The DD said he had not reviewed the modified texture diet menu extensions. -However, according to the meal extensions, the resident should have received a pureed beef tostada and not a cut-up soft flour tortilla. (see meal extensions above) At 12:35 p.m. a puree test tray was provided. The puree texture test tray consisted of puree beef, mashed potatoes, pureed peas and carrots and chocolate pudding for dessert. -The puree vegetable served to the resident included peas which should not have been pureed (see interview below). -The peas and carrots provided on the test tray had visible pieces of carrots and peas in the puree peas and were not smooth. The puree meat had small visible lumps. IV. Staff interviews CK #1 and the DD were interviewed together on 3/25/25 at approximately 12:30 p.m. (during meal service). CK #1 said the facility had a book of modified texture diet menu extensions in the kitchen. The DD said the facility had modified texture diet menu extensions but he needed to check with the registered dietitian (RD) to see if the modified texture diet menu extensions were correct. The DD and the NHA were interviewed together on 3/26/25 at 12:00 p.m. The DD said the facility was transitioning to IDDSI and was in the process of training the staff to the proper standards on IDDSI. The DD said the residents prescribed a puree diet had received puree peas and carrots for lunch on 3/25/25. The DD said the staff should not have pureed the peas and he noticed the puree peas after the meals had been sent to residents. The DD said a food with a hull, such as peas, should not be pureed. The DD said the facility would transition to minced and moist level five and soft and bite size level six diet textures (of IDDSI diets) to replace the mechanical soft diet texture the facility used. The DD said he was notified during lunch by facility staff the modified diet textures were incorrect, but it was too late to do anything about it. The DD said if modified textures were served incorrectly the residents were at risk for choking. The NHA said all staff were trained during their initial onboarding on how to recognize modified textures.

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for three (#54, #85 and #96) of four residents out of 36 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #54, Resident #85 and Resident #96 and/or their representatives understood the agreement before signing the arbitration agreement; and, -Ensure the facility staff provided evidence Resident #54, Resident #85 and Resident #96 and/or their representatives acknowledged understanding of the components of the agreement. Findings include: I. Facility policy and procedure The Binding Arbitration Agreement policy, November 2023, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. The policy read in pertinent part, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about the important aspects of their health, welfare and safety. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a form and manager that he or she understands, taking into consideration the resident's (or representative's) language, literacy and stated preference for learning. After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. A signature alone is not sufficient acknowledgement of understanding. The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement. II. Resident interviews Resident #54 and Resident #85 were interviewed during a group interview on 3/25/25 at 10:30 a.m. Resident #54 and Resident #85 said they did not know what an arbitration agreement was and did not remember signing an arbitration agreement. Resident #96 was interviewed on 3/25/25 at 3:00 p.m. Resident #96 said she did not remember signing an arbitration agreement when she signed her paperwork upon admission. Resident #96 said she did not know what an arbitration agreement was and that she had no difficulties or disputes with the facility. IV. Record review The NHA provided a list of residents who signed arbitration agreements on 3/23/25 at 10:55 a.m. -The list documented Resident #54 and Resident #85 signed an arbitration agreement. However, the list of residents was created in June 2024 and not updated to include residents that had admitted since. The admissions coordinator (AC) provided an additional list of residents who signed arbitration agreements on 3/25/25 at approximately 2:00 p.m. Resident #96 signed the arbitration agreement on 2/13/25 IV. Staff interviews The AC and the business office manager (BOM) were interviewed together on 3/26/25 at 12:20 p.m. The AC said she reviewed and read aloud to the resident or the responsible party that signed the admission paperwork and the arbitration agreement. -However, the facility failed to provide documentation of acknowledgement by the residents or their representatives that they understood the arbitration agreement.

Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity by providing care in a dignified, respectful and individualized manner for one (#26) of four residents reviewed out of 36 sample residents and on one of three units. Specifically, the facility failed to: -Ensure residents who were prescribed a puree diet received the menu options as listed on the main menu or according to their preference and prescribed diet order; and, -Provide residents on the Aspen unit with non-disposable beverage cups at meals. Findings include: I. Failed to ensure residents who were prescribed a puree diet, received the menu options as listed on the main menu or according to their preference and prescribed diet order A. Facility policy and procedure The Resident Food Preferences policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/26/25 at 11:32 a.m. It read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and meal times. Nursing staff will document the resident's food and eating preferences in the care plan. B. Resident representative interview Resident #26's representative was interviewed on 3/24/25 at 2:42 p.m. The resident representative said she could never find the puree diet menu. The resident representative said she had tried sitting down with Resident #26 and selecting things from the menu he would like, but when Resident #26 received his tray, he did not receive the menu items he had ordered. The resident's representative said she never knew what food items were on Resident #26's plate, so she would have the resident guess what he was eating. C. Observations and test tray During a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen: The posted menu was beef tostada with shredded lettuce and tomato and fruit crisp. At 11:12 a.m. cook (CK) #1 assembled a meal plate with mashed potatoes and puree meat and placed the meal in the serving window. The resident's meal ticket documented the resident was on a mechanical soft diet with puree meat and' cheeseburger' was written on the ticket. Restorative aide (RA) #1 looked at the meal and told CK #1 the resident ordered a cheeseburger and walked away from the serving window. At 11:13 a.m. RA #1 picked up the meal plate from the serving window and delivered it to the resident without a cheeseburger on the plate. At 12:35 p.m. a puree test tray was provided. The puree texture test tray consisted of puree beef, mashed potatoes, pureed peas and carrots and chocolate pudding for dessert. -The puree test tray did not include puree fruit crisp or puree noodles as documented on the diet modification spreadsheet. D. Record review The facility menus and puree daily standards were provided by the NHA on 3/24/25 at 3:24 p.m. The puree daily standards documented high quality leftovers from the previous meal/day would be saved and pureed to proper consistency following International Dysphagia Diet Standardization initiative IDDSI) standard for the next meal period. Lunch was pureed and served for dinner and dinner for lunch (the following day). Breakfast would be pureed fresh daily and the puree items were tossed after each meal period. The menu diet modification spreadsheet was provided by the dietary director (DD) on 3/26/25 at 5:00 p.m. The spreadsheet documented that for the lunch meal served on 3/25/25 the puree lunch included puree beef and noodles with sauce, and a puree fruit crisp and puree green chili stew. -However, the residents were served puree beef, mashed potatoes, puree peas and carrots and chocolate pudding. E. Staff interviews RA #1 was interviewed on 3/25/25 at 11:45 a.m. RA #1 said she did not know why the resident did not receive a cheeseburger with his meal. She said she thought maybe it was because the resident would also have puree bread with puree meat (of his cheeseburger). The DD and the NHA were interviewed together on 3/26/25 at 12:00 p.m. The DD said the staff pureed leftover food served at the previous meal for residents prescribed a puree diet. The DD said the test tray consisted of roast beef, mashed potato and peas and carrots. The DD said he did talk to the dietary staff after lunch on 3/25/25 and educated the staff to serve the resident a puree burger if that was the resident's preference. The DD said the resident had a mechanical soft diet order with an additional order for puree texture meat. The NHA said he thought the dietary staff pureed food from the previous meal so the staff could have the puree items ready to go ahead of time. The NHA said he had not previously heard any concerns about the puree food items. 20287 II. Failed to provide residents on the Aspen unit with non-disposable beverage cups at meals. A. Observations On 3/25/25 at 11:30 a.m. the residents in the Aspen women's secured unit were served their meals. The residents were served their milk, punch and coffee in paper and styrofoam cups instead of plastic cups. On 3/25/25 at 5:00 p.m. the residents on the Aspen women's secured unit were served their meals. The residents were served their beverages in paper and styrofoam cups instead of plastic cups. On 3/26/25 at 11:30 a.m. the residents in the Aspen women's secured unit were served their noon meals. The residents were again served all of their beverages in paper and styrofoam cups instead of plastic cups. B. Staff interviews Certified nurse aide (CNA) #10 was interviewed on 3/25/25 at 12:00 p.m. CNA #10 said the residents on the women's secured unit always received both paper and styrofoam cups for their beverages. She said it had something to do with the kitchen, however she said she was not sure of the exact reason. Licensed practical nurse (LPN) #2 was interviewed on 3/26/25 at approximately 12:00 p.m. LPN #2 said the kitchen always sent paper cups for the residents' beverages on the women's secured unit. She said she was not sure of the reason. She said the men's secured unit received washable non-disposable plastic cups.

Based on observations, record review and interviews, the facility failed to ensure four (#59, #39, #97 and #42) of nine residents out of 36 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #59 and Resident #39 from sexual abuse by Resident #62; -Protect Resident #97 and Resident #34 from physical abuse by each other; and, -Protect Resident #42 from physical abuse by Resident #58. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 3/23/25 at 12:41 p.m. It read in pertinent part, Residents have the right to be free from abuse. The facility will implement measures to address factors that may lead to abusive situations. The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements. II. Incident of sexual abuse of Resident #59 and Resident #39 by Resident #62 on 3/21/25 A. Facility investigation The facility's incident investigation, undated, was provided by the NHA on 3/24/25 at 4:21 p.m. The investigation included a statement from certified nurse aide (CNA) #4, which revealed on 3/21/25 between 1:30 a.m. and 2:00 a.m., CNA #4 observed Resident #62 as he was halfway into Resident #39 and Resident #59's shared room. Resident #62 had exposed his genitals and was masturbating in the room. CNA #4 took Resident #62 back to his room and told him he could not be in other residents' rooms. Resident #39 was interviewed by the NHA on 3/21/25. Resident #39 said she did not have any incidents of abuse to report. Resident #39 said she felt safe in the facility. Resident #39 said she did not notice any disturbances during her sleep. Resident #39 said there was nothing else she wanted to share. Resident #59 was interviewed by the NHA on 3/21/25. Resident #59 said she did not have any incidents of abuse to report. Resident #59 said she felt safe in the facility. Resident #59 said she did not notice any disturbances during her sleep. Resident #59 said there was nothing else she wanted to share. The investigation included a secure neighborhood placement evaluation, dated 3/21/25, for Resident #62. -The documents did not include a formal abuse investigation, interviews with any other residents in the vicinity, an interview with Resident #62 or any other interviews with staff members. B. Resident #62 (assailant) 1. Resident status Resident #62, age 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included sexual dysfunction and major depressive disorder. The 12/17/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident needed setup or cleanup assistance for most activities of daily living (ADL). The MDS assessment documented the resident did not have physical or verbal behaviors directed toward others or other behavioral symptoms not directed toward others. 2. Record review The behavioral care plan, initiated 7/17/2020 and revised 4/14/23, revealed Resident #62 made verbally explicit comments and suggestions toward staff, masturbated in front of staff, asked female staff members if he could touch them or if the staff could touch him in a sexually inappropriate way. Pertinent interventions included explaining or reinforcing why his behavior was inappropriate or unacceptable, administering medications as ordered, educating staff on the importance of respecting Resident #62's wishes and emphasizing sexual outlet was a normal function, monitoring behavioral episodes and attempting to determine an underlying cause, redirecting any inappropriate public exposure and intervening as necessary to protect the rights and safety of others. The activities care plan, revised 3/18/25, revealed Resident #62 was part of an activities work reward program in which he passed out news bulletins on the South neighborhood as it gave him purpose and satisfaction to speak with his peers and staff daily. Pertinent interventions included ensuring Resident #62 had the appropriate leisure material in order to be set up for success and having staff remind and encourage Resident #62 to participate in the work reward program. The antipsychotic medication care plan, revised 12/30/24, revealed Resident #62 required an antipsychotic medication as evidenced by inappropriate sexual behavior, delusions and hallucinations. Pertinent interventions included administering antipsychotic medications as ordered, observing Resident #62's mood and response to the medication and observing and recording the effectiveness of the drug treatment as indicated. A progress note, dated 1/16/25 at 9:56 p.m., revealed Resident #62 was being inappropriate in his room and masturbating during medication pass. -However, the incident was not documented in the behavior tracking software or in the resident's treatment administration records (TAR). A progress note, dated 1/29/25 at 9:54 p.m., revealed Resident #62 was asking an unidentified nurse and CNA to come into his room. When the nursing staff members responded and asked Resident #62 what he needed, he did not respond. When the nurse was in Resident #62's room assisting his roommate, Resident #62 began looking at the nurse inappropriately and grunting. When the nurse exited the room, Resident #62 told her he loved her. -However, the incident was not documented in the behavior tracking software or in the TAR. A progress note, dated 3/21/25 at 12:39 p.m., revealed an unidentified CNA witnessed Resident #62 masturbating in another resident's room. The other residents slept through the situation and did not wake up. The CNA relocated Resident #62 away from the room and told the resident he could not perform those actions in others' rooms. The director of nursing (DON) spoke with Resident #62 and gave him choices to ensure his safety and the safety of others, and the resident agreed to relocate the resident to the all-male secured unit. The nursing staff were to continue to monitor Resident #62 for hypersexual behaviors. -However, the incident was not documented in the behavior tracking software or in the TAR. A quarterly interdisciplinary team (IDT) conference, initiated 3/20/25 at 12:21 p.m. and finalized 3/23/25 at 9:09 p.m., revealed Resident #62 was independent in his activities of choice. Resident #62 participated in the work therapy program by passing out the daily bulletin. Resident #62 enjoyed watching television (TV), visiting with his peers, and going out for scheduled smoke breaks. Resident #62 was re-educated on places in which it was appropriate to masturbate. Resident #62 was re-educated on not going into other residents' rooms. An IDT note, dated 3/25/25 at 9:30 a.m., revealed that on 3/21/25 at 1:30 a.m. Resident #62 was observed by a CNA masturbating in the doorway of Resident #39 and Resident #59's room. When confronted, Resident #62 said he did not know what they were talking about. Interventions implemented included moving Resident #62 back to the all-male secured unit. Risk factors included Resident #62's history of sexually inappropriate behavior and mental illnesses. A change in condition note, dated 3/26/25 at 3:33 p.m., revealed Resident #62 had a change in condition due to behavioral symptoms. The note documented the facility staff said Resident #62's behaviors were still present with masturbation in public view. No new interventions or orders were documented. Behavior tracking through the facility's behavior tracking software was reviewed from 9/24/24 through 3/25/25 and revealed the following: On 11/14/24 at 11:40 a.m. Resident #62 asked a CNA to wash his private area while she was assisting him with his shower and Resident #62 told the CNA he could see down her shirt as she was assisting him with putting on his socks. On 1/19/25 at 8:08 p.m. a CNA reported to the nurse that Resident #62 was masturbating and saying to her I know you're over there baby, come on over here repeatedly. The nurse educated Resident #62 that he could masturbate in his room privately but it was unacceptable to ask any staff members to help him. -However, the 1/19/25 incident was not documented in the progress notes or in the TAR. C. Resident #59 (victim) 1. Resident status Resident #59, age 75, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia and generalized muscle weakness. The 12/20/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. The resident was dependent or required maximal assistance with most ADLs. 2. Record review A progress note, dated 3/21/25 at 1:30 a.m., revealed a CNA reported she saw a resident in Resident #59's room sitting in his wheelchair exposing his genitals. The CNA moved the other resident out of Resident #59's room. Resident #59 remained asleep and did not appear to wake up or be aware of the incident. All parties were notified per facility protocol by the DON. A progress note, dated 3/23/25 at 11:55 p.m., revealed Resident #59 was resting in bed and did not voice any concerns to the nurse on staff. The nurse would continue to monitor the resident. An IDT note, dated 3/25/25 at 10:07 a.m., revealed on 3/21/25 at 1:30 a.m. a CNA observed a male resident in the doorway of Resident #59's room exposing his genitals. The resident was quickly removed from the room. Resident #59 was sleeping and was not aware of the man's presence. The NHA, the DON, the resident, and the resident's responsible party were notified. Interventions were put into place to prevent any recurrences. -However, the note did not specify what interventions were put into place to prevent recurrence. D. Resident #39 (victim) 1. Resident status Resident #39, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included generalized anxiety disorder, insomnia and depression. The 1/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident was dependent or required maximal assistance with most ADLs. 2. Record review A progress note, dated 3/21/25 at 1:30 a.m., revealed a CNA reported she saw a resident in Resident #39's room sitting in his wheelchair exposing his genitals. The CNA moved the other resident out of Resident #39's room. Resident #39 remained asleep and did not appear to wake up or be aware of the incident. All parties were notified per facility protocol by the DON. An IDT note, dated 3/25/25 at 9:43 a.m., revealed on 3/21/25 at 1:30 a.m. a CNA observed a male resident in the doorway of Resident #39's room exposing his genitals. The resident was quickly removed from the room. Resident #39 was sleeping and was not aware of the man's presence. The NHA, the DON, the resident, and the resident's responsible party were notified. Interventions were put into place to prevent any recurrences. -However, the note did not specify what interventions were put into place to prevent recurrence. E. Staff interviews CNA #6 was interviewed on 3/25/25 at 9:02 a.m. CNA #6 said Resident #62 had sexually inappropriate behaviors sometimes but never towards her. CNA #6 said she never personally witnessed any sexual behaviors from Resident #62. CNA #6 said Resident #62 was able to be redirected when he was having sexually inappropriate behaviors. CNA #6 said she knew Resident #62 had been inappropriate and masturbated in front of other CNAs. CNA #6 said Resident #62 had sexually inappropriate behaviors day and night, but was only interested in women. CNA #6 said she documented any behaviors Resident #62 exhibited into their behavior monitoring software and would notify the nurse and the social services director (SSD) if she saw any behaviors. CNA #6 said the activities department employed Resident #62 to deliver the daily bulletin to each resident's room. CNA #6 said Resident #62 would peek into residents' rooms while he delivered the news. CNA #5 was interviewed on 3/25/25 at 9:18 a.m. CNA #5 said she tried to avoid working with Resident #62 as much as possible because she had heard from other CNAs that he was inappropriate and would masturbate in front of them. CNA #5 said Resident #62 had not been inappropriate with her, but she said if he had been, she would have let the nurse know. CNA #5 said when Resident #62 distributed the daily bulletin he would slowly put them in the female residents' rooms and linger in their doorways peeking in. CNA #5 said she would close the residents' doors or redirect Resident #62 if she saw him lingering. CNA #7 was interviewed on 3/25/25 at 9:34 a.m. CNA #7 said Resident #62 would go into other residents' rooms and have sexually inappropriate behaviors. CNA #7 said Resident #62 had previously stayed in his room and not bothered anyone but after moving to a different unit, he began having behaviors. CNA #7 said Resident #62 had sexually inappropriate behaviors every two days or so and would masturbate in his room. Licensed practical nurse (LPN) #1 was interviewed on 3/25/25 at 9:58 a.m. LPN #1 said she never witnessed Resident #62 having inappropriate behaviors but she knew he would masturbate in front of staff. LPN #1 said Resident #62 had sexually inappropriate behaviors in front of ladies and was able to be redirected easily for a short time. LPN #1 said Resident #62 was moved back to the all-male secured unit for the safety of other residents after he masturbated in front of two female residents in their doorway. CNA with medication authority (CNA-Med) #1 was interviewed on 3/25/25 at 10:10 a.m. CNA-Med #1 said Resident #62 was very different in the all-male secured unit than he was in the unsecured unit. CNA-Med #1 said Resident #62 was mellow on the secured unit and spent his time hanging out in his room and playing dominos. CNA-Med #1 said Resident #62 was having sexually inappropriate behaviors on the South unit with staff and other residents approximately once per week. CNA-Med #1 said Resident #62 was able to be redirected when he was having sexually inappropriate behaviors. CNA-Med #1 said Resident #62 never had any sexually inappropriate behaviors when he lived in the secured unit previously. CNA-Med #1 said Resident #62 had a job with the activities department to go door to door and pass out the daily bulletins. CNA-Med #1 said behaviors were charted in the facility's behavior monitoring software or in the TAR. The DON was interviewed on 3/26/25 at 4:40 p.m. The DON said the incident involving Resident #62 happened overnight on 3/21/25. The DON said he received a call from CNA #4 who told him she was in another resident's room, heard a noise, and saw Resident #62 halfway in the doorway of Resident #59 and Resident #39's room. CNA #4 said Resident #62 had his genitals exposed and was masturbating. The DON said when he came in later on the morning of 3/21/25, the facility staff interviewed Resident #62 and discussed what his next steps would be. The DON said the facility did a trial move with Resident #62 out of the secured unit because he did not exhibit any hypersexual behaviors when he was on the secured unit. The DON said he notified the NHA of the incident immediately. The DON said Resident #62 was mellow and redirectable on the secured unit and had never displayed any sexually inappropriate behaviors when he was on the secured unit. The NHA was interviewed on 3/26/25 at 5:15 p.m. The NHA said any allegations of abuse needed to be reported to him regardless of the time. The NHA said if he was not available, abuse allegations should be reported to the nurse on-call. The NHA said any abuse allegations needed to be reported to the State Agency within 24 hours. The NHA said after reporting the allegation, the facility staff would launch an investigation, ask for staff statements and interview any residents within the vicinity of the incident. The NHA said he was notified later in the morning on 3/21/25 about Resident #62's incident on 3/21/25. The NHA said when CNA #4 reported the incident, the facility staff explained Resident #62's options to him and the resident elected to go back into the secured unit. The NHA said he got a statement from the CNA who witnessed the incident and that he interviewed Resident #59 and Resident #39 and they were both asleep. The NHA said he asked both Resident #59 and Resident #39 if they felt safe and if they had witnessed any abuse and neither resident expressed any knowledge of the situation. The NHA said he had not reported the incident to the State Agency as he had reached out to one of the facility's clinical consultants and was told the incident was not abuse. Cross-reference F609 for failure to report an allegation of abuse to the State Agency. The NHA said he did not interview any other residents, as CNA #4 said no other residents were in the hallway because the incident occurred overnight. The NHA said he did not feel the need to interview any other residents as they had not seen Resident #62 that night. 