Every finding on record at Rowan Community, Inc

Based on observations, record review and interviews, the facility failed to ensure one (#2) of five residents out of 14 sample residents were treated with respect, dignity and care in a manner that promoted quality of life or recognized the residents' individuality.Specifically, the facility failed to:-Knock prior to entering Resident #2's room, introduce themselves and the care they were going to be providing; and,-Respect Resident #2's wish to have staff enter her room wearing a face mask. Findings include:I. Resident #2A. Resident statusResident #2, age less than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), the diagnoses included bipolar disorder (mental illness), chronic respiratory failure and type 2 diabetes mellitus.The 9/3/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. She was dependent on staff for activities of daily living (ADL), including eating, oral hygiene, showering, toileting and dressing.B. ObservationsDuring a continuous observation on 10/1/25, starting at 1:50 p.m. and ending at 4:28 p.m. the following was observed:At 1:50 p.m. three handwritten signs were attached to Resident #2's door which requested any staff member who entered the resident's room, except to administer medications, wore a face mask over their nose. One of the handwritten signs was written in Spanish.At 3:44 p.m. an unidentified medical supply staff member entered Resident #2's room without knocking or wearing a mask. At 3:53 p.m. certified nursing assistant (CNA) #1 entered Resident #2's room without knocking or wearing a mask.C. Resident interviewResident #2 was interviewed on 10/6/25 at 5:00 p.m. Resident #2 said it made her feel horrible when the staff entered her room without wearing a face mask. She said the facility had face masks available. She said it made her feel bad when staff entered her room without knocking or announcing themselves.D. Record reviewReview of Resident #2's care plan, initiated on 11/6/21, revealed the resident preferred to wear a mask when outside of her room. The pertinent intervention included keeping a mask on Resident #2 at all times while she was out in the community.-However, Resident #2's care plan failed to include the resident's preference for staff members to wear a mask upon entering her room.E. Staff interviewsAn unidentified CNA was interviewed on 10/6/25 at 3:15 p.m. The CNA said there was a box of face masks available in Resident #2's room for staff members who did not present to the room wearing a face covering.The nursing home administrator (NHA) was interviewed on 10/7/25 at 11:46 a.m. The NHA said staff should have knocked on the resident's doors to announce themselves and the care they would provide in order to protect the resident's dignity. She said individual resident preferences, such as Resident #2's preference for staff to put on a face mask prior to entering the resident's room, should have been communicated in the care plan in order to provide consistent care. The NHA said in this case, Resident #2's family member placed the signs on the door to communicate the resident's preference to staff. She said face masks should have been donned prior to entering the resident's room, and face masks were accessible and stored at the nursing station. The NHA said the facility should have honored all of the residents' choices.

Based on observations and interviews, the facility failed to facilitate resident self-determination for one (#4) of five residents reviewed for choices and preferences out of 14 sample residents.Specifically, the facility failed to honor Resident #4's choice to return to his room. Findings include:I. Resident #4A. Resident statusResident #4, age less than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included traumatic brain injury (TBI), post traumatic seizures and chronic respiratory failure.The 8/25/25 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. He was dependent on staff for activities of daily living (ADL), including personal hygiene, dressing, eating and mobilizing.B. ObservationsDuring a continuous observation in the dining room on 10/1/25, starting at 12:55 p.m. and ending at 2:11 p.m., the following was observed:At 1:06 p.m. Resident #4 asked an unidentified staff member to assist him back to his room. The unidentified staff member told the resident his room was being cleaned and he had to wait 15 minutes.At 1:32 p.m. an unidentified housekeeping staff member asked Resident #4 how he was doing. The resident responded by saying he would like to go to his room. The staff member walked away without responding to the resident.At 2:02 p.m. Resident #4 began shouting get me the (explicit language) out of here.At 2:06 p.m. Resident #4 asked the activities director (AD) to bring him back to his room. The AD did not respond to the resident. Resident #4 then asked an unidentified kitchen staff member to bring him back to his room. The kitchen staff member said he would find a staff member to help him. The AD said she was busy setting up for the Bingo activity.At 2:11 p.m. Resident #4 said he wanted to go home, then repeated himself and said he wanted to go to his room. -The facility failed to assist Resident #4 out of the dining room for over an hour after he requested.C. Resident interviewResident #4 was interviewed on 10/6/25 at 2:00 p.m. Resident #4 said when he wanted to go back to his room he was often required to wait long periods of time it made him feel bad. D. Staff interviewsThe nursing home administrator (NHA) was interviewed on 10/7/25 at 11:46 a.m. The NHA said the facility should have honored all of the residents' choices. She said Resident #4's experience did not occur as a result of a staffing issue. The NHA said the unidentified staff member who told Resident #4 he would have to wait just 15 minutes to return to his room probably forgot to follow up with him.

Based on observations, record review and interviews, the facility failed to ensure a dependent resident received the necessary services to maintain activities of daily living (ADL) for two (#4 and #5) of five residents out of 14 sample residents.Specifically, the facility failed to:-Ensure timely repositioning and incontinence care for Resident #4; and,-Ensure timely repositioning for Resident #5. Findings include: I. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included traumatic brain injury (TBI), post traumatic seizures and chronic respiratory failure. The 8/25/25 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. He was dependent on staff for ADLs, including personal hygiene, dressing, eating and mobilizing. B. Resident interview and observation During a continuous observation on 10/2/25, starting at 12:37 p.m. and ending at 2:30 p.m., the following was observed: At 12:37 p.m. Resident #4 was sitting in his geri chair (specialty wheelchair) in the dining room staring at the wall. There were no activities or engagement for the residents and only dining room staff members were present. At 12:50 p.m. Resident #4 remained in the same position. At 1:37 p.m. Resident #4 remained in the same position At 1:54 p.m. Resident #4 remained in the same position At 2:00 p.m. Resident #4 said he had been sitting in his chair for a long time and would like to go back to his room. He said it had been a long time since he had been offered incontinence care. At 2:02 p.m. the activities director (AD) entered the dining room and was notified that Resident #4 would like to be assisted back to his room and changed. The AD left the dining room and said she would find a certified nursing assistant (CNA). At 2:04 p.m. the AD returned to the dining room and said she notified CNA staff. At 2:11 p.m. no staff members had come to the dining room to assist Resident #4. The AD was walking in and out of the dining room, but did not provide further assistance to the resident. At 2:14 p.m. CNA #2 arrived on shift and was asked to assist Resident #4 with incontinence care. CNA #2 assisted the resident to his room and said she was going to get the Hoyer lift (mechanical lift used to transfer residents) and would be right back. At 2:18 p.m. CNA #2 returned to Resident #4's room with the Hoyer lift. At 2:20 p.m. CNA #2 began to independently prepare the Hoyer lift to transfer Resident #4 from the geri chair to his bed when the nursing home administrator (NHA) entered the room to assist with the hoyer lift transfer. Once on his bed, Resident #4 said it felt better to lay down flat. The NHA left the room. At 2:23 p.m. Resident #4's room filled with the scent of foul urine. At 2:26 p.m. CNA #2 tossed a saturated urine brief into the trash can. The brief made a loud thud when it hit the bottom of the can. At 2:27 p.m. CNA #2 said she needed to get a new sling for the Hoyer lift because the previously used sling was wet with urine. -Resident #4 was not provided repositioning or incontinence care for two hours. Resident #4 was interviewed again on 10/6/25 at 9:30 a.m. Resident #4 said sitting in a wet incontinence brief for long periods of time made him feel bad and his skin would become irritated. D. Record review Review of Resident #4's comprehensive care plan, initiated on 8/18/25, revealed the resident had bowel and bladder incontinence. Pertinent interventions included providing perineal care after each incontinent episode, checking the resident frequently and as required for incontinence and changing the resident's clothing as needed after incontinence episodes. Review of Resident #4's electronic medical record (EMR) revealed weekly nursing assessments which document Resident #4 was incontinent of bowel and bladder. Further review of Resident #4's EMR revealed the following documentation of incontinence care on 10/2/25: Incontinence care was performed at 5:43 a.m. and again at 1:35 p.m. -However, Resident #4 was sitting in the dining room during a continuous observation between 12:37 p.m. and 2:15 p.m. and was not provided with incontinence care during that time (see observations above). E. Staff interviews Registered nurse (RN) #2 was interviewed on 10/6/25 at 9:38 a.m. RN #2 said the staff would check the residents for incontinence with every medication pass. RN #2 said foul smells and wet clothes or linens were an indication that a resident needed to be changed, and providing incontinence care was important because sitting in urine or stool for long amounts of time could cause skin breakdown. CNA #3 was interviewed on 10/6/25 at 11:48 a.m. CNA #3 said incontinence care was scheduled to be performed at the start of the shift, every two hours after that with rounds and as needed. She said wet pants and the smell of a bowel movement indicated that incontinence care might need to be performed more frequently. CNA #3 said incontinence care was important to maintain personal hygiene, provide skin protection and ensure the residents were comfortable and dry. The NHA was interviewed on 10/7/25 at 11:46 a.m. The NHA said incontinence care should be performed every two hours. She said if the resident was not soiled, then they should be repositioned. The NHA said smells of urine or agitation could indicate the resident was in need of changing, and providing incontinence care was important in order to prevent skin breakdown. II. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included Huntington's disease, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, anxiety disorder, depression and other abnormal involuntary movements. The 8/21/25 minimum data set (MDS) assessment revealed the resident scored a zero on the brief interview for mental status (BIMS) indicating severe cognitive impairment. The MDS assessment revealed Resident #5 was dependent on staff for all ADLs. B. Observations During a continuous observation on 10/1/25, beginning at 1:47 p.m. and ending at 4:20 p.m., the following was observed: At 1:47 p.m. Resident #5 was sitting in their wheelchair at the table in the dining room. At 2:06 p.m. the AD began setting up the dining room for Bingo. The staff did not reposition Resident #5. At 3:30 p.m. Resident #5 remained in her wheelchair at the table in the same position. At 4:20 p.m. Resident #5 was sitting in her wheelchair at the dining room table in the same position waiting for dinner. -Resident #5 was not repositioned or offered repositioning for over two and a half hours. C. Record review The comprehensive care plan, revised on 7/15/21, indicated Resident #5 used a wheelchair and occasionally had delusions that she can walk. Pertinent interventions included positioning the resident in a wheelchair and providing assistance with repositioning as indicated. -However observations revealed the facility failed to consistently assist Resident #5 with repositioning (see observations above). D. Staff interview CNA #4 was interviewed on 10/7/25 at 10:14 a.m. CNA #4 said Resident #5 was capable of offloading her own weight. CNA #4 saidResident #5 was capable of moving herself up in the chair if Resident #5 felt she was sitting too low in the wheelchair. CNA #4 said the staff would reposition Resident #5 when they were providing toileting care. CNA #4 said that Resident #5 was good about vocalizing her needs. CNA #4 said Resident #5 did not sit for long periods of time in her wheelchair because Resident #5 did not like to. -However, Resident #5's care plan indicated the resident needed assistance with repositioning (see care plan above). it