50690 III. Incident of physical abuse between Resident #97 and Resident #34 on 2/28/25 A. Facility investigation The facility's investigation was provided by the NHA on 3/25/25 at 1:00 p.m., revealed the following: On the morning of 2/28/25, a physical altercation was witnessed between Resident #34 and Resident #97. The altercation occurred in the hallway near Resident #34's bedroom. LPN #6 immediately separated the two residents and both residents were placed on 15-minute checks for the investigation period. LPN #6 assessed both residents and no injuries were present. Resident #34 said he could not recall the altercation with Resident #97. Resident #97 could not communicate any recollection of the incident to staff. Other residents from the unit and staff witnesses were interviewed and revealed the following: Other residents from the same unit stated that they got along with Resident #34 and Resident #97 and did not have any instances of abuse to report. The staff witnesses stated that Resident #97 was walking down the hallway and Resident #34 was in his way. Resident #34 was facing away from Resident #97. Resident #97 attempted to move Resident #34 from behind when Resident #34 reached back and made contact with Resident #97, without looking to see who was behind him. CNA #9 said that on 2/8/25 at approximately 9:30 a.m., she heard a loud noise in the hall and saw Resident #34 and Resident #97 fighting. She said she did not see any contact between the residents, but saw Resident #97 attempt to pick up his walker to hit Resident #34. She said she told Resident #97 everything was okay and tried to re-direct him away from Resident #34. She said when Resident #97 returned and walked near Resident #34 again another staff member re-directed Resident #97 back to his room and he laid down for a nap. LPN #6 said that on 2/8/25 at approximately 9:30 a.m., there was an altercation between Resident #34 and Resident #97. The altercation occurred in the hallway near Resident #34's bedroom. LPN #6 said that Resident #97 attempted to pass by Resident #34 in the hall and pushed Resident #34 aside. LPN #6 said Resident #34 became upset and attempted to hit Resident #97. LPN #6 said the situation did not escalate because the residents were separated. LPN #6 said the residents were assessed and no injuries were found. The NHA and the residents' representatives were notified. Care plans were reviewed and no changes were made. The altercation was unsubstantiated as an act of abuse. -However, abuse occurred because Resident #97 attempted to hit Resident #34 with his walker and Resident #34 retaliated and made physical contact with Resident #97. B. Resident #34 (assailant and victim) 1. Resident status Resident #34, age 71, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances. The 2/4/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a BIMS) of three out of 15. He walked independently but was dependent on staff assistance for all ADLs. The assessment indicated the resident had fluctuating inattention and disorganized thinking. He had delusions and physical behavioral symptoms directed toward others on one to three days during the assessment look-back review period. He had behavioral symptoms not directed toward others on a daily basis. 2. Record review Resident #34's medication care plan, revised 6/14/22, identified the resident was at risk of complications related to antipsychotic medication use for diagnoses of insomnia and dementia with behavioral disturbances. Resident #34's trigger behaviors for mood stabilizer use were impulsiveness and erratic/irrational response to stimuli. His trigger behaviors for antipsychotic use were physical aggression and erratic/irrational responses to stimuli. Interventions included administering antipsychotic medications as ordered and monitoring for any adverse side effects of medication use, consulting with pharmacy and the physician to consider dosage reduction when clinically appropriate, at least quarterly, and monitoring and documenting the resident's trigger behaviors (revised 2/18/23), giving the resident space when he was aggressive or upset, not approaching the resident from behind or the side due to the resident's visual impairments (revised 6/13/23), leading Resident #34 back to areas where staff were positioned in order to keep him visible, encouraging him to stay clear of door ways (revised 7/27/23) and keeping Resident #34 in line of sight if possible (revised 3/28/24). Resident #34's care plan for behaviors, initiated 4/13/22, revealed Resident #34 had behaviors including aggressiveness towards peers and staff and poor impulse control related to dementia, traumatic brain injury, post-traumatic stress disorder (PTSD) and a history of work as a prison guard. The resident had a history of attempting to, or threatening to hit staff. He hallucinated (reached for things that were nonexistent), had poor safety awareness and attempted to self-transfer. Resident #34's triggers included others speaking to him or about him and others approaching or touching him from the back or side and surprising him. Pertinent interventions included monitoring behavior episodes and attempting to determine the underlying cause, documenting behavior and potential causes, praising any indication of progress/improvement in behavior (initiated 4/13/22), performing frequent checks for 72 hours following any verbal or physical aggression observed or reported and providing opportunities for positive interaction and attention re-evaluation of medication management due to the resident's continued behaviors (revised 2/18/23), de-escalation by sitting with him with his back against a wall, when agitated, staff should offer him fluids and his preferred snacks (revised 3/13/23) and frequent checks and back scratches. He enjoyed being called gorgeous while having his back scratched (revised 2/26/24). A review of Resident #34's March 2025 CPO revealed the following physician's orders: Behavior monitoring for antipsychotic medication use every shift, ordered 12/12/24. Monitoring effectiveness of interventions for behaviors, ordered 12/12/24. Monitor resident every shift due to physical aggression initiated, monitor physical aggression until 2/11/25 at 11:59 p.m., ordered 2/9/25. A change in condition progress note, dated 2/8/25, revealed Resident #34 initiated an act of physical aggression. Resident #34's vital signs were within normal limits, and he had no changes in mental or physical status. The resident's representative was notified of the incident. An interdisciplinary team (IDT) progress note, dated 2/10/25, revealed Resident #34 had risk factors that contributed to his behavior, including a traumatic brain injury, dementia, poor situational and safety awareness. Interventions included separating the two residents, and for staff to ensure that other residents did not approach Resident #34 from behind. C. Resident #97 (victim and assailant) 1. Resident status Resident #97, age 85, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances. The 1/21/25 MDS assessment documented the resident had severely impaired cognition with a BIMS score of zero out of 15. He required partial or maximum assistance for transfers and used a walker for mobility. He required touching assistance or supervision with walking. The assessment indicated the resident had daily behaviors that were not directed toward others. 2. Record review Resident #97's behavioral care plan, revised 2/3/25, revealed the resident had a behavior problem related to his dementia, language and cultural barrier and he made nonsensical statements. He had a history of physical aggression towards females and was also possessive and overprotective of his belongings, peers and partners. The resident paced and sometimes inadvertently ran into others while walking. Pertinent interventions included providing frequent checks following any verbal or physical aggression, intervening as necessary to protect others, approaching him and speaking in a calm manner, diverting his attention, removing him from the situations to an alternate location if needed, monitoring behavior episodes and attempting to determine the underlying cause, documenting behavior and potential causes, praising any indication of progress/improvement in behavior and staff to ensure the resident was not too close to others while walking in the hallway. A progress note, dated 2/8/25, revealed an altercation between Resident #34 and Resident #97 occurred in the hallway. Resident #97 attempted to pass by Resident #34, pushing Resident #34 aside. Resident #34 got upset and swung at Resident #97. The two residents were separated. No injuries were found. The NHA and Resident #97's legal guardian were notified. An IDT progress note, dated 2/10/25, revealed on 2/8/25 at 12:41 p.m. there was a physical altercation between Resident #97 and another resident (Resident #34) while passing in the hallway. Resident #97 inadvertently pushed Resident #34 aside while walking past his wheelchair. Resident #34 swung at Resident #97 in response. The residents were immediately separated. No injuries were noted. The NHA was notified. Staff was to monitor for Resident #97 to have a path clear of wheelchairs while walking in the hallway. A progress note, dated 3/11/25 at 11:59 p.m., revealed completion of 72 hours of frequent 15-minute checks for Resident #97. No problems were reported. D. Staff interviews LPN #2 was interviewed on 3/26/25 at 3:28 p.m. LPN #2 said she could not remember who the aggressor was in the altercation between Resident #34 and Resident #97. She said what she remembered was that Resident #97 used to pace the hall with his walker. She said he was usually calm and collected, but at times the halls got crowded with residents. She said Resident #34 did sometimes have aggressive behaviors. CNA-Med #1 was interviewed on 3/26/25 at 3:45 p.m.CNA-Med #1 said she was not working the day of the altercation between Resident #97 and Resident #34. She said when she returned to work two days later, Resident #34 and Resident #97 were both being documented on frequently due to the altercation. She said she was told by the previous nurse that Resident #97 had been in a bad mood that day (2/8/25) and rammed his walker into the back of Resident #34's wheelchair. She said Resident #34 was easily triggered, sometimes mean, and had previously attempted to hit staff. She said staff normally walked away and let Resident #34 calm down when he was agitated, or staff who had good rapport with him would calm him down. She said she did not know if contact was made during the altercation on 2/8/25, but staff were told to keep an eye on both of the residents. She said she did not think the police were called, but families/representatives and the physician were notified. IV. Incident of physical abuse of Resident #42 by Resident #58 on 3/10/25 A. Facility investigation The facility's investigation was provided by the NHA on 3/25/25 at 1:00 p.m. revealed the following: On 3/10/25 an incident occurred between Resident #58 and Resident #42. Resident #58 allegedly made contact with another resident (Resident #42). Resident #58 attempted to kick Resident #42. The incident was witnessed by staff. Residents and staff from the unit were interviewed, statements were obtained from staff and the victim (Resident #42) was interviewed. The DON assessed Resident #42 and found no injuries. The assailant (Resident #58) was discharged to the hospital because he was unable to be redirected. Resident #42 (victim) had a history of delusions, and verbal aggression towards peers and staff. Resident #42 had a BIMS of 15 and had not been involved in any other occurrences in the past year. Resident #58 had a BIMS of three, required assistance for ADLs, and had a history of verbal and physical aggression towards staff and residents. Resident #58 had become physically aggressive towards other residents when they had food he wanted. When staff attempted to re-direct him, he sometimes attempted to hit staff. Resident #58 wandered into other residents' rooms. There was a care plan for his behaviors, including a communication board, anticipating his needs, offering snacks and redirecting. Resident #58 had been involved in other occurrences of physical abuse on 11/19/24, 1/18/25, 1/20/25. Staff stated that Resident #58 had been having more behavioral episodes recently. They were unable to identify why, except that the resident had a history of being physically aggressive towards others. There were no interactions between the victim (Resident #42) and Resident #58 leading up to the incident on 3/10/25. Care plans and documentation were reviewed. The conclusion was that there was contact made but that it did not rise to the definition of abuse. -However, abuse occurred because Resident #58 willfully kicked Resident #42 (see witness statements below). Changes were made to Resident #58's plan, including discharging him to the hospital with possible re-evaluation at a future date. The police, ombudsman, family/guardian, and physician were notified. Interviews during the investigation revealed the following: On 3/10/25, CNA-Med #1 reported that she saw Resident #58 open his bedroom door, quickly walk over to the dining room and start kicking Resident #42, who was sitting in the dining room watching television. CNA-Med #1 said she separated the residents and Resident #58 shoved her into the medication cart. Other staff intervened quickly and re-directed Resident #58 back to his bedroom to lay down. Both residents were assessed and no injuries were noted. The physician, ombudsman and the corporate support person were called. Resident #58 was transferred to the hospital non-emergently. When the emergency medical technicians (EMTs) arrived, Resident #58 had to be restrained and sedated. Resident #58 was taken to the emergency room because he had become a danger to himself and others and he could not be redirected. Resident #42 was interviewed on 3/10/25 by the DON, immediately after the incident. Resident #42 said he was sitting in the dining room watching television when Resident #58 started kicking him. Resident #42 said he was fine and did not get hurt and just went back to watching television. <[TRUNCATED]

Based on record review and interviews, the facility failed to develop a comprehensive care plan for three (#1, #75 and #249) of six residents out of 36 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure a comprehensive care plan was developed to address Resident #1's use of supplemental oxygen and a peripherally inserted central catheter (PICC); and, -Ensure a comprehensive care plan was developed to address Resident #75 and Resident #249's insomnia. Findings include: I. Facility policy and procedure The Comprehensive Person-Centered Care Plans policy, revised March 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:42 p.m. The policy read in pertinent part, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition and at least quarterly. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physicians orders (CPO), diagnoses included schizoaffective disorder (mental illness), vascular dementia and cellulitis of the left lower limb. The 2/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision to maximum assistance for most activities of daily living (ADL). B. Resident and resident representative interview Resident #1 and her representatives were interviewed together on 3/23/25 at 10:33 a.m. The resident's representatives said Resident #1 had an infection in her leg which became swollen and was treated with antibiotics. The resident's representatives said the facility placed a PICC line for the antibiotics. The resident's representatives said Resident #1 usually had her nasal cannula on and that she had been treated for pneumonia the week prior. Resident #1 said she needed supplemental oxygen all the time. C. Record review The end of life care plan, initiated 3/24/25 (during the survey process), revealed Resident #1 was receiving hospicare care. Pertinent interventions included providing supplemental oxygen as ordered. -Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or other interventions related to Resident #1's use of supplemental oxygen. -Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or interventions related to Resident #1's PICC line or maintenance of the PICC line. Review of the March 2025 CPO revealed the following physician's orders: Midline intravenous (IV) placement, ordered 3/7/25; Radiographs to check for midline (PICC) placement, ordered 3/7/25; Normal saline flush solution, with instructions to use 10 milliliters (ml) intravenously two times a day for cellulitis/pneumonia. Flush before and after medication, ordered 3/7/25; Vancomycin IV solution 750 milligrams (mg) per 150 ml, with instructions to use 750 mg intravenously every 12 hours for cellulitis for ten days, ordered 3/6/25 and discontinued 3/13/25; Vancomycin IV solution 500 mg per 150 ml, with instructions to use 1000 mg intravenously every 12 hours for cellulitis until 3/17/25, ordered 3/6/25; PICC line dressing change every seven days, ordered 3/25/25 (during the survey process); and, Oxygen 4 liters per minute (LPM) via nasal cannula. Check oxygen saturation each shift and as needed. Notify healthcare provider if saturation is less than 90%, ordered 3/23/25 (during the survey process). A progress note, dated 3/5/25 at at 10:14 a.m., revealed Resident #1 was receiving supplemental oxygen. A progress note, dated 3/7/25 at 10:14 a.m., revealed Resident #1 was ordered to receive an IV antibiotic and a PICC line was requested. A progress note, dated 3/13/25 at 3:44 p.m., revealed Resident #1 was receiving continuous supplemental oxygen via nasal cannula. D. Staff interviews The MDS coordinator (MDSC) was interviewed on 3/26/25 at 3:30 p.m. The MDSC said she reviewed the care plan and confirmed Resident #1's care plan did not address her use of oxygen or the use of the PICC line. The MDSC said the care plan should have interventions to elevate the head of the bed, ensure they were following physician's orders and also to check oxygen saturation levels. The MDSC said the care plan needed to include interventions for the PICC line that included keeping the line patent and monitoring for infections and directions for flushing. III. Resident #75 A. Resident status Resident #75, age 78, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia with anxiety, adult failure to thrive, insomnia and depression. The 2/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required supervision or touching assistance with most ADLs. The assessment documented the resident took several high-risk medications including antidepressants, antianxiety, antipsychotic, anticonvulsants, and opioids. B. Record review Review of Resident #75's comprehensive care plan, revised 2/25/25, did not reveal any focus or interventions related to her diagnosis of insomnia or use of medications to treat her insomnia. Review of the March 2025 CPO revealed the following orders: Trazodone 100 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 2/5/25; Melatonin 3 mg oral tablet, instructions to give two tablets by mouth one time a day for insomnia, ordered 2/5/25 and discontinued 3/25/25 (during the survey process); and, Melatonin 3 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia, ordered 3/25/25. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 12:45 p.m. LPN #1 said Resident #75 received trazadone for insomnia. She said the resident complained of not being about to sleep. She said the resident's hours of sleep were tracked. She said she slept during the day and that could affect her sleeping at night. She said the care plans were updated by the MDSC. The MDSC was interviewed on 3/26/25 at 3:30 p.m. The MDSC said each resident had a plan of care. She said the plan of care began on the admission with a baseline care plan. She said she was responsible to complete the care plan, however, the nurses and other departments were responsible to update the care plan as needed. The MDSC reviewed the care plan for Resident #75 and confirmed there was not a care plan for insomnia. She said a care plan to help with interventions for sleep should be written. 20287 IV. Resident #249 A. Resident status Resident #249, age 77, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia with severe agitation, insomnia and alcohol dependence with alcohol induced persisting. The 3/4/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident required supervision or touching assistance with most ADLs. The assessment documented the resident was prescribed several high-risk medications including antidepressants, antipsychotic, and opioids. B. Record review Review of Resident #249's comprehensive care plan, revised 3/19/25, did not reveal any focus or interventions related to her diagnosis of insomnia. Review of the March 2025 CPO revealed the following orders: Trazodone 50 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 3/6/25. C. Staff interviews LPN #2 was interviewed on 3/26/25 at 12:45 p.m. LPN # 2 confirmed Resident #249 received trazadone for insomnia. She said her sleep hours were tracked. She said due to her dementia diagnosis, she sundowned and she was up at night at times. The MDSC was interviewed on 3/26/25 at 3:30 p.m. The MDSC reviewed the care plan for Resident #249 and confirmed there was no care plan for insomnia. She said a care plan to help with interventions for sleep should be written.

Based on record review and interviews, the facility failed to ensure three (#95, #75 and #249) of five residents out of 36 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to: -Ensure consents were obtained that included the risks versus benefits for psychotropic medications for Resident #95, Resident #75 and Resident #249; and. -Ensure Resident #95 and Resident #75 had behavior monitoring in place for the use of psychotropic medications. Findings include: I. Facility policy and procedure The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. It revealed in pertinent part, Drugs in the following categories are considered psychotropic medications and are subject to specific prescribing, monitoring, and review requirements: anti-psychotics, anti-depressants, anti-anxiety medications and hypnotics. Residents, families and/or the representative are involved in the medication management process, including: indications for use, dose, duration, adequate monitoring for effectiveness and adverse consequences, and preventing, identifying and responding to adverse consequences. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Use of psychotropic medications may be appropriate in specific circumstances, such as for enduring conditions and/or new admissions where the resident is already on a psychotropic medication. Residents receiving psychotropic medications are monitored for adverse consequences and residents (and/or representatives) have the right to decline treatment with these medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. II. Resident #95 A. Resident status Resident #95, age [AGE], was admitted on [DATE]. According to the March 2025 computerized physician's orders (CPO), diagnoses included acute and chronic respiratory failure and major depressive disorder. The 2/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision or touching assistance with most activities of daily living (ADL). The assessment documented the resident took several high-risk medications including antidepressants, hypnotics and anticonvulsants. B. Resident and representative interview Resident #95 was interviewed on 3/26/25 at 12:26 p.m. Resident #95 said her representative signed all of her documents on admission. Resident #95 said she was not sure what documents her representative signed. Resident #95's representative was interviewed on 3/26/25 at 3:19 p.m. The representative said she did not think the facility staff reviewed any medication side effects with her. The representative said she did not remember signing any medication consent forms. C. Record review The antidepressant care plan, initiated 2/20/25, revealed Resident #95 was taking an antidepressant medication to treat her diagnosis of major depressive disorder. Pertinent interventions included educating Resident #95 and her representatives on the risks, benefits, and side effects of the drugs being given, giving the antidepressant medication as ordered, monitoring and documenting ongoing signs or symptoms of depression, and monitoring and documenting medication side effects. The hypnotic care plan, initiated 2/20/25, revealed Resident #95 was taking a hypnotic medication to treat her insomnia (difficulty sleeping). Pertinent interventions included administering the medication as ordered and monitoring and documenting medication side effects. Review of the March 2025 CPO revealed the following physician's orders: Mirtazapine 30 milligram (mg) tablets instructions to give 30 mg by mouth at bedtime for depression, ordered 1/31/25; Venlafaxine extended release 150 mg oral tablet, instructions to give 150 mg by mouth one time a day for depression, ordered 2/1/25; Venlafaxine extended release 37.5 mg oral tablet, instructions to give 37.5 mg by mouth one time a day for depression, ordered 2/1/25; and, Zaleplon 5 mg oral capsule, instructions to give 5mg by mouth at bedtime for insomnia, ordered 1/31/25 and discontinued 3/12/25. -Review of the March 2025 CPO, as well as Resident #95's electronic medical record (EMR), did not reveal any orders for antidepressant or hypnotic medication side effect monitoring or monitoring of target behaviors for depression. -Review of Resident #95's EMR did not reveal any psychoactive medication consent forms. III. Resident #75 A. Resident status Resident #75, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia with anxiety, adult failure to thrive, insomnia and depression. The 2/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS assessment score of 14 out of 15. The resident required supervision or touching assistance with most ADLs. The assessment documented the resident took several high-risk medications including antidepressants, antianxiety, antipsychotic, anticonvulsants, and opioids. B. Resident and representative interview Resident #75 and her representative were interviewed together on 3/26/25 at 12:25 p.m. Resident #75 said she did not remember signing any consent forms for her anxiety medications. Resident #75 and her representative said did not remember signing any forms with any medication side effect information. C. Record review The antianxiety medication care plan, initiated 2/25/25, revealed Resident #75 was taking an antianxiety medication to treat her anxiety disorder. Pertinent interventions included monitoring and documenting medication side effects, and observing Resident #75's mood and response to the medication. The antidepressant care plan, initiated 2/25/25, revealed Resident #75 was taking an antidepressant medication. Pertinent interventions included administering the medication as ordered, monitoring and documenting medication side effects and observing Resident #75's mood and response to the medication. The antipsychotic care plan, initiated 2/25/25, revealed Resident #75 was taking an antipsychotic to treat her depression. Pertinent interventions included administering the medication as ordered, monitoring and documenting medication side effects and monitoring target behaviors. Review of the March 2025 CPO revealed the following physician's orders: Olanzapine 5mg oral tablet, instructions to give one tablet by mouth at bedtime for depression, ordered 2/5/25; Trazodone 100mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 2/5/25; Fluoxetine 60mg oral tablet, instructions to give 60mg by mouth one time a day for depression, ordered 2/6/25; Melatonin 3mg oral tablet, instructions to give two tablets by mouth one time a day for insomnia, ordered 2/5/25 and discontinued 3/25/25 (during the survey process); and, Melatonin 3mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia, ordered 3/25/25. -Review of the March 2025 CPO, as well as Resident #75's EMR, did not reveal any orders for antidepressant or hypnotic medication side effect monitoring or monitoring of target behaviors for depression. -Review of Resident #75's EMR did not reveal any psychoactive medication consent forms. IV. Staff interviews Licensed practical nure (LPN) #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #75 was on several sleep medications and one of them was recently discontinued. LPN #1 said Resident #75's physician had just lowered her dose of melatonin from 6 mg to 3 mg. -However, review of Resident #75's EMR did not reveal any psychoactive consent forms pertaining to any sleep aides or changes in sleep aide doses. LPN #1 was interviewed again on 3/26/25 at 1:13 p.m. LPN #1 said when a resident started a new psychoactive medication the nursing staff would monitor their behaviors and for any side effects for two weeks. LPN #1 said this was monitored in the treatment administration record (TAR). LPN #1 said residents needed to have a signed consent form for any psychoactive medications prior to the medication being administered. LPN #1 said Resident #95 was on a few psychoactive medications for her depression. LPN #1 reviewed Resident #95's EMR and said she did not see any antidepressant side effect or behavior monitoring in her TAR. LPN #1 said she did not see any orders for antidepressant side effect or behavior monitoring in Resident #95's EMR. LPN #5 was interviewed on 3/26/25 at 2:46 p.m. LPN #5 said when a resident was prescribed psychotropic medications the staff monitored the resident's behavior and for any side effects. LPN #5 said this was usually documented in the resident's TAR, and a physician's order was obtained for side effects and behavior monitoring was usually in the CPO. LPN #5 said behavior and side effect monitoring were performed for psychotropic medications as the nursing staff and physicians wanted to ensure the medications were working appropriately, ensure the resident's symptoms are not worsening, and ensure the medication is not causing any side effects. LPN #5 said behavior and side effect monitoring was performed so the practitioner could adjust the medication dose as needed or stop the medication altogether. LPN #2 was interviewed on 3/26/25 at 3:30 p.m. LPN #2 said when she received an order for a new psychotropic medication or a change in dosage she confirmed the order before documenting it on a list at the nurse's station. LPN #2 said the list was used to notify the nurse on the next shift to monitor the resident for adverse reactions and behavior monitoring and document it in their EMR. LPN #2 said she had never obtained consent for a new medication or a change in medications. The director of nursing (DON) was interviewed on 3/26/25 on 3:35 p.m. The DON said the facility nurses did not obtain the consent forms when a resident had orders for a new psychoactive or change in a psychoactive medication/dosage. The DON said the unit managers and nursing leadership, including himself, obtained consent either from the resident or the resident representative before the initiation of the medication. The DON said the psychoactive medication consent was a form that is filled out on the EMR. The DON said if the consent form was not in the EMR it was not obtained. The DON was interviewed again on 3/26/25 at 4:40 p.m. The DON said behavior and side effect monitoring were initiated on admission or within 24 hours of starting a psychoactive medication. The DON said target behavior monitoring was used to see if the treatment was effective and to find the lowest effective dose of medication interventions. The DON reviewed Resident #95's orders and said she was not able to find any orders for behavior or side effect monitoring.IV. Resident #249 A. Resident status Resident #249, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, diagnoses included severe unspecified dementia with agitation and Wernicke's encephalopathy (severe neurological disorder caused by thiamine deficiency). The baseline care plan, initiated 2/28/25, revealed the resident was cognitively impaired due to a diagnosis of dementia. It documented she had a history of falls, was taking psychoactive medications and needed assistance with ADLs. B. Record review The psychoactive drug care plan, initiated on 3/19/25, documented the resident required an antipsychotic medication related to dementia with behaviors (delusions and inappropriate behaviors in public). Interventions included administering antipsychotic medications as ordered, attempting gradual dose reductions as indicated/ordered or if condition improved, utilizing non-pharmacological approaches prior to medication administration, such as providing a quiet and dark environment, assessing pain/discomfort, providing back rubs, offering warm beverages, encouraging out of room activity, providing activity materials of choice, going outdoors, encouraging family/friend visitation and encouraging her to verbalize feelings. Observe for and document the effectiveness of treatment, and report signs of medication side effects (including insomnia) or adverse reactions. The anti-depressant care plan, initiated on 3/19/25, documented the resident was prescribed an antidepressant medication related to anxiety and post-traumatic stress disorder (PTSD). Pertinent interventions included administering anti-depressant medications as ordered, monitoring/documenting side effects and effectiveness, educating family/caregivers about risks, benefits, side effects and/or toxic symptoms of the anti-depressant medications, and monitoring/documenting/reporting to the physician any ongoing signs and symptoms of depression unchanged by medication use. Review of the March 2025 CPO revealed the following physician's orders: Trazadone hydrochloride (hcl) oral tablet 50 mg, give one tablet by mouth at bedtime for insomnia, may use half of a 100 mg tablet, ordered 3/6/25; and, Zyprexa oral tablet 10 mg (Olanzapine), give 0.5 tablet by mouth in the afternoon for dementia with agitation for four days and give one tablet by mouth in the afternoon for dementia with agitation, ordered 3/20/25. -Review of Resident #249's EMR did not reveal documentation indicating consent forms were obtained prior to the administration of the trazadone and Zyprexa. C. Staff interviews LPN #2 was interviewed on 3/26/25 at 3:30 p.m. She said when she received a physician's order for a new psychotropic medication or a change in dosage, she confirmed the order. She said she notified the oncoming nurse to monitor and document adverse reactions and behaviors. She said she had never obtained consent for a new medication or a change in medications. The DON was interviewed on 3/26/25 on 3:35 p.m. He said when a resident was prescribed a new psychoactive drug or a change in a psychoactive medication/dosage, the nurses did not obtain consent. He said the unit managers and nursing leadership, including himself, obtained consent either from the resident or the resident's representative before the initiation of the change. He said the consent was a form that was filled out in their EMR system for informed consent for psychoactive medication. He said if it was not there, it was not done.