Based on observations, record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#51) of five residents reviewed out of 32 sample residents. Resident #51, who was at risk for falls and had a history of falls, experienced 21 falls between 1/13/25 to 5/15/25. The facility's interdisciplinary team (IDT) met after the falls to determine a root cause for the resident's falls and implement interventions. However, the facility's review of the falls was not always timely. The root cause identified for 19 of the resident's 21 falls was poor safety awareness, however, the facility did not identify a more specific root cause in order to determine if the fall interventions were appropriate and effective for preventing further falls. However, the facility failed to ensure multiple documented interventions were initiated and the resident was observed, during the survey, without several of the observations in place (see observations below). On 4/21/25, the resident experienced a fall which resulted in a laceration to his left eyebrow and a laceration to his chin. He was sent to the emergency department (ED) for evaluation and returned to the facility with five stitches on his left eyebrow and three stitches on his chin. The facility documented an intervention after the 4/21/25 fall for the medical director to review the resident's medication to see if any medications were possibly contributing to the resident's falls. However, there was no documentation to indicate this was completed and the resident continued to experience falls. Specifically, the facility failed to consistently review Resident #51's falls in a timely manner, identify specific root causes of the falls and ensure documented interventions were initiated and consistently in place. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:52 p.m. It read in pertinent part, A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Interventions are to be re-evaluated when a resident falls for efficacy. Document in the electronic medical record (EMR) the resident's response to interventions and revise interventions if they were not successful. II. Resident #51 A. Resident status Resident #51, age [AGE], was admitted [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Steele-[NAME]-[NAME] syndrome (a rare neurodegenerative disease that affects balance, eye movement, speech and swallowing), progressive supranuclear ophthalmoplegia (inability to move one's eyes at will), limitation of activities due to disability, muscle weakness, repeated falls, cognitive communication deficits, abnormalities of gait and mobility, other frontotemporal neurocognitive disorder (changes in behavior, personality and language) and history of falls. The 2/17/25 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. Resident #51 required extensive assistance with transfers and toilet use. The MDS assessment indicated the resident had had two or more falls since his prior assessment. B. Observations On 5/19/25 at 10:10 a.m. Resident #51's door was open. He was in bed, however, the resident's call light was on the floor behind his headboard. Resident #51 slowly rolled to the edge of the bed to reach for his call light. The resident had to stretch and roll close to the edge of his bed to reach the call light. He pushed the call light for assistance to reposition himself. An unidentified certified nurse aid (CNA) responded and asked from the doorway what Resident #51 needed. Resident #51 was difficult to understand. The unidentified CNA asked if he wanted water and said she would be back with water. The resident slowly repositioned himself. -The unidentified CNA did not notice the resident's close proximity to the edge of the bed. Observations of Resident #51's room on 5/19 at 10:10 a.m. did not reveal a helmet, grip tape on the resident's floor or a call don't fall sign in the resident's room (see care planned fall interventions below). C. Resident interviews Resident #51 was interviewed on 5/19/25 at 10:00 a.m. He said he had many falls and does not always use the call light because it was not answered in a timely manner. He said he had waited at least 45 minutes or more before anyone came in to help him. Cross-reference F550 for failure to respond to call lights in a timely manner. Resident #51 was interviewed a second time on 5/22/25 at 1:00 p.m. He said he did not know where his helmet was. D. Resident representative interview Resident #51's representative was interviewed on 5/21/25 at 10:50 a.m. Resident #51's representative said she had witnessed staff (via a camera in the resident's room) leaving Resident #51 standing in his room alone and shutting the door. She said Resident #51 had a floor to ceiling transfer pole that was removed a couple of months ago. Resident #51's representative said she and the resident's other representative had requested the transfer pole be reinstalled because the resident had had more falls since the pole was removed. Resident #51's representative said the resident would go many hours before a staff member checked on him. E. Record review The at risk for falls care plan, initiated 9/7/23 and revised 4/15/25, revealed Resident #51 was at risk for falls related to his progressive supranuclear ophthalmoplegia and history of falls. He had unsteady balance during transfers. Resident #51 became frozen (temporary inability to move) and had a hard time processing what he needed to do next. Resident #51 preferred to keep his room dark and preferred to not wear socks and shoes. Pertinent interventions included ensuring the resident's call light was within reach and encouraging him to use it, promptly responding to all requests for assistance, placing a call don't fall sign in the resident's room, frequent rounding, placing grip tape on the floor near the resident's bed, physical therapy (PT) to evaluate and treat as ordered or needed, checking the resident after meals for toileting, snacks and hydration and reminding Resident #51 to lock his wheelchair brakes, ask for assistance to change the room temperature and clean up spills. Review of Resident #51's electronic medical record (EMR) revealed the resident had 21 falls from 1/13/25 through 5/15/25. Review of Resident #51's falls between 1/13/25 and 5/15/25 revealed the following: 1. Fall incident on 1/13/25 - unwitnessed The 1/13/25 fall investigation documented Resident #51 was lying on the floor next to the bed, naked with dried blood over his left eyebrow. Resident #51 said he fell during the night. The resident's eyebrow was cleaned with saline and steri-strips were applied. The IDT risk management review note, dated 1/21/25, documented the root cause was poor safety awareness and a diagnosis of progressive supranuclear ophthalmoplegia. The intervention was to offer a helmet. -However, a helmet was not observed in the resident's room during the survey (see observations above). -The IDT risk management review of the fall was not completed until eight days after the fall and after Resident #51 had sustained another fall on 1/15/25 (see below). 