Based on record review and interviews, the facility failed to ensure the residents right to be free from abuse, neglect, misappropriation of property, or exploitation for two (#1 and #2) of three residents reviewed for abuse out of seven sample residents. The facility failed to ensure Resident #1 was free from staff to resident abuse which resulted in a fall and a major injury of a [MEDICAL CONDITION] which required surgical repair and caused a decline in her physical function due to certified nurse aide (CNA) #1 failures to follow her plan for her behaviors. Cross-reference F744 failure to provide treatment and services for dementia care. Furthermore, the facility failed to ensure Resident #2 was free from resident to resident abuse by Resident #3 which resulted in bruises and skin abrasions. Findings include: I. Facility policy and procedure The Abuse Policy, revised 11/15/19, was provided by the nursing home administrator (NHA) on 9/10/2020 at 8:15 a.m. It read, in pertinent part: -The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. -When an employee of the facility abuses or is suspected of abuse of a resident, the employee is placed on immediate suspension while the matter is under investigation. In the event the investigation concludes that abuse did occur, appropriate disciplinary action will be carried out. -If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, upt and including hospitalization can then be implemented. When another resident jeopardizes the safety of one resident, alternative placement may be considered for that resident. II. Staff to resident abuse for Resident #1 A. Resident #1 Resident #1, age 84, was admitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 7/10/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of six out of 15. She exhibited delusions and verbal behaviors. She required extensive assistance of two staff members with mobility and activities of daily living (ADLs) with the exception of eating. B. Staff to resident abuse incident A. Incident 6/25/2020 On 6/25/2020 at 6:31 a.m. a progress note revealed the registered nurse (RN) #1 was alerted by the certified nurse aide (CNA) #1 that Resident #1 had fallen. The note read the CNA reported the resident was banging on another resident's door while she was attempting to provide care to the other resident. The CNA reported the resident forced herself into the room and when she tried to redirect the resident, her legs became twisted in her walker and she put herself on the floor and laid down in the hallway. The RN assessed the resident, the fall was witnessed with no head involvement. The resident denied any pain or discomfort, she was independent with ambulation with the use of a front wheeled walker. The resident refused vital signs, there were no observed or reported injuries. The resident was assisted up and walked to her room by staff. On 6/25/2020 at 9:59 a.m. a fall risk management note revealed the root cause of the resident's fall was impulsiveness and poor safety awareness, anxiety, and agitation. On 6/25/2020 at 9:16 p.m. a progress note revealed the resident began reporting pain in her knees and back related to being old. On 6/25/2020 a further investigation of the resident's fall was started by the NHA because the description given by the CNA did not make sense. The investigation included a review of the video footage from the hallway where the resident fell . The description of the video footage was as follows: The CNA was seen entering a resident room around 4:23 a.m. At 4:24 a.m., Resident #1 was seen leaving her room and walking across the hall to the other resident room and knocking on the door to get the CNA's attention, the knocking continued for approximately one minute (4:25 a.m.). When the door was not answered by the CNA, the resident began ramming her walker into the door to get the CNA's attention, the ramming continued for approximately one minute (4:26 a.m.). The resident then opened the door to the other resident's room and started to enter the room, though something stopped her in the doorway. The resident was seen to continue to attempt to enter the room and is continuously stopped. After several minutes of this, the resident appeared to be struggling with something inside the resident room and appeared to be being pushed out of the room. The resident attempted one more time to enter the room and she was pushed out again, stumbled to the side and tripped falling on her side. It was visible in the video that the CNA's hands were on the resident's walker. The CNA was seen stepping over the resident and walking to the secure door to get the nurse. The expanded fall investigation was turned into an abuse investigation and staff and resident interviews were conducted. The RN was interviewed on 6/25/2020 at 6:00 p.m. She stated Resident #1 was frequently needing to be redirected throughout the shift. She stated the CNA had reported when she was trying to exit the other resident's room, Resident #1's feet got crossed and she fell putting herself on her bottom. She stated the CNA did not say that she touched or moved the resident's walker. The CNA was interviewed on 6/25/2020 at 10:00 p.m. She stated the resident had been having behaviors all night, could not be redirected and nothing was enough for her that shift. She stated when she attempted to redirect the resident, her feet crossed and twisted and she fell . She stated she was speaking to the resident from the other side of the resident door explaining she could not provide care to her at the time and she had propped the other resident's bathroom door against the room door so Resident #1 could not enter. She stated she did not know if she had acted [MEDICATION NAME] or calmly when interacting with Resident #1 and she did not remember if she pushed the resident or not. Resident #1 was interviewed as part of the investigation on 6/26/2020 and stated she had been pushed and harmed by a staff member and she did not feel safe. When asked to explain, she stated there was an argument at that person's door. I pushed on the door cause she was closing it on my fingers and then it just escalated from there. Now my legs, back and hips are all jacked up. In the course of the investigation, the facility determined staff to resident abuse had occurred and the CNA was suspended and ultimately terminated, the police were notified, and the CNA was reported to the department of regulatory agencies (DORA) for case review. On 6/26/2020 at 9:30 a.m. a progress note revealed the resident reported shortness of breath, pain in her knees and back. No bruising, redness or swelling was observed related to her fall. Pain medications were administered per physician orders. On 6/26/2020 at 5:57 p.m. a progress note revealed the nurse practitioner was notified of the resident's pain in her knee and back. An order was given for the resident to go to the emergency room for evaluation. The resident returned to the facility on [DATE] after being diagnosed with [REDACTED]. Additional review of the resident's medical record revealed [REDACTED]. The resident's previous MDS assessment dated [DATE] revealed the resident was independent with her mobility prior to her fall and [MEDICAL CONDITION]. B. Staff interviews RN #1 was interviewed on 9/10/2020 at 5:30 a.m. She stated Resident #1 was anxious and needed redirection and reassurance often. She stated she was the nurse working the night of the fall. She stated the resident was difficult at times but calmed down when staff took the time to address her needs. She stated the CNA involved did not tell her the full story regarding the fall. CNA #2 was interviewed on 9/10/2020 at 5:39 p.m. She stated Resident #1 could be difficult to redirect at times, though she usually responded well to explaining that her needs will be met as soon as possible. She stated if the resident was insistent on receiving attention right then, she would try to stop what she was doing and help Resident #1. She stated she would not redirect a resident by touching or turning their walker because that could cause them to fall. The NHA was interviewed on 9/10/2020 at 12:28 p.m. She stated that upon review of the fall, the video surveillance and the circumstances around the fall, she and the interdisciplinary team felt the action was deliberate and the direct action of the CNA caused Resident #1 to fall. She stated the CNA's actions were abusive. The director of nursing (DON) was interviewed at 12:45 p.m. She stated the actions of the CNA would constitute abuse against the resident. She stated the actions did not follow the facility policy or training the staff received related to treatment of [REDACTED].#1's behaviors. III. Altercation between Resident #2 and Resident #3 A. Resident #2's status Resident #2, age under [AGE] years, was admitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 8/10/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of nine out of 15. He was independent with his mobility and ADLs requiring occasional set up assistance and had no behaviors. B. Resident #3's status Resident #3, age 73, was admitted on [DATE] and discharged on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 7/1/2020 MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status score of seven out of 15. He exhibited disorganized thinking, delusions, verbal and disruptive behaviors. He was independent with his mobility and ADLs. C. Altercation 7/16/2020 On 7/16/2020 at 3:17 p.m. a progress note revealed Resident #3 approached the nurse and asked for a bandage for his right hand. The nurse noticed his right hand was swollen, his second knuckle had scant bleeding and redness was noted to his right eye. The resident stated he beat him to the floor. An facility report from 7/16/2020 revealed a resident to resident altercation between Resident #2 and Resident #3. The report revealed Resident #2 and Resident #3 were roommates, the two exchanged words and Resident #3 came over to Resident #2's side of the room and began hitting him. Resident #2 was assessed and sustained right eye redness, abrasions to his scalp, nose, neck and right arm. Resident #3 also sustained right eye redness and an injury to his right hand. The facility documentation revealed the residents were immediately separated from each other and Resident #3 was moved to another room, he was placed on 15 minute safety checks and neurological checks were initiated and completed. His behavior and elopement care plans were updated to include new potential for aggression. The residents were both interviewed and neither resident expressed fear or feeling unsafe. Resident #2 did not remember why the altercation occurred and Resident #3 stated he hit his roommate first, though could not remember why. The investigation concluded with resident to resident abuse being substantiated. D. Staff interviews The NHA was interviewed on 9/10/2020 at 12:28 p.m. She stated the acts by the residents were intentional and the root cause was never fully determined by staff since the incident was not witnessed. She stated they thought it was possible Resident #3 was trying to go out the window which was on Resident #2's side of the room which may have started the verbal altercation and then the altercation turned physical. She stated the two residents had been roommates and had previously got along for a long time prior to the altercation on 7/16/2020. She stated neither resident had ever been physically or verbally abusive to other residents, though due to the injuries sustained by both residents and the statements they each made, resident to resident abuse was substantiated. She said the altercation was an isolated event and no further alterations have occurred with Resident #2 and Resident #3.

Based on record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with [REDACTED].#1) of three residents reviewed for dementia care out of seven sample residents. The facility failed to follow person-centered treatment and services to Resident #1 with a [DIAGNOSES REDACTED]. The resident had behaviors known to staff of a history of frequently making repetitive demands of staff, perseverating and exaggerating perceived health issues. Certified nurse aide (CNA) #1 failures to follow this plan caused Resident #1 to fall and sustain a [MEDICAL CONDITION] requiring surgical repair. Findings include: I. Professional reference The Alzheimer's Association (last updated 3/30/2020) Coronavirus (COVID-19): Tips for Dementia Caregivers in Long-Term or Community-Based Settings, retrieved on 9/15/2020 from: https://www.alz.org/professionals/professional-providers/coronavirus-covid-19-tips-for-dementia-caregivers?_ga=2XXX 437XXX XXX - XXX &_gac=1XXX 9244XXX .eaiaiqobchmiqfd6qvlr6wivqdbach2thgoceaayasaaegl_8pd_bwe. It read in pertinent part, Nonverbal dementia-related behaviors may be an option or response for a person living with dementia to communicate a feeling, unmet need or intention. These behaviors are triggered by the interaction between the individual and his or her social and physical environment. A response may include striking out, screaming, or becoming very agitated or emotional. The dementia care provider's role is to observe and attempt to understand what the person living with dementia is trying to communicate. Root causes of dementia-related behaviors may include: -Pain; -Hunger; -Fear, depression, frustration; -Loneliness, helplessness, boredom; -Hallucinations and/or overstimulation; -Changes in environment or routine; -Difficulty understanding or misinterpreting the environment; -Difficulty expressing thoughts or feelings; and, -Unfamiliarity with personal protective equipment or clothing, such as gowns or masks. Strategies to observe and respond to dementia-related behaviors include: -Rule out pain, thirst, hunger or the need to use the bathroom as a source of agitation; -Speak in a calm low-pitched voice; -Try to reduce excess stimulation; Ask others what works for them; -Validate the individual's emotions. Focus on the feelings, not necessarily the content of what the person is saying. Sometimes the emotions are more important than what is said; -Understand that the individual may be expressing thoughts and feelings from their own reality, which may differ from generally acknowledged reality. Offer reassurance and understanding, without challenging their words, can be effective; -Through behavioral observation and attempted interventions, try to determine what helps meet the person's needs and include the information in the individualized plan of care; Be aware of past traumas (veterans, abuse survivors, survivors of large-scale disasters); and, Never physically force the person to do something. Proactive strategies for addressing dementia-related behaviors It can be difficult to anticipate and respond to dementia-related behaviors in a changing environment - especially in emergency situations. However, applying some of the following strategies may help: -Provide a consistent routine; -Use person-centered care approaches for all individuals living with dementia during activities of daily living - every interaction or task is an opportunity for engagement; -Promote sharing of person-centered information across the care team; -Encourage all staff to treat individuals living with dementia with dignity and respect; and, -Put the person before the task. II. Facility census and conditions The facility census and conditions was provided by the nursing home administrator (NHA) on 9/8/2020. Of the 88 current residents, 53 residents (60%) had a [DIAGNOSES REDACTED]. III. Resident #1 A. Resident status Resident #1, age 84, was admitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 7/10/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of six out of 15. She exhibited delusions and verbal behaviors. She required extensive assistance of two staff members with mobility and activities of daily living (ADLs) with the exception of eating. B. Care plan A behavior care plan initiated on 10/7/19 and revised on 2/5/2020 read the resident had a history of [REDACTED]. Staff was encouraged to do cares in pairs (two staff) for this resident. The goal of the care plan read, the resident's behaviors would not negatively impact her environment through the next review date. The interventions for the care plan read, in pertinent part: -2/5/2020: Caregivers should provide opportunity for positive interaction and attention. Stop and talk with her as passing by. Assist the resident to express feelings and provide reassurance or redirect as needed. -10/7/19: Anticipate and meet the resident's needs. -10/7/19: Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved and situation. Document behavior and potential causes. -10/7/19: When behaviors occur, intervene as necessary to protect the rights and safety of others. Approach the resident and speak in a calm manner. Divert her attention. Remove her from the situation and take her to an alternate location as needed. However, even though these interventions were in place for Resident #1, CNA #1 did not implement the interventions to ensure Resident #1 was cared for in this manner. By not following the person centered care plan for Resident #1, Resident #1 sustained a [MEDICAL CONDITION] (cross-reference F600) See below. C. Staff to resident abuse incident On 6/25/2020 the facility investigated a fall experienced by the resident which was determined by interviews and video evidence to have been caused by a certified nurse aide (CNA) #1. The investigation revealed the resident had been exhibiting behaviors of anxiety and making demands of staff, the CNA entered another resident room to provide care and Resident #1 followed the CNA to the room, knocked on the door, then rammed into the door with her walker, for several minutes prior to opening the door and attempting to enter the room. The CNA stopped the resident and continued to struggle with the resident for several minutes in the doorway. The CNA then manually tried to redirect the resident's walker by pushing it backwards and turning the direction of the walker, causing the resident to stumble, trip and fall. The fall was determined to cause a [MEDICAL CONDITION] which required surgical repair the next day. Review of the staff to resident abuse incident revealed the CNA did not follow the person centered approaches to address the resident's behaviors related to her [DIAGNOSES REDACTED]. Cross reference F600 for failure to prevent abuse perpetrated by staff. IV. Staff interviews The NHA was interviewed on 9/10/2020 at 12:28 p.m. She stated the CNA involved with the incident did not follow the resident's interventions outlined in her plan of care to meet her needs regarding her behaviors related to her dementia. The director of nursing (DON) was interviewed on 9/10/2020 at 12:45 p.m. She stated the CNA did not follow the resident's care plan interventions or the facility trainings related to resident care in this instance including Understanding [MEDICAL CONDITION] and Dementia, A Day in the Life of Henry, and Dementia Care: Preventing Catastrophic Reactions. She stated the CNA did not follow the dementia care practices followed by facility staff which all staff were trained on a regular basis. -All facility staff were re-educated on the above mentioned dementia trainings between 6/26/2020 and 7/2/2020.

Based on observation, interviews and record review, the facility failed to ensure residents were free from abuse. Specifically, the facility failed to ensure residents, including one of 17 sample residents (#5), was protected from inappropriate sexual behaviors by resident #70. Specifically: Resident #70 was admitted to the facility on [DATE] from jail. He had previously resided at another long-term care facility where he was arrested for inappropriate sexual behavior and taken to jail in 2011. Resident #70 was then court ordered for secured unit placement at the current facility for the remainder of a two year probation term. Review of an occurrence reported to the Colorado Department of Public Health and Environment (CDPHE) on 12/10/12 revealed that on 12/9/12, resident #70, who was residing on the coed secure unit, had inappropriate sexual contact with his roommate, resident #5, who was totally physically and mentally dependent. Following the 12/9/12 incident, the resident was transferred back to secure male unit and placed with another roommate. Appropriate and effective steps to ensure residents were safe from inappropriate sexual contact by resident #70 were not implemented prior to or after the 12/9/12 incident. The facility's failure to ensure resident #5 and other residents were safe, created a situation of immediate jeopardy for serious harm. The findings include: I. Imposition of Immediate Jeopardy On 12/19/12 at 1:10 p.m., the nursing home administrator (NHA), the director of nursing (DON), regional nurse consultant (RNC), the outgoing regional vice president (RVP) and incoming RVP were informed by CDPHE that the facility's failure to ensure resident #5 and others remained protected from abuse by resident #70 created a situation of immediate jeopardy. II. Facility Response and Removal of the Immediate Jeopardy On 12/19/12 at 2:56 p.m., the facility submitted an incomplete plan to remove immediate jeopardy that was not specific regarding sexual abuse, investigation, follow-up and ensuring safety of others, specifically, resident #70's current roommate. In addition, the facility currently had six other residents with documented inappropriate sexual behaviors (registered sex offenders) three of whom resided on the men's secured unit and three of whom resided on the open unit. A final plan to remove immediate jeopardy was presented on 12/19/12 at approximately 6:00 p.m. According to the plan, resident #70 was moved to a private room with 1 to 1 staff supervision on 12/19/12 at 2:00 p.m., and he would remain on 1 to 1 supervision until discharged from the facility. Staff education, particularly on sexual abuse, began on 12/18/12 and was continuing 12/19/12 at 3:15 p.m., onsite training was scheduled for staff by "MESA" an organization, "Moving to End Sexual Assault." All staff on duty would be trained on abuse investigation and follow up, and starting 12/20/12, all employees would be trained prior to their next shift. The NHA, DON and RNC were trained on abuse, specifically sexual abuse, on 12/19/12. The six other residents that were registered sex offenders and rooming with at risk roommates would be moved immediately. The facility would no longer accept registered sex offenders and current residents that were registered sex offenders would be reviewed monthly. On 12/19/12 at 6:30 p.m., the NHA, VP, DON and RNC were notified the plan was accepted and the immediate jeopardy was lifted. However, deficient practice still remained at harm level. III. Facility Policies, Procedures in Effect Prior to the Immediate Jeopardy Review of the Abuse Prevention Policy, Response and Reporting revealed, in part, "It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion ...All possible measures considered by the facility should be taken to assure the resident is maintained in a safe environment ...A thorough assessment of the resident's physical condition must be completed if an incident has occurred. If the injuries require a physician's intervention or if there's is a possibility of sexual assault, the physician should be notified and the resident should be sent to the hospital. The initial assessment information, including the suspected cause of the injury, should be forwarded to the hospital physician." IV. Resident to Resident Abuse A. Resident #70 1. Resident #70 was admitted to the facility's secure men's unit (Mountain View) from a county jail on 3/20/12. Diagnoses, according to the face sheet included [MEDICAL CONDITION]. The 3/26/12 admission Minimum Data Set (MDS) assessment documented the resident was alert, oriented and cognitively intact. He was essentially independent with activities of daily living (ADLs), though he required staff oversight/supervision. The resident exhibited physical behaviors towards others such as, hitting, pacing, rummaging, public sexual acts, disrobing, etc. The 9/3/12 quarterly MDS assessment documented the brief Interview for mental status (BIMS) score was at 13, indicating he was cognitively intact. He exhibited no physical behaviors, even though there was inappropriate sexual contact with another resident that was documented from 8/11/12. The most recent quarterly MDS assessment dated [DATE], documented the resident's BIMS score remained at 13. No mental status assessment was indicated as the resident was "able to complete interview." He had no memory problems and exhibited no physical behaviors towards others. 