2. Fall incident on 1/15/25 - unwitnessed The 1/15/25 fall investigation documented Resident #51 was sitting on the floor by the dresser. The wheelchair was away from him and the wheelchair brakes were not on. Resident #51 said he was fixing stuff on top of his dresser. The resident had no injury. The IDT risk management review note, dated 1/21/25, documented the root cause was poor safety awareness and the resident's wheelchair brakes were unlocked. The intervention was to add anti-rollback devices to the resident's wheelchair. -The IDT risk management review of the fall was not completed until six days after the fall. 3. Fall incident on 1/21/25 - unwitnessed The 1/21/25 fall investigation documented Resident #51 was sitting at the bathroom door with fecal matter smeared across the floor and his hands. Resident #51 had an abrasion on his left shoulder. Resident #51 said he fell.The IDT risk management review note, dated 1/23/25, documented the root cause was diagnosis of progressive supranuclear ophthalmoplegia and poor safety awareness. The intervention was to remind Resident #51 to call for assistance, motion sensor lights in the room and increased rounds. -The IDT risk management review of the fall was not completed until two days after the fall 4. Fall incident on 2/10/25- unwitnessed The 2/10/25 fall investigation documented Resident #51 was sitting on the floor with his wheelchair in front of him and his legs under the wheelchair. Resident #51 said he was not hurt. Resident #51 had a scratch to the skin on his back. The IDT risk management review note, dated 2/10/25, documented the root cause was poor safety awareness. The intervention was to remind Resident #51 to lock his brakes before standing from his wheelchair. 5. Fall incident on 2/11/25 - unwitnessed The 2/11/25 fall investigation documented Resident #51spilled a pitcher of water, slipped and fell in his room. The resident had no injury. The IDT risk management review note, dated 2/23/25, documented the root cause was the wet floor. Interventions were to ensure the floor was free from spills and remind Resident #51 to notify staff immediately of spills so they could be cleaned up. -The IDT risk management review of the fall was not completed until ten days after the fall. 6. Fall incident on 2/24/25 - unwitnessed The 2/24/25 fall investigation documented Resident #51 was sitting on the floor holding the transfer pole with his helmet on. Resident #51 said he fell from his wheelchair. The resident had no injury. The IDT risk management review note, dated 3/5/25, documented the root cause was poor safety awareness and a diagnosis of progressive supranuclear ophthalmoplegia. The intervention was to conduct more frequent rounds. -The IDT risk management review of the fall was not completed until nine days after the fall and after the resident had sustained another fall on 2/25/25 (see below). 7. Fall incident on 2/25/25 - unwitnessed The 2/25/25 fall investigation documented Resident #51 was sitting on the floor behind his door. Resident #51 said he fell. The resident had no injury. The IDT risk management review note, dated 3/5/25, documented the root cause was poor safety awareness and a diagnosis of progressive supranuclear ophthalmoplegia. The intervention was to encourage the resident to wear shoes or grip socks when out of bed or with transfers. -The IDT risk management review of the fall was not completed until eight days after the fall. 8. Fall incident on 3/16/25 - unwitnessed The 3/16/25 fall investigation documented Resident #51 was lying on his right side in the center of his room. Resident #51 said he wanted to get up. The resident had no injury. The IDT risk management review note, dated 3/18/25 documented the root cause was poor safety awareness. The intervention was to educate the Resident #51 on the use of his call light when he needed assistance and to put his shoes on before getting out of bed. -The IDT risk management review of the fall was not completed until two days after the fall. 9. Fall incident on 3/21/25 - unwitnessed The 3/21/25 fall investigation documented Resident #51 was sitting on the floor in his room near his refrigerator. Resident #51 said he was trying to open the refrigerator. The resident had no injury. The IDT risk management review note, dated 4/7/25, documented the root cause was poor safety awareness. The interventions were rounding or answering his call light, encouraging Resident #51 to inform staff of all his needs so he would not need to get up independently. -The IDT risk management review of the fall was not completed until 17 days after the fall. 10. Fall incident on 3/24/25 - unwitnessed The 3/24/25 fall investigation documented Resident #51 was sitting on the floor, wearing only a shirt, by the side of the bed. It appeared as though Resident #51 lost his balance and fell/sat down after using the bathroom. The area next to his bed was frequently wet from Resident #51 urinating in the trash can. Resident #51 said he sat down on the floor. The IDT risk management review note, dated 4/15/25, documented the root cause was poor safety awareness. The intervention was to encourage Resident #51 to not sit on the floor and take rest breaks when tired. -The IDT risk management review of the fall was not completed until 22 days after the fall. 11. Fall incident on 4/8/25 - unwitnessed The 4/8/25 fall investigation documented Resident #51 was standing up holding on to his dresser and fell. Resident #51 did not explain why he was standing holding on to the dresser or how he fell. He hit his head on the door. The IDT risk management review note, dated 4/8/25, documented the root cause was the diagnosis of progressive supranuclear ophthalmoplegia and poor safety awareness. The intervention was to encourage the dresser to be moved. 12. Fall incident on 4/10/25 - witnessed by family member The 4/10/25 fall investigation documented Resident #51 was outdoors with his sister and he fell out of his wheelchair. Resident #51's sister explained he was not well positioned in his chair. There was a bruise on his left knee. The IDT risk management review note, dated 4/11/25, documented the root cause was poor safety awareness. The intervention was to educate family when they took Resident #51 out of the building to ensure he was properly seated in the wheelchair. 13. Fall incident on 4/11/25 - unwitnessed The 4/11/25 fall investigation documented Resident #51 was sitting on the floor by his bed and he was not wearing shoes. Resident #51 said he wanted to get up. The resident had no injury. The IDT risk management review note, dated 4/11/25, documented the root cause was poor safety awareness and the diagnosis of supranuclear ophthalmoplegia. The intervention was placing grip tape on the floor near the bed. -However, observation during the survey revealed there was no grip tape on the resident's floor (see observations above). 14. Second fall incident on 4/11/25 - unwitnessed The 4/11/25 fall investigation documented Resident #51 was sandwiched between the closed bathroom door and his wheelchair. Resident #51 could not tell how he ended up behind the wheelchair. The resident had no injury. The IDT risk management review note, dated 4/11/25, documented the root cause was the diagnosis of supranuclear ophthalmoplegia and poor safety awareness. The intervention was to place a call don't fall sign in his room. -However, observations during the survey revealed there was no call don't fall sign posted in his room (see observations above). 15. Fall incident on 4/17/25 - witnessed The 4/17/25 fall investigation documented Resident #51 was leaning towards his night stand to place a water pitcher when he leaned forward, hitting his stomach against the night stand and lost his balance. He fell onto his left side without hitting his head. He had a skin tear to his left knee, pain rated at a 5 out of 10 to the left knee and a small bruise on his abdomen. He had Xrays taken of his left hip and lumbar spine, which were negative for any injury. The IDT risk management review note, dated 4/18/25, documented the root cause was poor safety awareness and the diagnosis of progressive supranuclear ophthalmoplegia. The intervention was the dresser was moved. -However the intervention was documented for the 4/8/25 fall (see above) and not completed until 4/18/25. 16. Fall incident on 4/19/25 - unwitnessed The 4/19/25 fall investigation documented Resident #51 was sitting and holding the bathroom door handle in his left hand. Resident #51 did not say how he fell. He had redness on the left elbow. The IDT risk management review note, dated 4/24/25, documented the root cause was poor safety awareness. The intervention was to review history on the resident's previous falls to track trends. Resident #51 fell multiple times of day and the falls tended to be between meals. Staff was to check on the resident after meals to see if he needed toileted, snacks or hydration. -The IDT risk management review of the fall was not completed until five days after the fall and after the resident had sustained another fall on 4/21/25 (see below). 17. Fall incident on 4/21/25 - unwitnessed The 4/21/25 fall investigation documented Resident #51 was sitting on the floor between the doorway and the wheelchair was to his left. Resident #51 said he was trying to get to the doorway to stand up and hold on. Resident #51 had a laceration to his left eyebrow and a laceration to his chin. He was sent to the ED for evaluation. Resident #51 returned with five stitches on his left eyebrow and three stitches on his chin. The IDT risk management review note, dated 4/25/25, documented the root cause was poor safety awareness. The intervention was to refer to the medical director for review of Resident #51's medications to determine if any medications were contributing to the resident's falls. -The IDT risk management review of the fall was not completed until four days after the fall and after the resident had sustained another fall on 4/24/25 (see below). -Additionally, there was no documentation to indicate the facility had notified the medical director to review the resident's medications and/or what the findings of the review were if it was completed. 18. Fall incident on 4/24/25 - unwitnessed The 4/24/25 fall investigation documented Resident #51 was on the floor behind the door which prevented staff from fully opening the door. The wheelchair was tipped over on its side and leaning on the resident. Resident #51 was unable to provide a description of the fall. The resident had no injury. The IDT risk management review note, dated 4/28/25, documented the root cause was poor safety awareness and disease process. The intervention was to offer hipsters, which Resident #51 declined, and the use of a helmet. -However, the helmet had been identified as an intervention after the resident's fall on 1/13/25 (see above) and a helmet was not observed in the resident's room during the survey (see observations above). -The IDT risk management review of the fall was not completed until four days after the fall. 19. Fall incident on 5/7/25 - unwitnessed The 5/7/25 fall investigation documented Resident #51 was behind the door in his room. The resident had urinated on the floor and slipped on the urine when he tried to transfer from bed to chair. The urinal was not within reach. Resident #51 said he tried to transfer from his bed to the wheelchair. The resident had no injury. The IDT risk management review note, dated 5/9/25, documented the root cause was poor safety awareness and the diagnosis of progressive supranuclear ophthalmoplegia. The intervention was to keep the urinal near the resident on the trash can, per resident preference. -The IDT risk management review of the fall was not completed until two days after the fall and after the resident had sustained another fall on 5/8/25 (see below). 20. Fall incident on 5/8/25 - unwitnessed The 5/8/25 fall investigation documented Resident #51 was sitting in the hallway by his room. Resident #51 was unable to give a description of what happened. The resident had no injury. The IDT risk management review note, dated 5/9/25, documented the root cause was poor safety awareness and progressive supranuclear ophthalmoplegia. The intervention was to educate the resident to utilize his wheelchair and keep it near him when he stood up and not to walk away from it. 21. Fall incident on 5/15/25 - unwitnessed The 5/15/25 progress note documented the resident was found on the floor. The resident had no injury. -There was no IDT risk management review documented for the fall. -Out of Resident #51's 21 reviewed falls, the facility documented the same root cause for 19 of the falls. There was no follow up documentation to indicate what interventions had been successful or why an intervention was discontinued. III. Staff interviews CNA #3 was interviewed 5/20/25 at 3:45 p.m. CNA #3 said the Kardex (quick reference guide for patient care), which was on the computer, informed staff about who was a fall risk. CNA #3 said Resident #51's wellness varied from day to day and on bad days he needed more assistance with his activities of daily living (ADL) and transfers. He said the resident used his call light at times. CNA #3 said Resident #51 was a fall risk and she tried to check on him every one to one and a half hours. CNA #2 was interviewed on 5/22/25 at 9:25 a.m. CNA #2 said she knew a resident was a fall risk if there was a fall mat in the room or the bed was in the lowest position. CNA #2 said she was notified of fall risks in morning report. She said if a resident was a fall risk, staff should check on the resident at least every two hours and if they were a high fall risk, staff should check on the resident every 30 minutes to an hour. CNA #2 said she documented it when she checked on a resident, however, she could not find that documentation on the computer. She said the Kardex was on the computer, but she did not carry a paper copy with her The NHA was interviewed on 5/22/25 at 2:08 p.m. The NHA said there was no specific fall committee who reviewed resident falls. She said falls, root causes and interventions were discussed every morning at the department head meeting. She said there was no floor staff present at the meetings. The NHA said if fall interventions did not work, the intervention would be discontinued and resolved on the care plan. She said Resident #51 had a transfer pole in his room but it had been removed because it was identified as contributing to his falls. The NHA said the resident had had less falls since the removal of the transfer pole on 3/18/25. The NHA said there had not been a recent referral to PT or occupational therapy (OT) for Resident #51, however, she said a therapy referral would be appropriate for the resident due to all of his falls. -However, Resident #51 had nine falls from 1/13/25 to 3/16/18 and 12 falls from 3/18/25 through 5/15/25. There was no documentation in the EMR why the pole was removed or the effectiveness of removing this intervention. Resident #51's representative requested the transfer pole back on 4/11/25. The care plan had an intervention of referring to PT as indicated. The director of nursing (DON) was interviewed on 5/22/25 at 4:07 p.m. The DON said falls were discussed at the department head meeting every morning. She said the meeting did not include floor staff. She said she or the NHA communicated any changes related to residents' fall interventions that were discussed in the department head meeting to the floor staff. The DON said she expected the floor staff to verbally notify in-coming shifts of any changes to residents' fall interventions. The DON said the floor staff were responsible for logging onto the computer to look for communications related to resident changes which had been posted by her or the NHA. The DON said she did not monitor when floor staff checked the computers for the updates. The DON said that if frequent checks were an intervention, ideally those would be completed every 15 minutes, but residents should be checked on at least every hour. She said the nurses and CNAs were to perform the frequent checks. The DON said there was no documentation system in place to track if frequent checks were completed.