2. Resident Status - Known History of Inappropriate Sexual Behavior Review of a brief Psychiatric Initial assessment form from a local county detention facility, documented the resident was taken to jail from another nursing facility following a sexual offense. The assessment notes documented that, "He (resident #70) feels that once they (the former facility) learned he had a past sex offense, they wanted him to leave and that someone had it 'in for him.' He denies touching someone inappropriately, stating, 'I don't remember that.' ...when asked directly if he had thoughts of touching others sexually, he seems confused or will state, 'I don't know.' "Notes from NH (former nursing home prior to jail) were reviewed with odd behaviors noted - masturbating in public, rubber band temp. on genitals." Review of a district court document, dated 3/16/12 and amended 3/28/12, revealed, in part, "Def (defendant) ordered released to (the current facility).... the defendant is to be held in a secured unit for the duration of his probation in the (facility)." The resident was his own responsible party. Review of a Neurological Rehab Behavior Consult, dated 4/11/12, revealed it read in pertinent part: -The resident was admitted to the facility on [DATE] from a county jail. He had been arrested due to sexually inappropriate behaviors at a previous nursing home. Info in chart revealed that he also was sexually inappropriate while in jail. He has continued with sexually inappropriate behavior on the locked, all male unit at this facility- consisting of masturbating in his room with the curtain open for others to watch. He has been court-ordered to remain in secure unit for 2 years and is now classified as a registered sex offender." -Problems identified included, behavior disturbance secondary to [MEDICAL CONDITION] dementia; patient masturbates publicly, recent history (previous nursing home of inappropriate sexual touching) -Under the summary and comment section; "He has some memory impairment secondary to [MEDICAL CONDITION] dementia, but long term memory and distract reasoning were mostly intact. He denied reason for inappropriate sexual behavior at previous nursing home, but did not deny such when confronted about sex behavior in jail and excess/inappropriate masturbation's while at current facility.... 3. Documentation of Sexually Inappropriate Behavior and Physical Aggression 3/26/12 through 11/29/12. Review of neurological rehab behavioral (NRB) notes, nurses' notes (NN) and social service (SS) notes revealed sexually inappropriate and physically aggressive behaviors after admission. -SS note 3/26/12 (6 days after admission) documented the resident was masturbating in showers with certified nurse aides (CNAs) present, as well as in his room. "Resident's roommate is having increased behaviors due to his masturbation. SS met with the resident to discuss concerns. Resident was agreeable to keeping the curtains drawn for privacy and not to masturbate if CNAs were present. -SS note 4/3/12 documented the resident was involved in a physical altercation in his room with another resident who was found sleeping in his bed. -NN notes 8/11/12 documented resident #70 sat down beside another resident, who was watching TV, and asked that resident if he could pay him for sex. The other resident said no, and then reported to staff that resident #70 grabbed his crotch. Resident #70 was moved to a different room.' -NRB 8/27/12 quarterly treatment plan documented "Masturbates publicly, history of inappropriate sexual behavior . . . pt accused by another of inappropriate sexual behavior." -NN notes 11/25/12 and SS notes 11/25/12 documented a physical altercation with roommate that day. Per SS, resident #70 was seen by staff, pushing his roommate in the room. "The roommate grabbed his arm and pushed him out of the room." -SS note 11/29/12 documented the resident stated he was pushed by the same resident (see above) on 11/25/12. He lost his balance and fell . -SS note 11/30/12 documented the resident had another incident, involving another resident, stating he (resident #70) was fearful of the other resident. -NRB note 12/3/12 documented the resident's former roommate pushed resident #70 three times, prompting a move for safety reasons. 4. Facility Response to Resident's Known Behaviors a. Care Plans The 3/20/12 care plan documented the resident was a registered sex offender with a history of unlawful sexual contact with at risk adult. The goal was for the resident to have no sexual inappropriateness through next review. Approaches included: -Contact police department to register this resident with the city, -Accompany resident (if) police are present, to assist with documentation as needed, -Notify the police when monies arrive to pay initial registration fee in November and every November after that, -15 minute checks or as needed if becomes sexually inappropriate with other residents, -Court ordered secure unit placement. A second care plan problem, 3/20/12, documented the resident was observed masturbating in room without curtains drawn and in shower with certified nurse aides (CNAs). The goal was for the resident to masturbate in private through next review. Approaches listed included: -Discuss concern with resident 1 to 1, -Staff to provide reminders as needed to keep curtains closed when requiring privacy, -CNAs to provide reminder, prior to shower, not to masturbate with CNAs present, -Obtain mental health order to eval and treat, advise of any concerns, -Moved bed away from room door for increased privacy. A third care plan problem, 3/20/12, documented the resident was sexually inappropriate (i.e. will masturbate in front of privacy curtains, so others will see and when in shower, will open door so others may see him as they walk by.) The goal was for the resident to masturbate in the privacy of his own room through next review. Approaches included: -Provide 1 to 1 reminders re: privacy and of respecting others, -1 to 1 social services to remind resident of criminal history, -Advise mental health of concerns relating to inappropriate sexual behaviors, -Provide resident with magazines (porn) if desires, A fourth care plan problem documented, in part; date initiated 3/26/12, under behavioral symptoms, "resident will have fewer episodes of masturbation." Interventions included: -redirect as needed, -convey acceptance of resident during periods of inappropriate behavior, -encourage diversional activities, -privacy curtains. b. Medication Review of physician orders [REDACTED]. According to Mosby's "Nursing 2013 Drug Handbook," page 1223, [MEDICATION NAME] is an anti-depressant with genitor- urinary side effects that include male sexual dysfunction. According to one of the licensed psychologists familiar with resident #70, "[MEDICATION NAME] is a very typical treatment for [REDACTED]. Further review of the orders revealed [MEDICATION NAME] was reduced 10/19/12 and discontinued 11/2/12. c. Neurological Rehab 1 to 1 health and behavioral treatment. -According to the Neurological Rehab Behavioral consult note 4/11/12 (see above), the recommendation was for resident #70 to receive treatment "2 x weekly until pt shows improved adjustment and behavior." Documentation revealed neurological (neuro) rehab psycho physiological progress notes dated 4/18/12, 4/30/12, 5/9/12, 5/16/12 and 5/23/12 for 1 to 1 health and behavioral treatment to reduce inappropriate sexual behavior. d. Room changes According to SS, the resident changed rooms (per his request) on 6/5/12, 8/10/12, and 11/26/12 on Mountain View unit. He was moved to the coed secure unit (Aspen unit) on 11/30/12, to share a room with resident #5. Interview with Director of Nursing on 12/18/12 at 4:19 p.m. revealed there were 15 residents on the coed Aspen unit. It is a smaller unit, (residents) were more visible to nursing staff. Interview with a registered nurse (RN) who worked on the Aspen unit stated during an interview on 12/18/12 at 5:25 p.m., that she was told the resident was transferred to the Aspen unit from the Mountain View unit because "(resident #70) was targeted by another resident due to sexual advances, doing things." 5. Failures in Facility Response to Incidents 3/26/12 - 11/30/12. a. Failure to thoroughly investigate, communicate and address incidents of sexually inappropriate behavior, events triggering physically aggressive behavior and room changes to ensure resident #70 and roommate safety. Review of resident #70's NN, SS and physician progress notes [REDACTED]. Documentation of incidents (see above) revealed no details about the incidents, such as triggering events and no specific plans to address behaviors, other than separating the residents involved or educating resident #70. -There was no documentation that either resident #70 'targeted' other residents or that other residents 'targeted' resident #70 and no intervention plans to direct staff to monitor resident interactions to promote resident safety. -There was no evidence that the resident's room changes and concurrent roommate changes were assessed for appropriateness, given the resident's known behaviors. In an interview with the admission coordinator on 12/27/12 at 2:21 p.m., she stated that the determination of roommates is often based on bed availability and social services decides who is going to be compatable. In an interview with the social services director (SDD) on 12/24/12 at 11:17 a.m., the SSD said "If something happens, the team need to get together and ask residents who they want to room with. (We) will ask those who like to be moved, see who would be best roomed together, based on medical care and psych well-being." -There was no evidence that the resident's care plan interventions on masturbation and sexually inappropriate behaviors (see above) were reviewed and/or revised. And, a plan to address the incident 8/11/12 (see above) was not initiated until 8/13/12. This plan, documenting that resident #70 sat on his roommate's bed, requested a sexual favor and grabbed the roommate's groin over the roommate's clothing, included 15 minute checks "x 1 week or prn;" however, it also included many of the same interventions found in earlier care plans. b. Failure to continue mental treatment and communicate with NRB staff. Review of the NRB progress notes revealed no NRB notes after 5/23/12, until 8/27/12, when a quarterly treatment plan summary note documented "Resuming treatment with patient after 3 month absence, pt accused by another of inappropriate sexual behavior." In an interview with the resident's licensed professional counselor on 12/20/12 at 12:15 p.m., he said he was not aware of the 8/11/12 incident of inappropriate sexual behavior by resident #70 toward another resident. He said he had only resumed seeing resident #70 in 9/12, and no one told him of the incident. He also stated he was unaware the resident's [MEDICATION NAME] was discontinued 11/2/12. He said the resident should have continued on the [MEDICATION NAME] and if he'd known, he would have intervened when it was discontinued. In an interview with the Social Services Resident Life Coordinator on 12/27/12 at 1:54 p.m., she confirmed that psych services had been changed so that residents were not followed appropriately for some time. B. Event 12/9/12 Review of SS notes revealed resident #70 was transferred to the Aspen unit, a coed secure unit, on 11/30/12 at 2:00 p.m. and placed in a room with resident #5. 1. Resident #5 Resident #5 was admitted to the facility on [DATE]. Diagnoses, according to the face sheet, included dementia. According to a "Petition for Appointment of Guardian for Incapacitated Person," dated 12/14/92, resident #5, "suffered a severe [MEDICAL CONDITION] which deprived his brain oxygen. He is unable to make rational decisions; is very difficult to understand due to speech problems...." According to a "Consensual Sexual Activity Assessment, dated 8/31/11, "Resident unable to communicate safe sex practices. As of 3/19/12, no changes." The 11/30/12 MDS assessment documented the resident was rarely/never understood, had both long and short-term memory problems, had no recall and severe cognitive impairment. He exhibited no behavior symptoms and required extensive assistance with all activities of daily living (ADLs). He had impaired range of motion in both upper extremities. Care Plans review revealed the resident was identified 2/22/07, to be at risk for being victimized related to dementia. Other problems included cognitive deficits (as evidenced by confusion, disorientation, poor short and long- term memory and difficulty with communication related to dementia) and the need for assistance with ADLs to cognitive impairment. 2. Events 12/9/12 and Facility Response a. Record Review Nine days after resident #70 was transferred to the Aspen unit, NN documented on 12/9/12 at 7:30 p.m. that resident #70 was found on (resident #5's) side of the room. Documentation revealed, "(Resident #70 was naked from the waist down. The roommate (resident #5) cannot get out of chair by himself or talk. The roommate's penis was pulled up out of his briefs and he is unable to do this himself. Took resident #70 to the TV room while called nurse manager to report this suspected sexual abuse. Roommate told staff by shaking head, yes that he had been hurt and touched.....I called police and they came and filed a report. Resident (#70) moved (back) to the Mountain View (men's secure unit) after got order from Dr ..." Is own responsible party." Review of the facility investigation report, completed by facility staff on 12/9/12 at 7:30 p.m. revealed it read in pertinent part: "CNA went into room to change resident #5's brief and saw resident #70 run back to his own side of the room. He was naked from the waist down and had been behind his roommate's curtain. The roommate was in a recliner chair and his penis was pulled up out of his briefs, and he is not able to do that himself. There was semen and urine in the roommates brief. Immediately separated this resident from the room and kept him in the TV room while nurse manager called and notified DON, NHA (nursing home administrator), also called police who came and filed a report. Dr. also notified. Resident is his own responsible party, resident transferred to Mountain View (male) secure unit." Further review of NN dated 12/9/12 and signed by the nurse working the Aspen unit that evening revealed the following: "At approx 7:30 p.m., CNA went into resident room to change his brief and saw the curtain in the room was pulled. The CNA noted that on entry, the resident's roommate (#70) ran back over to his side of the room as he had been on this resident's side and the roommate was naked from his waist down. This resident was noted to be in his recliner chair with his brief being down a bit and his penis exposed. This resident is unable to pull himself out of his brief like this. There was semen and urine mixed in the brief or on it; unable to determine. Immediately separated the roommate and asked this resident in private if he had been hurt by this man, and he stated, yes and then asked him if the man touched him and stated yes by shaking head yes in front of CNA as witness and this nurse took roommate to TV room and called nursing on call to report suspected sexual abuse by this roommate and also notified police and Dr, and reported to roommate's guardian. Placed resident on 15 minute checks for safety. Roommate (#70) moved off unit to MT view unit. Police came and took report." Review of a facility report dated 12/9/12 showed the documented event above, however, additional notes revealed the victim had been behind the privacy curtain, "in his recliner, with his erect penis sticking out of his diaper and he is unable to pull himself out of his diaper like that. Resident #70 had been behind the curtain on the victim's side. There was semen noted mixed with urine in/on the victim's diaper." According to the reported occurrence to CDPHE, dated 12/10/12, at approximately 7:50 p.m. on 12/9/12 a, "CNA went into the resident's room to find the assailant without his underwear and he ran back to his side of the room from the victim's side of the room. The victim was observed in his recliner and his penis was pulled up out of his briefs. There was semen and urine noted on the victim. Victim was not interviewed as he was not interviewable. No rape kit done. When asked about the victim's response, if he was fearful, the resident/victim is demented and unaware of the incident. The incident was substantiated based on the findings in the room. For the safety of others, the assailant was moved to secure unit. Interventions put in place included: residents were separated." Review of a statement documented by the NHA revealed, "On 12/9/12, I became aware of an occurrence between two residents on the Aspen View unit. One resident was observed by a staff member running to his side of the room. The other resident was observed by the same staff to have an erect penis and what appeared to be semen and urine. This event was immediately reported by the staff member to the nurse in charge. An initial report of this was submitted by me to (CDPHE). Both residents were immediately separated and assailant was returned to the secured men's unit. Both residents were assessed for pain or fear. Neither exhibited any fear or pain. Additionally, there was no evidence of physical injury. The assailant is court ordered to be at the facility and is serving his sentence at the facility. " b. Interviews On 12/18/12 4:05 p.m., the CNA who entered resident #70 and #5's room on 12/9/12 and witnessed the residents together was interviewed. The CNA, a facility employee for 6 years, said she walked into the room to change resident #5. All the curtains pulled. She looked, as she thought that was odd, and found resident #70 moving quickly back to his side of the room. He was naked from the waist down and resident #5's penis was out. She said she had not witnessed resident #70 touching resident #5 but assumed that happened. She said she had, "Worked with resident #5 a long time, and he has never masturbated or done anything like that." She said she reported her observations to the nurse, the residents were separated and police were called. On 12/18/12 at 5:25 p.m., the RN who was working the unit on 12/9/12 was interviewed. -The RN, who said she had been employed at the facility for 14 months, said she was called by the CNA to the resident #70 and #5's room. She said resident #70, "scurried over from resident #5's side of the room. He was naked from the waist down. Resident #5 cannot talk or get up and move by himself. He is able to make sounds. His (resident #5) penis was out of his pants; he can't do that himself. Resident #5 cannot manipulate his hands well. She said when there are two staff required in one room, it's hard to watch the rest of the unit." -The RN said she brought resident #70 out to the TV room and asked him what he was doing. He said his roommate's blanket had fallen and he was helping. When asked if he touched resident #5, resident #70 responded, " Well not really." The RN then called the supervisor and the police and moved him then to another unit. - The RN said she tried to ask resident #5 questions however, it was "really hard because he doesn't talk." She said when she asked him if he was touched, he nodded up and down and then responded with, "Jess." -The RN said at the time of the incident resident #70 was on 15 minutes checks. She said he had always been on them because of his history. c. Facility Follow-up (1) In addition to moving resident #70 to the Mountain View unit and calling police, resident #70 was placed on 15 minute checks. (2) Review of the NN and SS notes revealed that following the 12/9/12 event, on 12/10/12, resident #5 was monitored and noted to exhibit increased anxiety and restlessness. His care plan was updated 12/11/12 to keep the resident safe and to monitor for signs and symptoms of distress, trauma, or changes in mood. (3) SS notes documented on 12/10 and 12/14/12, that resident #70 was educated on the current situation, reminded of his probation and informed that authorities would be notified. The resident was informed of possible consequences of recent incident. "Informed resident to stay out of others rooms and not to entice others sexually in anyway because it may be a violation of his probation. Res stated understanding....still awaiting call back from (law enforcement) clerk. Also contacted (name) with sex offender registry and they suggested contacting the district attorney. Message left." (4) On 12/17/12, orders were received to restart the resident on [MEDICATION NAME] 50 mg daily. 3. Failures in Facility Response to 12/9/12 Incident a. Failure to Preserve Evidence and Provide a Comprehensive Report to Police on 12/9/12 On 12/17/12 at 3:32 p.m., the police officer who responded to the call on 12/9/12 was interviewed. He said by the time he arrived, resident #5 was up in a chair and cleaned up. He said staff did not report there was any semen or urine. On 12/18/12 at 4:05 p.m., the CNA who entered resident #70 and #5's room on 12/9/12 and witnessed the residents together said then she and the nurse changed resident #5 and put a new brief on him and changed him into a gown because he was wet. On 12/18/12 at 5:25 p.m., the RN working 12/9/12 with the CNA above stated she helped the CNA change resident #5 and said she felt she smelled semen. b. Failure to Adequately Monitor Resident #70 after 12/9/12 The Nursing Home Administrator (NHA), interviewed on 12/18/12 at 4:19 p.m. stated 15 minute checks were implemented after the 12/9/12 incident and that resident #70 was "watched all the time." The NHA further stated that resident #70 had a roommate (on the Mountain View unit), but, "(The roommate) is able to defend himself." He further stated the facility had no private rooms, so resident #70 had always been with a roommate. However: -Review of the record for resident #70's roommate (as of 12/18/12), revealed the roommate's most recent MDS, dated [DATE], revealed this resident, as resident #5, was cognitively impaired. -Review of the 'behavior and 15 minute checks' sheets revealed the resident was not consistently monitored every 15 minutes and behavior documentation was inconsistent. -Review of NN 12/10/12, the day after the incident involving resident #5, revealed documentation at 8:45 p.m., resident #70 was in room with another resident and both residents were naked on the bed. ("Both denied any sexual contact happened, both denied fear, both feel safe and weren't pressured into uncomfortable situations.") -Review of resident #70's room on the Mountain View unit on 12/20/12 revealed it was at the end of the hall, away from the nurses' station. C. Interviews - Evidence of Systemic Failures to Ensure Resident Safety The CNA who discovered resident #70 and #5 on 12/9/12 stated during an interview that resident #70 was moved to the Aspen when it was her day off. She was not aware initially that resident #70 came from jail. Regarding training, she said the administration, "Tell us how to take care of residents, and we have silver chair, (computerized based training), if you suspect it (abuse) report it, any kind of abuse. Separate the residents, call police and 15 minute checks. The NHA, DON and RNC were interviewed on 12/18/12 at 4:19 p.m. -The NHA stated that regarding suspected sexual abuse, there had never been any discussion about what to do or not do with any evidence and there was no policy regarding preserving evidence or the area. Per the DON, "never thought about it, that's what the police are supposed to do." She said staff was trained on silver chair yearly. -Regarding expectations with suspected sexual assaults, the NHA said, they would take statements from everyone. However, they first had to determine if the sexual encounter was consensual. "If not, we investigate. We separate and diffuse, deescalate, then call the police. If a resident is unsafe we move off the unit immediately." Preserving the scene or any evidence was not done. The RN working 12/9/12 stated during an interview 12/18/12 at 5:25 p.m. that with regarding training, she had worked with these types of residents and locked units. However, there had been no training regarding preservation of the scene or any evidence. The RN said she did not feel safe on the men's unit; there were no specific care plans. She stated the basic response was to separate and call the police and the supervisor. She said there was a psych hot line; however, "They either do not respond timely or will say call 911." She called the director of restorative (DOR) on 12/9/12 because she was on-call, and the DOR, "told me what to do; to notify management and the police." The DOR was interviewed on 12/18/12 at 6:00 p.m. She said she had been employed at the facility for almost 7 years. -She said she was on call on 12/9/12 and took the call at 8:00 p.m. (on Sunday) from the RN, the floor nurse. She was informed of the CNA's observations and instructed the RN to constantly supervise them and call the police. The DOR then called don who called NHA and the consultant. -She said staff has training on abuse, initial training, before starting on the floor, as well as back ground checks. She said the silver chair was the main source of ongoing education. In-services mandatory once a month. She said for suspected abuse, you first call the on-call, even if you are just uncomfortable and not sure. On 12/19/12 at 5:00 p.m. the responding police officer's supervisor was interviewed at the facility. He stated he interviewed resident #70 and determined, "He is aware and knows what he is doing. He seeks out and preys on the most vulnerable individuals." He said there was probable cause to arrest the resident, so resident #70 was arrested and taken back to jail. On 12/20/12 at 9:56 a.m., the medical director stated he was aware of the resident #70's situation and the occurrence 12/9/12. He stated the resident was moved off the unit for his physical safety from others, and said, "Unfortunately our choices of where to put him were very limited. Resident #5's room was the only male bed available, and unfortunately that turned out to be a bad choice." He then stated he had nothing further to add, th