Based on observations, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well being for one (#16) of three residents reviewed for mental health out of 32 sample residents. Resident #16, was admitted on [DATE] and readmitted on [DATE], with diagnoses of bipolar disorder and dissociative disorder. The resident had a previous reported history of suicidal ideation with self-harm. Resident #16 had documented behaviors of becoming easily agitated, verbally reactive and frequently calling emergency medical services (EMS) for all issues. Resident #16 had a behavioral care plan in place, which included monitoring mood/behavior and consulting with behavioral health services. However, the resident did not have a safety plan in place based on a past history of making suicidal ideations or triggering behaviors when her manic behaviors were escalating, including exhibiting an inability to sleep, crying and becoming easily agitated. On 2/4/25 Resident #16 self-inflicted cuts to her wrists with a pair of scissors after spending 45 minutes on the phone with the mental health crisis center. Resident #16 was sent to the hospital for her suicidal ideation and attempt to cut her wrists with scissors. Resident #16 returned from the hospital on 2/13/25 with a safety plan that included identifying warning signs, identifying internal coping strategies, identifying people and social settings that provided distraction and identifying people to ask for help during crisis, making the environment safer with no access to firearms, no access to medications and removing scissors out of her room and giving them to staff. -However, the facility failed to include the crisis/safety plan interventions in the care plan after the resident returned to the facility on 2/13/25. On 2/22/25 Resident #16 called the mental health crisis center again and asked them to call EMS for her. She told the mental health crisis center she did not feel safe and felt like killing herself. Resident #16's room was checked by facility staff for sharp objects and she was sent to the hospital for suicidal ideation. Resident #16 returned from the hospital approximately five hours later and the facility progress notes documented a safety plan was in place. -However, the facility again failed to include the crisis/safety plan interventions in the care plan after Resident #16's return from the hospital for the second incident of suicidal ideation in less than one month. On 3/16/25 the facility again received a call from the mental health crisis center informing the facility that Resident #16 was having suicidal ideations. The nurse went to check on Resident #16 who was on the back patio with a pair of black scissors held to her left wrist and the resident had self-inflicted superficial cuts to her left wrist with a small amount of blood present. The nurse removed the scissors, placed the resident on one-to-one supervision and called the physician and EMS. The resident was transported to the hospital and admitted for suicidal ideation and bipolar mood disorder. The resident returned from the hospital on 3/27/25 after being determined to be medically and psychiatrically stable. A safety plan was not initiated and coordinated with behavioral health and interventions placed in the care plan until 4/2/25, Resident #16's third incident of suicidal ideation and her second attempt to cut her wrist with scissors in less than six weeks. Specifically, the facility failed to coordinate and implement timely person-centered behavioral and safety interventions which resulted in Resident #16 experiencing three incidents of suicidal ideation on 2/4/25, 2/22/25 and 3/16/25 and two attempts to cut her wrists with scissors on 2/4/25 and 3/16/25. Findings include: I. Facility policy and procedure The Behavioral Health Services policy and procedure, revised February 2019, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:29 p.m. It read in pertinent part, The facility will provide, and residents will receive, behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Staff training regarding behavioral health services includes, but is not limited to recognizing changes in behavior that indicate psychological distress; implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs; monitoring care plan interventions and reporting changes in condition; protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties, history of trauma and post traumatic stress disorder. II. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included bipolar disorder, dissociative identity disorder and suicide attempts. The 4/29/25 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. She was independent with eating, toileting, personal hygiene, bed mobility and transfers. The MDS assessment indicated she did not exhibit behaviors of little interest and pleasure in doing things or feeling down and depressed or hopeless. The MDS assessment indicated she did not exhibit other behaviors that were not directed at others which included hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste or verbal/vocal symptoms such as screaming, disruptive sounds. B. Observations On 5/19/25 at 11:28 a.m. Resident #16 was ambulating to her room with her walker. She was yelling at the nurse standing in the hallway that someone needed to help her. She yelled expletives and yelled, I have peed in my pants. Registered nurse (RN) #2 went in to Resident#16's room and explained to Resident #16 that she had to finish checking on another resident and offered to take Resident #16 to the bathroom. On 5/21/25 at 8:30 a.m. Resident #16 was sitting on her bed in her room. Observation of the resident and her room revealed there was not a wanderguard visible on her wrists or ankles or on her walker and there was not a camera observed in her room (see 4/1/25 safety care plan below). C. Record review The mood/behavior care plan, initiated 7/3/23 and revised 3/6/25, documented Resident #16 had a history of bipolar disorder and would call EMS if she felt her needs were not being met. It documented Resident #16 had a family reported history of suicidal ideations with taking pills to try to overdose and slit her wrists. She yelled and cursed when agitated. Interventions included providing two staff members with cares (initiated 2/10/23), consulting with the behavioral/mental health services provider as needed (initiated 9/18/23), monitoring/recording the resident's mood to determine causes (initiated 9/18/23), administering medications as ordered (initiated 7/3/23), encouraging positive affirmation and short one-to-one visits when she sought out staff for concerns to not call EMS (initiated 10/10/23), moving the resident closer to the nursing station to keep in her in line of sight to assist the resident with feeling comfortable with staff assistance (initiated 1/10/24), reminding the resident when she asked for something and the staff were in the middle of a task, they would be able to assist her once completed (initiated 6/18/24), seeing the behavioral/mental health provider weekly or as needed for psychotherapy (initiated 4/1/25), encouraging the resident to express her needs/concerns and offering validation and affirmation to get over stress situations that caused her distress (initiated 4/1/25). The safety plan for suicidal ideation, initiated 4/1/25, documented Resident #16 was at increased risk for suicidal ideation due to her bipolar disorder and family reported previous history of suicidal attempts of taking pills to overdose and slitting her wrists. Interventions included increasing monitoring, frequently checking belongings in her room, changing rooms, adding a camera in her room for additional monitoring, continuing behavioral health visits, implementing a wanderguard for safety, intervening by staff as needed for safety and sending the resident out to the hospital, coordinating with behavioral health services for a crisis plan for the resident's suicidal ideations/attempts, completing triggers when her bipolar mania started up, which included the resident not sleeping, being more anxious, heart racing, blaming everyone and being tearful, encouraging her to write in her affirmation books, encouraging her to talk to children and encouraging activities. -The safety plan was not implemented until 4/1/25, after Resident #16 experiencing three incidents of suicidal ideation on 2/4/25, 2/22/25 and 3/16/25 and two attempts to cut her wrists with scissors on 2/4/25 and 3/16/25 (see record review below). -A comprehensive review of the care plan failed to identify Resident #16 was no longer using the wanderguard or allowing a camera in her room for additional monitoring (see interviews below). -The care plan additionally failed to identify frequent 15-minute checks as the increased monitoring intervention for the resident's safety (see interviews below). The May 2025 CPO revealed a physician's order to document Resident #16's target behaviors and the interventions attempted and their effectiveness. Target behaviors included suicidal ideation, mood fluctuations with anxiety and attention seeking. Interventions to be documented included redirection, one-to-one, diversional activity, offer to call family or friends and reassurance and check for respiratory distress, ordered 12/6/24. The 1/29/25 behavioral health screening progress note documented an initial assessment regarding Resident #16's depression related to medical issues, anxiety disorder and insomnia. It documented therapeutic interventions to assist processing through thoughts and feelings. It documented assisting with reality orienting skills and pro-social skills. It documented Resident #16 was a strong advocate for her needs. The 2/3/25 behavioral health psychotherapy progress note documented therapeutic interventions to assist processing through thoughts and feelings. It documented assisting with reality orienting skills and pro-social skills. It documented the plan was to provide therapeutic and case management support and for the resident to be seen by the nurse practitioner. The 2/4/25 at 7:36 p.m. change of condition nursing progress note documented Resident #16 had cut her wrist with a pair of scissors and EMS was called for transfer of the resident to the hospital. The 2/4/25 at 11:16 p.m. nursing progress note documented Resident #16 was sent to the hospital at 7:15 p.m. via EMS for cutting her wrists. The 2/5/25 at 12:32 a.m. nursing behavior progress note documented that at 6:40 p.m. Resident #16 returned from the outside patio to her room and was on the phone talking to the mental health crisis center. The nurse then spoke with the crisis center and the crisis center told her that they had been on the phone with Resident #16 for 45 minutes because the resident had told the them she was suicidal. The nurse told the crisis center Resident #16 had not told staff at the nursing home that she was suicidal but she was now aware and would help Resident #16. Resident #16 screamed at the nurse that she was going to kill herself. The nurse asked the resident how she was planning on doing that. Resident #16 said she would do it with scissors. The nurse asked if Resident #16 had scissors and did not get a response from Resident #16. The nurse checked the resident's drawers, tables and her walker seat and pouch and asked for Resident #16 to check behind her. Resident #16 refused and threw the remote control to the television and a shoe at the nurse. The nurse called Resident #16's representative and Resident #16 refused to speak with her. The nurse then notified Resident #16's representative that Resident #16 needed to go to the hospital. The nurse called EMS from the nurses station and was placed on hold. While the nurse was on hold with EMS, Resident #16 was heard screaming that she had cut herself. The nurse hung up the phone, went to Resident #16's room and found her bleeding from her left wrist with a pair of scissors in her right hand. The nurse removed the scissors and asked a certified nurse aide (CNA) to stay with the resident. The nurse dressed the cut and applied pressure to the wrist, stayed with Resident #16 and called EMS from her personal cell phone. EMS arrived at 7:10 p.m. and transported Resident #16 to the emergency room. -Resident #16 was not placed on one-to-one supervision or kept in direct line of sight while the nurse called EMS, despite the resident having just threatened to cut herself with scissors. The 2/7/25 interdisciplinary team (IDT) risk management progress note documented Resident #16 had a self-inflicted injury with the root cause identified as an exhibited behavior after the resident's daughter did not come to the facility as she had stated she would. The 2/13/25 hospital discharge summary documented Resident #16 was admitted to the hospital wth suicidal ideation. The summary documented a safety plan that included identifying warning signs, identifying internal coping strategies, identifying people and social settings that provide distraction, and identifying people to ask for help during crisis, making the environment safer with no access to firearms, no access to medications and removing scissors out of her room and giving them to staff. It documented the resident was to follow up with the behavioral health care provider for an appointment on 2/14/25 for medication management and therapy. -However, there was no documentation in the resident's EMR to indicate the resident was seen by her behavioral health care provider on 2/14/25. The 2/13/25 hospital discharge crisis plan, signed by Resident #16 on 2/12/25, included ways for the resident to stay well, prevention measures to stay well, identification of warning signs, strategies to take her mind off negative thoughts and identification of people she would be willing to ask for help. -However, the crisis safety plan was not initiated on the resident's care plan upon the resident's return to the facility on 2/13/25 (see care plan above). A comprehensive review of the EMR failed to reveal documentation of a follow up with the behavioral health provider. The 2/22/25 behavioral nursing progress note documented nursing staff received a call from EMS at 7:35 p.m. to notify staff that EMS had received a call from Resident #16 and to check on her. Nursing staff found Resident #16 outside crying and on the phone to the mental health crisis center. She said she wanted to kill herself, she was not being treated for her depression and she felt unsafe. Resident #16 asked the crisis center to call EMS for her again. The facility nurse checked Resident #16's belonging for sharp items and was unable to locate any. Resident #16 hung up the phone and was calm and told nursing staff the paramedics were coming to get her. EMS arrived at 7:53 p.m. and transported the resident to the hospital. The 2/23/25 at 2:19 a.m. nursing progress notes documented Resident #16 had returned from the hospital at 1:52 a.m. with a safety plan. -However, the safety plan was not initiated on the resident's care plan upon the resident's return to the facility on 2/23/25 (see care plan above). The 3/16/25 nursing progress documented Resident #16 was sent to hospital at 4:30 p.m. due to attempting suicidal acts. -However, a review of the resident's electronic medical record (EMR) revealed there was no documentation of the incident prior to the resident being transported to the hospital. The 3/16/25 facility investigation documented the facility received a call from the mental health crisis center informing them that Resident #16 was having suicidal ideations. The facility nurse went to check on Resident #16 who was on the back patio with a pair of black scissors held to her left wrist and she had self-inflicted superficial cuts to her left wrist with a small amount of blood present. The nurse removed the scissors, placed the resident on one-to-one supervision and called the physician and EMS. The 3/20/25 hospital psychiatric progress note documented Resident #16 was hospitalized with a brief suicidal ideation and documented the resident's bipolar symptoms were improved and, from a psychiatric standpoint, she was no longer a danger to herself and she could return to facility. Recommendations were to continue with her current behavioral health provider The 3/27/25 hospital discharge summary documented Resident #16 presented to the emergency room with mood disorder and past attempts with suicidal ideation. Resident #16 was being followed by psychiatry, suicide precautions were discontinued and she was deemed stable to return to the facility. The 3/29/25 preadmission screening and referral program (PASRR) Level II evaluation documented Resident #16 was medically and psychiatrically stable before discharge from the hospital. It documented she had a significant history of suicidal ideation and attempts. The recommended specialized services were psychiatry case consultation, individual therapy, crisis intervention/individual safety plan, additional one-on-one engagement support and other services, including peer mentor, intensive outpatient program (IOP), and referral to the transitions program. The 4/2/25 psychosocial/social services note documented the behavioral health provider met with the facility's social worker and a clinician to discuss an action plan to prevent Resident #16 from harming herself. The plan was placed in the resident's chart. The