Based on record review and interviews, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically: The facility failed to ensure a comprehensive policy regarding sexual abuse was in place and failed to implement a portion of an abuse policy they did have. Resident #70 sexually abused resident #5 on 12/9/12. The facility's failure to develop and implement a comprehensive sexual abuse policy contributed resident to resident abuse and an inadequate response after the abuse that placed facility residents at risk for further harm by resident #70. Cross-reference F 223 Abuse. The findings include: A. Facility Policy Review of the facility's Abuse Prevention Policy, Response and Reporting revealed, in part: -"It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion ...All possible measures considered by the facility should be taken to assure the resident is maintained in a safe environment ... -A thorough assessment of the resident's physical condition must be completed if an incident has occurred. If the injuries require a physician's intervention or if there's is a possibility of sexual assault, the physician should be notified and the resident should be sent to the hospital. The initial assessment information, including the suspected cause of the injury, should be forwarded to the hospital physician." B. Failure to Develop and Implement a Comprehensive Sexual Abuse Policy 1. Resident #70 Resident #70 was admitted to the facility from a county jail on 3/20/12. Diagnoses, in part, according to the face sheet included, [MEDICAL CONDITION]. The 3/26/12 admission Minimum Data Set (MDS) assessment documented the resident was alert, oriented and cognitively intact. He was essentially independent with activities of daily living (ADLs), though required staff oversight/supervision. The resident exhibited physical behaviors towards others such as, hitting, scratching self, pacing, rummaging, public sexual acts, disrobing, etc. The 9/3/12 quarterly MDS assessment documented the Brief Interview for Mental Status (BIMS) score was at 13, indicating he was cognitively intact. He exhibited no physical behaviors, even though there was inappropriate sexual contact with another resident that was documented from 8/11/12. The most recent quarterly MDS assessment, dated 11/30/12, documented the resident's BIMS score remained at 13. No mental status assessment was indicated as the resident was "able to complete interview." He had no memory problems and exhibited no physical behaviors towards others. Resident #70 was admitted to the facility from jail as a known sex offender on 3/12/12. Resident #70 had previously resided at another long term care facility where he was arrested and taken to the jail in 2011, following inappropriate sexual behavior at that facility. He was court ordered for secured unit placement at the current facility for the remainder of a two year probation term. 2. Resident #5 Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to a "Petition for Appointment of Guardian for Incapacitated Person," dated 12/14/92, in part, resident #5 "suffered a severe [MEDICAL CONDITION] which deprived his brain oxygen. He is unable to make rational decisions; is very difficult to understand due to speech problems...." According to a, "Consensual Sexual Activity Assessment, dated 8/31/11, "Resident unable to communicate safe sex practices. As of 3/19/12, no changes." The 11/30/12 MDS assessment documented the resident was rarely/never understood, had both long and short term memory problems, had no recall and severe cognitive impairment. He exhibited no behavior symptoms and required extensive assistance with all activities of daily living (ADLs). He had impaired range of motion in both upper extremities. The care plan, dated 2/22/07, identified that the resident was at risk for being victimized related to dementia. The goal was for the resident to not be victimized. Approaches included; -monitor mood for signs and symptoms of distress, -provide supervision when off locked unit, -1 to 1 to allow verbalization, conversation. 3. Event 12/9/12 Review of an occurrence reported to the Colorado Department of Public Health and Environment on 12/10/12, revealed resident #70 had inappropriate sexual contact with resident #5 on 12/9/12. Specifically, when resident #70 was transferred from the secured men's unit to the coed secured unit on 11/30/12, he was knowingly placed in a room with a male resident (#5) who was totally physically and mentally dependent. According to the medical record, on 12/9/12 at 7:30 p.m., resident #70 was found on the roommate's side of the room. Documentation revealed, "He was naked from the waist down. The roommate cannot get out of chair by himself or talk. The roommate's penis was pulled up out of his briefs and he is unable to do this himself. Took resident #70 to the TV room while called nurse manager to report this suspected sexual abuse. Roommate told staff by shaking head, yes that he had been hurt and touched.....I called police and they came and filed a report. Resident (#70) moved (back) to the Mountain View (men's locked unit) after got order from Dr. Remains on 15 minute checks. Is own responsible party." 4. Failures in Facility Response a. Failure to protect facility residents after 12/9/12 to prevent reoccurrence. After the 12/9/12 event, resident #70 was transferred back to his original unit and placed with another roommate. The Nursing Home Administrator (NHA), interviewed on 12/18/12 at 4:19 p.m. stated 15 minute checks were implemented after the 12/9/12 incident and that resident #70 was "watched all the time." The NHA further stated that resident #70 had a roommate (on the Mountain View unit), but, "(The roommate) is able to defend himself." He further stated the facility had no private rooms, so resident #70 had always been with a roommate. However: -Review of the record for resident #70's roommate (as of 12/18/12), revealed the roommate's most recent MDS, dated [DATE], revealed this resident, as resident #5, was cognitively impaired. -Review of the 'behavior and 15 minute checks' sheets revealed the resident was not consistently monitored every 15 minutes and behavior documentation was inconsistent. -Review of NN on 12/10/12, the day after the incident involving resident #5, revealed documentation at 8:45 p.m., resident #70 was in room with another resident and both residents were naked on the bed. ("Both denied any sexual contact happened, both denied fear, both feel safe and weren't pressured into uncomfortable situations.") -Review of resident #70's room on the Mountain View unit on 12/20/12 revealed it was at the end of the hall, away from the nurses' station. b. Failure to Preserve Evidence, Provide a Comprehensive Report to Police on 12/9/12, and send Resident #5 to the hospital per Facility Policy On 12/17/12 at 3:32 p.m., the police officer who responded to the call on 12/9/12 was interviewed. He said by the time he arrived, resident #5 was up in a chair and cleaned up. He said staff did not report there was any semen or urine. On 12/18/12 at 4:05 p.m., the CNA who entered resident #70 and #5's room on 12/9/12 and witnessed the residents together said then she and the nurse changed resident #5 and put a new brief on him and changed him into a gown because he was wet. On 12/18/12 at 5:25 p.m., the RN working 12/9/12 with the CNA above stated she helped the CNA change resident #5 and said she felt she smelled semen. Review of resident #5's record revealed he was not sent to the hospital, as expected per facility policy (see above). On 12/18/12 at 4:19 p.m. the NHA, DON and RNC were interviewed The NHA stated that regarding suspected sexual abuse, there had never been any discussion about what to do or not do with any evidence and there was no policy regarding preserving evidence or the area. Per the DON, "never thought about it, that's what the police are supposed to do." She said staff was trained on silver chair yearly. The NHA, DON, and RNC were interviewed again on 12/27/12 at 4:10 p.m. Regarding a policy for sexual offenders, the NHA said that was still in the discussion phase and would require involvement of the VP of clinical operations. Cross-reference F 223 for further details.

Based on observation, interviews and record review, the facility failed to ensure residents were free from abuse. Specifically, the facility failed to ensure residents, including one of 17 sample residents (#5), was protected from inappropriate sexual behaviors by resident #70. Specifically: Resident #70 was admitted to the facility on [DATE] from jail. He had previously resided at another long-term care facility where he was arrested for inappropriate sexual behavior and taken to jail in 2011. Resident #70 was then court ordered for secured unit placement at the current facility for the remainder of a two year probation term. Review of an occurrence reported to the Colorado Department of Public Health and Environment (CDPHE) on 12/10/12 revealed that on 12/9/12, resident #70, who was residing on the coed secure unit, had inappropriate sexual contact with his roommate, resident #5, who was totally physically and mentally dependent. Following the 12/9/12 incident, the resident was transferred back to secure male unit and placed with another roommate. Appropriate and effective steps to ensure residents were safe from inappropriate sexual contact by resident #70 were not implemented prior to or after the 12/9/12 incident. The facility's failure to ensure resident #5 and other residents were safe, created a situation of immediate jeopardy for serious harm. The findings include: I. Imposition of Immediate Jeopardy On 12/19/12 at 1:10 p.m., the nursing home administrator (NHA), the director of nursing (DON), regional nurse consultant (RNC), the outgoing regional vice president (RVP) and incoming RVP were informed by CDPHE that the facility's failure to ensure resident #5 and others remained protected from abuse by resident #70 created a situation of immediate jeopardy. II. Facility Response and Removal of the Immediate Jeopardy On 12/19/12 at 2:56 p.m., the facility submitted an incomplete plan to remove immediate jeopardy that was not specific regarding sexual abuse, investigation, follow-up and ensuring safety of others, specifically, resident #70's current roommate. In addition, the facility currently had six other residents with documented inappropriate sexual behaviors (registered sex offenders) three of whom resided on the men's secured unit and three of whom resided on the open unit. A final plan to remove immediate jeopardy was presented on 12/19/12 at approximately 6:00 p.m. According to the plan, resident #70 was moved to a private room with 1 to 1 staff supervision on 12/19/12 at 2:00 p.m., and he would remain on 1 to 1 supervision until discharged from the facility. Staff education, particularly on sexual abuse, began on 12/18/12 and was continuing 12/19/12 at 3:15 p.m., onsite training was scheduled for staff by MESA an organization, Moving to End Sexual Assault. All staff on duty would be trained on abuse investigation and follow up, and starting 12/20/12, all employees would be trained prior to their next shift. The NHA, DON and RNC were trained on abuse, specifically sexual abuse, on 12/19/12. The six other residents that were registered sex offenders and rooming with at risk roommates would be moved immediately. The facility would no longer accept registered sex offenders and current residents that were registered sex offenders would be reviewed monthly. On 12/19/12 at 6:30 p.m., the NHA, VP, DON and RNC were notified the plan was accepted and the immediate jeopardy was lifted. However, deficient practice still remained at harm level. III. Facility Policies, Procedures in Effect Prior to the Immediate Jeopardy Review of the Abuse Prevention Policy, Response and Reporting revealed, in part, It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .All possible measures considered by the facility should be taken to assure the resident is maintained in a safe environment .A thorough assessment of the resident's physical condition must be completed if an incident has occurred. If the injuries require a physician's intervention or if there's is a possibility of sexual assault, the physician should be notified and the resident should be sent to the hospital. The initial assessment information, including the suspected cause of the injury, should be forwarded to the hospital physician. IV. Resident to Resident Abuse A. Resident #70 1. Resident #70 was admitted to the facility's secure men's unit (Mountain View) from a county jail on 3/20/12. Diagnoses, according to the face sheet included [MEDICAL CONDITION]. The 3/26/12 admission Minimum Data Set (MDS) assessment documented the resident was alert, oriented and cognitively intact. He was essentially independent with activities of daily living (ADLs), though he required staff oversight/supervision. The resident exhibited physical behaviors towards others such as, hitting, pacing, rummaging, public sexual acts, disrobing, etc. The 9/3/12 quarterly MDS assessment documented the brief Interview for mental status (BIMS) score was at 13, indicating he was cognitively intact. He exhibited no physical behaviors, even though there was inappropriate sexual contact with another resident that was documented from 8/11/12. The most recent quarterly MDS assessment dated [DATE], documented the resident's BIMS score remained at 13. No mental status assessment was indicated as the resident was able to complete interview. He had no memory problems and exhibited no physical behaviors towards others. 2. Resident Status - Known History of Inappropriate Sexual Behavior Review of a brief Psychiatric Initial assessment form from a local county detention facility, documented the resident was taken to jail from another nursing facility following a sexual offense. The assessment notes documented that, He (resident #70) feels that once they (the former facility) learned he had a past sex offense, they wanted him to leave and that someone had it 'in for him.' He denies touching someone inappropriately, stating, 'I don't remember that.' .when asked directly if he had thoughts of touching others sexually, he seems confused or will state, 'I don't know.' Notes from NH (former nursing home prior to jail) were reviewed with odd behaviors noted - masturbating in public, rubber band temp. on genitals. Review of a district court document, dated 3/16/12 and amended 3/28/12, revealed, in part, Def (defendant) ordered released to (the current facility). the defendant is to be held in a secured unit for the duration of his probation in the (facility). The resident was his own responsible party. Review of a Neurological Rehab Behavior Consult, dated 4/11/12, revealed it read in pertinent part: -The resident was admitted to the facility on [DATE] from a county jail. He had been arrested due to sexually inappropriate behaviors at a previous nursing home. Info in chart revealed that he also was sexually inappropriate while in jail. He has continued with sexually inappropriate behavior on the locked, all male unit at this facility- consisting of masturbating in his room with the curtain open for others to watch. He has been court-ordered to remain in secure unit for 2 years and is now classified as a registered sex offender. -Problems identified included, behavior disturbance secondary to [MEDICAL CONDITION] dementia; patient masturbates publicly, recent history (previous nursing home of inappropriate sexual touching) -Under the summary and comment section; He has some memory impairment secondary to [MEDICAL CONDITION] dementia, but long term memory and distract reasoning were mostly intact. He denied reason for inappropriate sexual behavior at previous nursing home, but did not deny such when confronted about sex behavior in jail and excess/inappropriate masturbation's while at current facility. 3. Documentation of Sexually Inappropriate Behavior and Physical Aggression 3/26/12 through 11/29/12. Review of neurological rehab behavioral (NRB) notes, nurses' notes (NN) and social service (SS) notes revealed sexually inappropriate and physically aggressive behaviors after admission. -SS note 3/26/12 (6 days after admission) documented the resident was masturbating in showers with certified nurse aides (CNAs) present, as well as in his room. Resident's roommate is having increased behaviors due to his masturbation. SS met with the resident to discuss concerns. Resident was agreeable to keeping the curtains drawn for privacy and not to masturbate if CNAs were present. -SS note 4/3/12 documented the resident was involved in a physical altercation in his room with another resident who was found sleeping in his bed. -NN notes 8/11/12 documented resident #70 sat down beside another resident, who was watching TV, and asked that resident if he could pay him for sex. The other resident said no, and then reported to staff that resident #70 grabbed his crotch. Resident #70 was moved to a different room.' -NRB 8/27/12 quarterly treatment plan documented Masturbates publicly, history of inappropriate sexual behavior . pt accused by another of inappropriate sexual behavior. -NN notes 11/25/12 and SS notes 11/25/12 documented a physical altercation with roommate that day. Per SS, resident #70 was seen by staff, pushing his roommate in the room. The roommate grabbed his arm and pushed him out of the room. -SS note 11/29/12 documented the resident stated he was pushed by the same resident (see above) on 11/25/12. He lost his balance and fell . -SS note 11/30/12 documented the resident had another incident, involving another resident, stating he (resident #70) was fearful of the other resident. -NRB note 12/3/12 documented the resident's former roommate pushed resident #70 three times, prompting a move for safety reasons. 4. Facility Response to Resident's Known Behaviors a. Care Plans The 3/20/12 care plan documented the resident was a registered sex offender with a history of unlawful sexual contact with at risk adult. The goal was for the resident to have no sexual inappropriateness through next review. Approaches included: -Contact police department to register this resident with the city, -Accompany resident (if) police are present, to assist with documentation as needed, -Notify the police when monies arrive to pay initial registration fee in November and every November after that, -15 minute checks or as needed if becomes sexually inappropriate with other residents, -Court ordered secure unit placement. A second care plan problem, 3/20/12, documented the resident was observed masturbating in room without curtains drawn and in shower with certified nurse aides (CNAs). The goal was for the resident to masturbate in private through next review. Approaches listed included: -Discuss concern with resident 1 to 1, -Staff to provide reminders as needed to keep curtains closed when requiring privacy, -CNAs to provide reminder, prior to shower, not to masturbate with CNAs present, -Obtain mental health order to eval and treat, advise of any concerns, -Moved bed away from room door for increased privacy. A third care plan problem, 3/20/12, documented the resident was sexually inappropriate (i.e. will masturbate in front of privacy curtains, so others will see and when in shower, will open door so others may see him as they walk by.) The goal was for the resident to masturbate in the privacy of his own room through next review. Approaches included: -Provide 1 to 1 reminders re: privacy and of respecting others, -1 to 1 social services to remind resident of criminal history, -Advise mental health of concerns relating to inappropriate sexual behaviors, -Provide resident with magazines (porn) if desires, A fourth care plan problem documented, in part; date initiated 3/26/12, under behavioral symptoms, resident will have fewer episodes of masturbation. Interventions included: -redirect as needed, -convey acceptance of resident during periods of inappropriate behavior, -encourage diversional activities, -privacy curtains. b. Medication Review of physician orders [REDACTED]. According to Mosby's Nursing 2013 Drug Handbook, page 1223, [MEDICATION NAME] is an anti-depressant with genitor- urinary side effects that include male sexual dysfunction. According to one of the licensed psychologists familiar with resident #70, [MEDICATION NAME] is a very typical treatment for [REDACTED]. Further review of the orders revealed [MEDICATION NAME] was reduced 10/19/12 and discontinued 11/2/12. c. Neurological Rehab 1 to 1 health and behavioral treatment. -According to the Neurological Rehab Behavioral consult note 4/11/12 (see above), the recommendation was for resident #70 to receive treatment 2 x weekly until pt shows improved adjustment and behavior. Documentation revealed neurological (neuro) rehab psycho physiological progress notes dated 4/18/12, 4/30/12, 5/9/12, 5/16/12 and 5/23/12 for 1 to 1 health and behavioral treatment to reduce inappropriate sexual behavior. d. Room changes According to SS, the resident changed rooms (per his request) on 6/5/12, 8/10/12, and 11/26/12 on Mountain View unit. He was moved to the coed secure unit (Aspen unit) on 11/30/12, to share a room with resident #5. Interview with Director of Nursing on 12/18/12 at 4:19 p.m. revealed there were 15 residents on the coed Aspen unit. It is a smaller unit, (residents) were more visible to nursing staff. Interview with a registered nurse (RN) who worked on the Aspen unit stated during an interview on 12/18/12 at 5:25 p.m., that she was told the resident was transferred to the Aspen unit from the Mountain View unit because (resident #70) was targeted by another resident due to sexual advances, doing things. 5. Failures in Facility Response to Incidents 3/26/12 - 11/30/12. a. Failure to thoroughly investigate, communicate and address incidents of sexually inappropriate behavior, events triggering physically aggressive behavior and room changes to ensure resident #70 and roommate safety. Review of resident #70's NN, SS and physician progress notes [REDACTED]. Documentation of incidents (see above) revealed no details about the incidents, such as triggering events and no specific plans to address behaviors, other than separating the residents involved or educating resident #70. -There was no documentation that either resident #70 'targeted' other residents or that other residents 'targeted' resident #70 and no intervention plans to direct staff to monitor resident interactions to promote resident safety. -There was no evidence that the resident's room changes and concurrent roommate changes were assessed for appropriateness, given the resident's known behaviors. In an interview with the admission coordinator on 12/27/12 at 2:21 p.m., she stated that the determination of roommates is often based on bed availability and social services decides who is going to be compatable. In an interview with the social services director (SDD) on 12/24/12 at 11:17 a.m., the SSD said If something happens, the team need to get together and ask residents who they want to room with. (We) will ask those who like to be moved, see who would be best roomed together, based on medical care and psych well-being. -There was no evidence that the resident's care plan interventions on masturbation and sexually inappropriate behaviors (see above) were reviewed and/or revised. And, a plan to address the incident 8/11/12 (see above) was not initiated until 8/13/12. This plan, documenting that resident #70 sat on his roommate's bed, requested a sexual favor and grabbed the roommate's groin over the roommate's clothing, included 15 minute checks x 1 week or prn; however, it also included many of the same interventions found in earlier care plans. b. Failure to continue mental treatment and communicate with NRB staff. Review of the NRB progress notes revealed no NRB notes after 5/23/12, until 8/27/12, when a quarterly treatment plan summary note documented Resuming treatment with patient after 3 month absence, pt accused by another of inappropriate sexual behavior. In an interview with the resident's licensed professional counselor on 12/20/12 at 12:15 p.m., he said he was not aware of the 8/11/12 incident of inappropriate sexual behavior by resident #70 toward another resident. He said he had only resumed seeing resident #70 in 9/12, and no one told him of the incident. He also stated he was unaware the resident's [MEDICATION NAME] was discontinued 11/2/12. He said the resident should have continued on the [MEDICATION NAME] and if he'd known, he would have intervened when it was discontinued. In an interview with the Social Services Resident Life Coordinator on 12/27/12 at 1:54 p.m., she confirmed that psych services had been changed so that residents were not followed appropriately for some time. B. Event 12/9/12 Review of SS notes revealed resident #70 was transferred to the Aspen unit, a coed secure unit, on 11/30/12 at 2:00 p.m. and placed in a room with resident #5. 1. Resident #5 Resident #5 was admitted to the facility on [DATE]. Diagnoses, according to the face sheet, included dementia. According to a Petition for Appointment of Guardian for Incapacitated Person, dated 12/14/92, resident #5, suffered a severe [MEDICAL CONDITION] which deprived his brain oxygen. He is unable to make rational decisions; is very difficult to understand due to speech problems. According to a Consensual Sexual Activity Assessment, dated 8/31/11, Resident unable to communicate safe sex practices. As of 3/19/12, no changes. The 11/30/12 MDS assessment documented the resident was rarely/never understood, had both long and short-term memory problems, had no recall and severe cognitive impairment. He exhibited no behavior symptoms and required extensive assistance with all activities of daily living (ADLs). He had impaired range of motion in both upper extremities. Care Plans review revealed the resident was identified 2/22/07, to be at risk for being victimized related to dementia. Other problems included cognitive deficits (as evidenced by confusion, disorientation, poor short and long- term memory and difficulty with communication related to dementia) and the need for assistance with ADLs to cognitive impairment. 2. Events 12/9/12 and Facility Response a. Record Review Nine days after resident #70 was transferred to the Aspen unit, NN documented on 12/9/12 at 7:30 p.m. that resident #70 was found on (resident #5's) side of the room. Documentation revealed, (Resident #70 was naked from the waist down. The roommate (resident #5) cannot get out of chair by himself or talk. The roommate's penis was pulled up out of his briefs and he is unable to do this himself. Took resident #70 to the TV room while called nurse manager to report this suspected sexual abuse. Roommate told staff by shaking head, yes that he had been hurt and touched.I called police and they came and filed a report. Resident (#70) moved (back) to the Mountain View (men's secure unit) after got order from Dr . Is own responsible party. Review of the facility investigation report, completed by facility staff on 12/9/12 at 7:30 p.m. revealed it read in pertinent part: CNA went into room to change resident #5's brief and saw resident #70 run back to his own side of the room. He was naked from the waist down and had been behind his roommate's curtain. The roommate was in a recliner chair and his penis was pulled up out of his briefs, and he is not able to do that himself. There was semen and urine in the roommates brief. Immediately separated this resident from the room and kept him in the TV room while nurse manager called and notified DON, NHA (nursing home administrator), also called police who came and filed a report. Dr. also notified. Resident is his own responsible party, resident transferred to Mountain View (male) secure unit. Further review of NN dated 12/9/12 and signed by the nurse working the Aspen unit that evening revealed the following: At approx 7:30 p.m., CNA went into resident room to change his brief and saw the curtain in the room was pulled. The CNA noted that on entry, the resident's roommate (#70) ran back over to his side of the room as he had been on this resident's side and the roommate was naked from his waist down. This resident was noted to be in his recliner chair with his brief being down a bit and his penis exposed. This resident is unable to pull himself out of his brief like this. There was semen and urine mixed in the brief or on it; unable to determine. Immediately separated the roommate and asked this resident in private if he had been hurt by this man, and he stated, yes and then asked him if the man touched him and stated yes by shaking head yes in front of CNA as witness and this nurse took roommate to TV room and called nursing on call to report suspected sexual abuse by this roommate and also notified police and Dr, and reported to roommate's guardian. Placed resident on 15 minute checks for safety. Roommate (#70) moved off unit to MT view unit. Police came and took report. Review of a facility report dated 12/9/12 showed the documented event above, however, additional notes revealed the victim had been behind the privacy curtain, in his recliner, with his erect penis sticking out of his diaper and he is unable to pull himself out of his diaper like that. Resident #70 had been behind the curtain on the victim's side. There was semen noted mixed with urine in/on the victim's diaper. According to the reported occurrence to CDPHE, dated 12/10/12, at approximately 7:50 p.m. on 12/9/12 a, CNA went into the resident's room to find the assailant without his underwear and he ran back to his side of the room from the victim's side of the room. The victim was observed in his recliner and his penis was pulled up out of his briefs. There was semen and urine noted on the victim. Victim was not interviewed as he was not interviewable. No rape kit done. When asked about the victim's response, if he was fearful, the resident/victim is demented and unaware of the incident. The incident was substantiated based on the findings in the room. For the safety of others, the assailant was moved to secure unit. Interventions put in place included: residents were separated. Review of a statement documented by the NHA revealed, On 12/9/12, I became aware of an occurrence between two residents on the Aspen View unit. One resident was observed by a staff member running to his side of the room. The other resident was observed by the same staff to have an erect penis and what appeared to be semen and urine. This event was immediately reported by the staff member to the nurse in charge. An initial report of this was submitted by me to (CDPHE). Both residents were immediately separated and assailant was returned to the secured men's unit. Both residents were assessed for pain or fear. Neither exhibited any fear or pain. Additionally, there was no evidence of physical injury. The assailant is court ordered to be at the facility and is serving his sentence at the facility. b. Interviews On 12/18/12 4:05 p.m., the CNA who entered resident #70 and #5's room on 12/9/12 and witnessed the residents together was interviewed. The CNA, a facility employee for 6 years, said she walked into the room to change resident #5. All the curtains pulled. She looked, as she thought that was odd, and found resident #70 moving quickly back to his side of the room. He was naked from the waist down and resident #5's penis was out. She said she had not witnessed resident #70 touching resident #5 but assumed that happened. She said she had, Worked with resident #5 a long time, and he has never masturbated or done anything like that. She said she reported her observations to the nurse, the residents were separated and police were called. On 12/18/12 at 5:25 p.m., the RN who was working the unit on 12/9/12 was interviewed. -The RN, who said she had been employed at the facility for 14 months, said she was called by the CNA to the resident #70 and #5's room. She said resident #70, scurried over from resident #5's side of the room. He was naked from the waist down. Resident #5 cannot talk or get up and move by himself. He is able to make sounds. His (resident #5) penis was out of his pants; he can't do that himself. Resident #5 cannot manipulate his hands well. She said when there are two staff required in one room, it's hard to watch the rest of the unit. -The RN said she brought resident #70 out to the TV room and asked him what he was doing. He said his roommate's blanket had fallen and he was helping. When asked if he touched resident #5, resident #70 responded, Well not really. The RN then called the supervisor and the police and moved him then to another unit. - The RN said she tried to ask resident #5 questions however, it was really hard because he doesn't talk. She said when she asked him if he was touched, he nodded up and down and then responded with, Jess. -The RN said at the time of the incident resident #70 was on 15 minutes checks. She said he had always been on them because of his history. c. Facility Follow-up (1) In addition to moving resident #70 to the Mountain View unit and calling police, resident #70 was placed on 15 minute checks. (2) Review of the NN and SS notes revealed that following the 12/9/12 event, on 12/10/12, resident #5 was monitored and noted to exhibit increased anxiety and restlessness. His care plan was updated 12/11/12 to keep the resident safe and to monitor for signs and symptoms of distress, trauma, or changes in mood. (3) SS notes documented on 12/10 and 12/14/12, that resident #70 was educated on the current situation, reminded of his probation and informed that authorities would be notified. The resident was informed of possible consequences of recent incident. Informed resident to stay out of others rooms and not to entice others sexually in anyway because it may be a violation of his probation. Res stated understanding.still awaiting call back from (law enforcement) clerk. Also contacted (name) with sex offender registry and they suggested contacting the district attorney. Message left. (4) On 12/17/12, orders were received to restart the resident on [MEDICATION NAME] 50 mg daily. 3. Failures in Facility Response to 12/9/12 Incident a. Failure to Preserve Evidence and Provide a Comprehensive Report to Police on 12/9/12 On 12/17/12 at 3:32 p.m., the police officer who responded to the call on 12/9/12 was interviewed. He said by the time he arrived, resident #5 was up in a chair and cleaned up. He said staff did not report there was any semen or urine. On 12/18/12 at 4:05 p.m., the CNA who entered resident #70 and #5's room on 12/9/12 and witnessed the residents together said then she and the nurse changed resident #5 and put a new brief on him and changed him into a gown because he was wet. On 12/18/12 at 5:25 p.m., the RN working 12/9/12 with the CNA above stated she helped the CNA change resident #5 and said she felt she smelled semen. b. Failure to Adequately Monitor Resident #70 after 12/9/12 The Nursing Home Administrator (NHA), interviewed on 12/18/12 at 4:19 p.m. stated 15 minute checks were implemented after the 12/9/12 incident and that resident #70 was watched all the time. The NHA further stated that resident #70 had a roommate (on the Mountain View unit), but, (The roommate) is able to defend himself. He further stated the facility had no private rooms, so resident #70 had always been with a roommate. However: -Review of the record for resident #70's roommate (as of 12/18/12), revealed the roommate's most recent MDS, dated [DATE], revealed this resident, as resident #5, was cognitively impaired. -Review of the 'behavior and 15 minute checks' sheets revealed the resident was not consistently monitored every 15 minutes and behavior documentation was inconsistent. -Review of NN 12/10/12, the day after the incident involving resident #5, revealed documentation at 8:45 p.m., resident #70 was in room with another resident and both residents were naked on the bed. (Both denied any sexual contact happened, both denied fear, both feel safe and weren't pressured into uncomfortable situations.) -Review of resident #70's room on the Mountain View unit on 12/20/12 revealed it was at the end of the hall, away from the nurses' station. C. Interviews - Evidence of Systemic Failures to Ensure Resident Safety The CNA who discovered resident #70 and #5 on 12/9/12 stated during an interview that resident #70 was moved to the Aspen when it was her day off. She was not aware initially that resident #70 came from jail. Regarding training, she said the administration, Tell us how to take care of residents, and we have silver chair, (computerized based training), if you suspect it (abuse) report it, any kind of abuse. Separate the residents, call police and 15 minute checks. The NHA, DON and RNC were interviewed on 12/18/12 at 4:19 p.m. -The NHA stated that regarding suspected sexual abuse, there had never been any discussion about what to do or not do with any evidence and there was no policy regarding preserving evidence or the area. Per the DON, never thought about it, that's what the police are supposed to do. She said staff was trained on silver chair yearly. -Regarding expectations with suspected sexual assaults, the NHA said, they would take statements from everyone. However, they first had to determine if the sexual encounter was consensual. If not, we investigate. We separate and diffuse, deescalate, then call the police. If a resident is unsafe we move off the unit immediately. Preserving the scene or any evidence was not done. The RN working 12/9/12 stated during an interview 12/18/12 at 5:25 p.m. that with regarding training, she had worked with these types of residents and locked units. However, there had been no training regarding preservation of the scene or any evidence. The RN said she did not feel safe on the men's unit; there were no specific care plans. She stated the basic response was to separate and call the police and the supervisor. She said there was a psych hot line; however, They either do not respond timely or will say call 911. She called the director of restorative (DOR) on 12/9/12 because she was on-call, and the DOR, told me what to do; to notify management and the police. The DOR was interviewed on 12/18/12 at 6:00 p.m. She said she had been employed at the facility for almost 7 years. -She said she was on call on 12/9/12 and took the call at 8:00 p.m. (on Sunday) from the RN, the floor nurse. She was informed of the CNA's observations and instructed the RN to constantly supervise them and call the police. The DOR then called don who called NHA and the consultant. -She said staff has training on abuse, initial training, before starting on the floor, as well as back ground checks. She said the silver chair was the main source of ongoing education. In-services mandatory once a month. She said for suspected abuse, you first call the on-call, even if you are just uncomfortable and not sure. On 12/19/12 at 5:00 p.m. the responding police officer's supervisor was interviewed at the facility. He stated he interviewed resident #70 and determined, He is aware and knows what h

Based on record review and interviews, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically: The facility failed to ensure a comprehensive policy regarding sexual abuse was in place and failed to implement a portion of an abuse policy they did have. Resident #70 sexually abused resident #5 on 12/9/12. The facility's failure to develop and implement a comprehensive sexual abuse policy contributed resident to resident abuse and an inadequate response after the abuse that placed facility residents at risk for further harm by resident #70. Cross-reference F 223 Abuse. The findings include: A. Facility Policy Review of the facility's Abuse Prevention Policy, Response and Reporting revealed, in part: -It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .All possible measures considered by the facility should be taken to assure the resident is maintained in a safe environment . -A thorough assessment of the resident's physical condition must be completed if an incident has occurred. If the injuries require a physician's intervention or if there's is a possibility of sexual assault, the physician should be notified and the resident should be sent to the hospital. The initial assessment information, including the suspected cause of the injury, should be forwarded to the hospital physician. B. Failure to Develop and Implement a Comprehensive Sexual Abuse Policy 1. Resident #70 Resident #70 was admitted to the facility from a county jail on 3/20/12. Diagnoses, in part, according to the face sheet included, [MEDICAL CONDITION]. The 3/26/12 admission Minimum Data Set (MDS) assessment documented the resident was alert, oriented and cognitively intact. He was essentially independent with activities of daily living (ADLs), though required staff oversight/supervision. The resident exhibited physical behaviors towards others such as, hitting, scratching self, pacing, rummaging, public sexual acts, disrobing, etc. The 9/3/12 quarterly MDS assessment documented the Brief Interview for Mental Status (BIMS) score was at 13, indicating he was cognitively intact. He exhibited no physical behaviors, even though there was inappropriate sexual contact with another resident that was documented from 8/11/12. The most recent quarterly MDS assessment, dated 11/30/12, documented the resident's BIMS score remained at 13. No mental status assessment was indicated as the resident was able to complete interview. He had no memory problems and exhibited no physical behaviors towards others. Resident #70 was admitted to the facility from jail as a known sex offender on 3/12/12. Resident #70 had previously resided at another long term care facility where he was arrested and taken to the jail in 2011, following inappropriate sexual behavior at that facility. He was court ordered for secured unit placement at the current facility for the remainder of a two year probation term. 2. Resident #5 Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to a Petition for Appointment of Guardian for Incapacitated Person, dated 12/14/92, in part, resident #5 suffered a severe [MEDICAL CONDITION] which deprived his brain oxygen. He is unable to make rational decisions; is very difficult to understand due to speech problems. According to a, Consensual Sexual Activity Assessment, dated 8/31/11, Resident unable to communicate safe sex practices. As of 3/19/12, no changes. The 11/30/12 MDS assessment documented the resident was rarely/never understood, had both long and short term memory problems, had no recall and severe cognitive impairment. He exhibited no behavior symptoms and required extensive assistance with all activities of daily living (ADLs). He had impaired range of motion in both upper extremities. The care plan, dated 2/22/07, identified that the resident was at risk for being victimized related to dementia. The goal was for the resident to not be victimized. Approaches included; -monitor mood for signs and symptoms of distress, -provide supervision when off locked unit, -1 to 1 to allow verbalization, conversation. 3. Event 12/9/12 Review of an occurrence reported to the Colorado Department of Public Health and Environment on 12/10/12, revealed resident #70 had inappropriate sexual contact with resident #5 on 12/9/12. Specifically, when resident #70 was transferred from the secured men's unit to the coed secured unit on 11/30/12, he was knowingly placed in a room with a male resident (#5) who was totally physically and mentally dependent. According to the medical record, on 12/9/12 at 7:30 p.m., resident #70 was found on the roommate's side of the room. Documentation revealed, He was naked from the waist down. The roommate cannot get out of chair by himself or talk. The roommate's penis was pulled up out of his briefs and he is unable to do this himself. Took resident #70 to the TV room while called nurse manager to report this suspected sexual abuse. Roommate told staff by shaking head, yes that he had been hurt and touched.I called police and they came and filed a report. Resident (#70) moved (back) to the Mountain View (men's locked unit) after got order from Dr. Remains on 15 minute checks. Is own responsible party. 4. Failures in Facility Response a. Failure to protect facility residents after 12/9/12 to prevent reoccurrence. After the 12/9/12 event, resident #70 was transferred back to his original unit and placed with another roommate. The Nursing Home Administrator (NHA), interviewed on 12/18/12 at 4:19 p.m. stated 15 minute checks were implemented after the 12/9/12 incident and that resident #70 was watched all the time. The NHA further stated that resident #70 had a roommate (on the Mountain View unit), but, (The roommate) is able to defend himself. He further stated the facility had no private rooms, so resident #70 had always been with a roommate. However: -Review of the record for resident #70's roommate (as of 12/18/12), revealed the roommate's most recent MDS, dated [DATE], revealed this resident, as resident #5, was cognitively impaired. -Review of the 'behavior and 15 minute checks' sheets revealed the resident was not consistently monitored every 15 minutes and behavior documentation was inconsistent. -Review of NN on 12/10/12, the day after the incident involving resident #5, revealed documentation at 8:45 p.m., resident #70 was in room with another resident and both residents were naked on the bed. (Both denied any sexual contact happened, both denied fear, both feel safe and weren't pressured into uncomfortable situations.) -Review of resident #70's room on the Mountain View unit on 12/20/12 revealed it was at the end of the hall, away from the nurses' station. b. Failure to Preserve Evidence, Provide a Comprehensive Report to Police on 12/9/12, and send Resident #5 to the hospital per Facility Policy On 12/17/12 at 3:32 p.m., the police officer who responded to the call on 12/9/12 was interviewed. He said by the time he arrived, resident #5 was up in a chair and cleaned up. He said staff did not report there was any semen or urine. On 12/18/12 at 4:05 p.m., the CNA who entered resident #70 and #5's room on 12/9/12 and witnessed the residents together said then she and the nurse changed resident #5 and put a new brief on him and changed him into a gown because he was wet. On 12/18/12 at 5:25 p.m., the RN working 12/9/12 with the CNA above stated she helped the CNA change resident #5 and said she felt she smelled semen. Review of resident #5's record revealed he was not sent to the hospital, as expected per facility policy (see above). On 12/18/12 at 4:19 p.m. the NHA, DON and RNC were interviewed The NHA stated that regarding suspected sexual abuse, there had never been any discussion about what to do or not do with any evidence and there was no policy regarding preserving evidence or the area. Per the DON, never thought about it, that's what the police are supposed to do. She said staff was trained on silver chair yearly. The NHA, DON, and RNC were interviewed again on 12/27/12 at 4:10 p.m. Regarding a policy for sexual offenders, the NHA said that was still in the discussion phase and would require involvement of the VP of clinical operations. Cross-reference F 223 for further details.

Based on observation, record review and staff interview, the facility failed to ensure two (#60 and #95) of 46 sample residents received and the facility provided the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically: The facility failed to ensure residents #60 and #95 were free from medication error. Resident #60 received a narcotic [MEDICATION NAME] that was intended for resident #95. Resident #60 was hospitalized for [REDACTED]. The findings include: A. Facility Policy Policy Review: Review of the 11/16/09 facility policy "Narcotic [MEDICATION NAME] Drug Delivery System (Nur-1383) revealed the purpose of the policy was: "To administer narcotic medication through the skin for continuous absorption while the patch is in place, through proper placement of the patch and continued monitoring of the site. The procedure, in pertinent part was as follows: 1. Select an appropriate site location. a. Observe site of previous application. Rotate placement sites. b. Remove the old patch before applying the new patch. 2. Remove patch from package. Check package expiration date. Date and initial the patch. 5. Document administration to include date and time of application. 6. Patch should be checked each shift to verify continued placement and documented on the MAR (Medication Administration Record). A missing patch should be reported to your supervisor immediately. An investigation should be initiated prior to the nurse leaving his/her shift. (a line lead to a hand written phrase "Treat as a missing narcotic!") 7. Follow physician orders [REDACTED]. 8. (hand written at the bottom of the policy) "Always sign disposal of old patches with 2 (two) nurses." At the bottom of the page was hand written "5 (Five) rights-make sure you know them & use them for each med(ication) you pass! --Person, --Medication, --Dose, --Route, --Time." In interview on 10/18/12 at approximately 1:30 p.m., with the Acting Director of Nursing (ADON) revealed the policy is currently under revision by the corporate entities managing the facility, but had not yet been approved. When the revisions were made, or if they will remain in place as written were unclear. B. Resident #60 Resident #60, age 74, originally was admitted to the facility on [DATE]. According to the Face Sheet (printed 1/31/12), [DIAGNOSES REDACTED]. 1. Resident Status Minimum Data Set (MDS) According to the 9/11/12 minimum data set (MDS), the resident had adequate hearing and impaired vision. He had unclear, slurred or mumbled speech and as a result, he was rarely or never understood. He usually understood the communication of others. He had cognitive skill for daily decision-making. -He did not experience depression, fidgeting or restlessness, and as a result, had a mood severity score of "1," indicating little mood disturbance. He did not experience psychoses, physical, verbal, care rejecting or wandering behaviors. -He required extensive assistance of two or more persons for transfers and toilet use. He exhibited no range of motion limitation of the upper extremities, and bilateral impairment of both lower extremities. -He was independent for eating, and required staff set-up only. He required extensive assistance of one person for locomotion on the unit. -He was frequently incontinent of urine and bowel. Care Plan: Review of the resident's comprehensive care care plan revealed the following pertinent problems: (1) Problem - dated 12/29/11- revealed a problem of altered communication due to progressed [MEDICAL CONDITION]. The resident had difficulty initiating speech & annunciating words. The resident refused treatment for [REDACTED]. -The goal was he would have his needs met until the next review period. -Approaches included allowing the resident time to speak when he is trying, anticipating needs as able, ST as needed, ask simple "yes or no" questions as possible to clarify, ask the resident to write down communication as needed, and ask the resident to use gestures as needed, for example one finger for "yes" and two fingers for "no." A 6/29/12, hand-written note on the computer-generated care plan showed he was now "rarely or never understood" on the MDS. (2) Problem - dated 3/27/12 - At risk for choking and aspiration related to [MEDICAL CONDITION], dysphagia. The resident declined an altered diet after education regarding risk. He declined to sit at the restorative or assisted dining tables. -The goal was he would have nutritional needs met with least restrictive diet tolerated. -Approaches included the resident was provided with education and signed waiver. The staff was to cue and assist the resident during meals. If he had not completed the meal by the end of the second meal, staff was to assist with feeding. Staff was to continue to educate and encourage the resident in the least restrictive diet for safety, and ease of dining. He was to have close monitoring by staff, with encouragement to hold head up while eating, and encouraging in bite, adequate chewing, hard swallow and sip of fluid. Staff was to report any coughing during meals to the charge nurse, and lung assessment was to be done after any incidents of coughing. He was to have no food or fluids in his room. 2. hospitalization [DATE] for Respiratory Distress Secondary to Medication Error Hospital History and Physical (H&P): Review of the 9/23/12 hospital H&P revealed the resident arrived at the hospital from the facility unresponsive and was initially placed on a non-rebreather mask. Unresponsiveness was due to use of [MEDICATION NAME] 2 mg during a possible [MEDICAL CONDITION]. An arterial blood gas showed an Oxygen level of 72 (normal is above 90). His chest x-ray showed poor inspiratory effort, though no infiltrates. The cause of his altered mental status was unknown. He was identified to have multiple system abnormalities. Hospital Discharge Summary: Review of the 9/28/12 hospital Discharge Summary revealed: The resident was brought into the hospital the night of 9/23/12 because of altered mental status and episodes of apnea (not breathing). The resident was given [MEDICATION NAME] (a narcotic antagonist) by paramedics prior to transport to hospital. His respirations improved briefly. He had some jerky movements and was given [MEDICATION NAME] 2 milligrams (mg) to counteract a possible [MEDICAL CONDITION]. The resident was initially unresponsive, but maintained his airway. The resident was initially admitted to a step-down unit, but he again became apneic and was intubated (a procedure to place a breathing tube into the trachea to allow easier breathing), and placed on mechanical ventilation. The patient then started developing a fever, confused mental status, and there was a strong suspicion of aspiration pneumonia (inhalation of vomit into the lungs). A more thorough assessment the night of admission revealed he had a [MEDICATION NAME] (strong narcotic [MEDICATION NAME] medication) patch on him, which was immediately removed. The physician contacted the nursing care facility and confirmed the resident did not have an order for [REDACTED]." The resident was admitted to the intensive care unit once intubated, and remained on mechanical ventilation until 9/26/12, when he was extubated. He received a peripheral intravenous central catheter (PICC) as well as arterial lines for administration of medications, fluids and monitoring. The discharge plan and instructions were that the resident would return to the facility. The treating physician strongly advised against the use of any narcotics or benzodiazepines. Facility Attending H&P: Review of the 9/29/12 attending physician History and Physical (H&P) showed the resident was given another resident's 100 microgram (mcg) [MEDICATION NAME], probably a day or two before his altered mental status. The physician noted the resident had dementia and was practically non-verbal. She noted he had [MEDICAL CONDITION] with [MEDICAL CONDITION] (low blood Oxygen level), accidental drug overdose due to a nursing error involving [MEDICATION NAME], aspiration pneumonia,[MEDICAL CONDITION], dysphagia (difficulty swallowing), [MEDICAL CONDITION], and Lewy-body dementia. Associated Interview: In interview on 10/18/12 at 11:15 a.m., the attending physician said it was her opinion the resident was more debilitated since his return from the hospital after the [MEDICATION NAME] overdose. She confirmed she did not examine the resident at the hospital. Resident Observation: Observation on 10/18/12 at approximately 12:10 p.m., revealed the resident in the dining room seated in a geriatric chair. Staff sat to his right and fed him lunch. He did not verbalize while eating or participate in feeding himself. (See MDS above; as of 9/11/12, the resident was independent with eating and required staff set up only.) Nurse's Notes: Review of the Nurse's Notes (NN) in facility chart revealed the following: - 9/23/12 at 7:05 a.m., the resident was reported to have rested in bed all night. No complaints were voiced or noted. His pulse oximetry (measure of arterial Oxygen level) was 92%, (normal above 90%). - 9/23/12 at 10:15 a.m., oxygen level was 85%, with a rapid pulse of 103 beats per minute (normal is 60 to 100 per minute), and a respiratory rate of 9 (normal is 16 to 22 per minute). The resident received Oxygen at 2 liters per minute (lpm) using a nasal cannula to maintain a pulse oximetry (pulse Ox) of 90%. Raising the Oxygen administered to 3 lpm/nasal cannula yielded a pulse Ox of 91%. Despite the Oxygen, the respiratory rate remained 9 per minute, well below the normal rate. The resident was transported to the local hospital, and admitted . 3. Facility Response to 9/23/12 Incident Facility Investigation: The facility began an investigation of the incident on 9/24/12 at an undetermined time. The facility conducted an audit of all residents, and determined six residents currently used [MEDICATION NAME]es. An inspection of each resident revealed resident #95 had a [MEDICATION NAME] in place that was dated on 9/19/12. This patch, per orders, should have been removed and a new patch applied the evening of 9/22/12. Medication Error Report: Review of a 9/24/12 Medication Error Report revealed the error involving resident #60 occurred on 9/22/12. -The nurse on duty on 9/22/12 during the evening shift (2:00 to 10:00 p.m.) normally worked the night shift. She thought resident #60 was resident #95, and applied the [MEDICATION NAME] 100 mcg patch to the wrong resident. She reported the resident looked different sitting up than while lying in bed. -The nurse on duty reported she called resident #60 by the name of resident #95. Resident #60 did not reply and correct her. -The nurse on duty was suspended pending further investigation, and was subsequently terminated and reported to the Board of Nursing (BON). Associated Medication Error Report: Review of the associated 9/24/12 Medication Error Report revealed resident #95 did not get the [MEDICATION NAME] as ordered on [DATE]. -Review of the 9/12 Medication Administration Records (MARs) for resident #95 revealed the nurse placed the [MEDICATION NAME] 100 mcg [MEDICATION NAME] on the right upper back of a resident, but was unable to locate the previous patch for removal. -There was no evidence she notified the Assistant Director of Nursing (ADON) or other supervisory nursing personnel of the missing patch, as required in facility procedures for [MEDICATION NAME]es (see above). -There was also no evidence of monitoring for ongoing patch placement each shift between patch changes as required in the facility procedures for [MEDICATION NAME]es (see above). Staff Training: In an interview on 10/17/12 at 5:40 p.m., nurse A said she got training from ADON on the [MEDICATION NAME] policy/procedure (see above). Patches were to be monitored each shift for placement. If a patch was not located on the resident or in their bedding, the Director of Nursing (DON) was to be notified. She said it would be helpful if there were updated photographs of each resident in the MARs. In an interview on 10/17/12 at 5:43 p.m., nurse B said she got training on the patches by the ADON after the 9/22/12 incident. If a patch could not be located, the DON was to be notified immediately. In interview on 10/17/12 at 5:55 p.m., nurse C identified only one resident on her unit that wore a pain patch. She was able to describe the correct procedure for patch disposal, appropriate placement and labeling, and the need for monitoring of the patch placement for each shift. In an interview on 10/18/12 at 10:20 a.m., nurse D recited pertinent parts of the policy. She said training on pain patches was conducted by the ADON after the 9/22/12 incident. In an interview on 10/18/12 at 10:30 a.m., nurse E verified she was to check for patch placement every shift. She said after removing an old patch, she immediately got the nurse from the other secure unit to witness disposal of the patch in the sharps container. She said the DON was taking updated photographs to place in the charts and MARs. Photos taken the previous day (10/17/12). New photos were not yet placed in the MARs. In an interview on 10/18/12 at 12:05 p.m., nurse F was able to articulate the correct process for patch verification per shift, and knew to report missing patches to DON. She described turning the MARs over on a monthly basis was the responsibility of many nurses, who performed this duty when they had a few spare minutes. In an interview on 10/17/12 at 5:10 p.m. and again on 10/18/12 at 11:40 a.m., the ADON confirmed she had presented the inservice on the policy and procedure for pain patch management to all nursing staff. Those staff that were not present got retrained prior to beginning their shift. This occurred until all the nurses were retrained on this policy and procedure. The ADON also confirmed the initial audit on 9/24/12, revealed some residents did not have verification of patch placement per shift, and should have. MAR Review and Facility Audit: Review of all 9/12 and 10/12 MARs of the six residents using the [MEDICATION NAME] revealed staff began monitoring the placement of pain patches on 9/25/12. A nursing audit 9/28/12, conducted after training nursing staff on the policy and procedure for [MEDICATION NAME] use, revealed each of the six residents had pain patches in place as ordered, each patch was labeled per the policy, and ongoing patch placement was monitored according to the policy. 4. Failure in Facility Response Observation on 10/17/12 at 1140 a.m., showed the nurse verifying resident #86's pain patch placement during medication pass, and on 10/18/12 at 1:40 p.m., the nurse showed resident #58's patch was in place and ordered. However: -Observations in the facility throughout the survey (10/11/12 to 10/18/12) revealed no evidence of individual resident identification. Observations revealed residents lived in rooms with either two or four beds. The room numbers were on the outside of the doors. There were no resident names posted outside the room doors and the residents did not wear arm bands or other identification devices. -Observation of the resident MARs on 10/18/12 also revealed no recent resident pictures on the MARs. Resident #60's photo was taken at the time of his admission several years before, as was resident #95's.