behavioral health crisis action plan, signed by Resident #16 on 4/2/25, documented identification of triggers that were a cue for unhealthy or ineffective behaviors which included mania that made it difficult to sleep at night, anxiety and depression such as crying, heart racing, tending to blame others and no energy. It documented identification of personal warning signs such as heart racing, crying and losing sleep. It documented interventions for Resident #16 to keep her environment safer, such as going outside when the weather was cold, removing access to scissors and other sharp objects and going to activities. It documented intervention to promote well being, such as writing in a gratitude journal, attending group activities and going on outings with children. It identified people that could provide support for Resident #16. The 4/4/25 IDT risk management progress note documented Resident #16 was sent to the hospital (on 3/16/25) and the root cause was behavioral. A comprehensive review of Resident #16's EMR failed to reveal behavioral provider notes from immediately after the 2/4/25, 2/22/25 or the 3/16/25 incidents. The May 2025 CPO documented a physician's order for a wanderguard to prevent Resident #16 from going out of the facility unassisted, ordered 3/31/25 and discontinued 4/4/25. The May 2025 CPO further documented a physician's order for a wanderguard to prevent Resident #16 from leaving the facility unassisted, to be kept on her walker not her person, ordered 4/4/25 and discontinued 5/15/25. A review of Resident #16's frequent 15-minute check monitoring sheets, beginning 3/31/25 and ending 5/17/25, failed to reveal documentation of frequent monitoring of the resident on the following days: 4/4/25, 4/6/25, 4/7/25, 4/8/25, 4/9/25, 4/18/25 and 5/13/25. A comprehensive review of Resident #16's EMR did not reveal suicide risk assessments before the resident's 2/22/25 3/16/25 suicide attempts. III. Staff interviews RN #2 was interviewed on 5/21/25 at 10:36 a.m. RN #2 said Resident #16 escalated easily and reacted verbally. She said she did not observe the resident's suicidal behaviors but she had heard about the resident using scissors to cut her wrists. She said she was not sure where the resident had found the scissors. She said staff tried to do frequent checks of her room but it was difficult because staff were not allowed to search or remove anything from a resident's room without permission from the resident. She said nursing staff had been checking Resident #16 frequently for a while and she was on frequent 15-minute checks indefinitely due to her behaviors. She said the staff documented the monitoring on a paper form that she kept on her cart and it was turned in to medical records after it was filled out. She said Resident #16 used to have a wanderguard but the resident removed it from her walker and did not want it. She said staff had tried to install a camera in her room but she removed it and did not want it reinstalled. The director of nursing (DON) was interviewed on 5/21/25 at 1:45 p.m. The DON said Resident #16 had a long standing history of behaviors where she would call EMS when she became angry, anxious or things were not going her way. She said they had witnessed, on camera, her throwing herself on the floor. She said recently Resident #16 had been experiencing shortness of breath and chest pain because of her chronic obstructive pulmonary disease (COPD) and she had threatened to kill herself. She said Resident #16 had called the mental health crisis center and notified them of her suicidal ideations without telling the staff. She said Resident #16 also called EMS frequently on her own for multiple things. She said the frequent EMS calls by Resident #16 had gotten so bad that EMS would no longer automatically come to the facility. The DON said Resident #16 had been seen by a behavioral health care provider but had started a new behavioral provider less than a year ago that she preferred. She said Resident #16 would no longer allow the wanderguard or the camera in her room and staff should be doing frequent checks and documenting the checks. She said there was behavioral monitoring in place for the resident's triggers to try to capture behaviors before she escalated and started calling EMS. She said Resident #16 called EMS for perceived medical issues, not just mental health issues. She said her triggering behaviors when she was escalating were crying, not sleeping, screaming at staff and blaming others. She said the care plan and the safety plan should reflect what current interventions were in place. The DON said when Resident #16 did make suicidal ideations to staff, it should be taken seriously and the resident should be kept safe. She said the resident's suicidal ideations should trigger a suicide risk assessment to determined resident's risk and if the resident had a plan to kill herself. She said it was unclear where Resident #16 had obtained the scissors she used to cut her wrists on 2/4/25 and 3/16/25. She said staff thought she may have obtained a pair of sewing scissors from a roommate. She said she was no longer roommates with that resident. She said another pair of scissors may have been obtained from a drawer at the front desk. She said since the incident, staff now had been locking that drawer. The DON said the facility tried putting Resident #16 in a room closer to the nurses' station but she had not liked her roommate and she had to be moved to another room. She said a camera was now in place on the patio in order to monitor her because Resident #16 had demonstrated behaviors, such as calling EMS and the mental health crisis and had one of her suicidal attempts on the patio. The licensed clinical social work mentor was interviewed on 5/22/25 at 11:45 a.m. The licensed clinical social work mentor said the facility had not had a social worker for about a month but had hired a social work assistant a few weeks ago. She said after review of Resident #16's medical record, she was unable to determine if a safety plan was in place prior to the current one that was initiated on 4/2/25. She said she was unable to determine what communication was being provided by the behavioral health care providers to the facility in order to manage the resident's behaviors and her suicidal ideations. The licensed clinical social work mentor said moving forward, she was formulating a tracking tool to document when the behavioral health care providers were in the building and obtaining their notes to better enhance communication between the facility and the providers. The licensed clinical social work mentor said she had reached out to the behavioral health providers but had not received communication from them yet regarding the visit documentation for Resident #16. The NHA, who was a social worker, was interviewed on 5/22/25 at 11:55 a.m. The NHA said Resident #16 had been seeing a different behavioral health care provider prior and had started with the current provider less than a year ago. She said when a resident presented with suicidal ideations, there was a form in the EMR that walked staff through the assessment process to determine the resident's risk for suicide. She said all of Resident #16's current interventions for behaviors and the safety care plan should be updated and current with documented triggering behaviors. IV. Facility follow up On 5/24/25 at 2:52 a.m., after the survey exit, the licensed clinical social work mentor provided the following behavioral health documentation: The 3/5/25 community treatment and management (CTT) progress note documented that Resident #16 was having difficulty with insomnia due to bipolar and exacerbating her depression. It documented an increase of her antipsychotic medication (Apripiprazole) and starting trazodone (an antidepressant that also helps with insomnia). -However, the resident returned from the hospital on 2/23/25 and the note was not written until 3/5/25, 10 days after the resident's return to the facility. The 3/18/25 CTT progress note documented Resident #16 was currently hospitalized after a witnessed suicidal gesture she made in front of staff. It documented consultation with an inpatient psychiatrist and discussed a plan of care and adjustment to medication. The psychiatrist had attempted referral to inpatient psychiatric units but due to the resident being dependent on oxygen, she was unable to be admitted to inpatient units. The 4/2/25 CTT progress note documented a solution focused brief therapy note. It documented a recent suicide attempt where Resident #16 cut her wrists with scissors. It documented a well being action plan. It documented a wanderguard to prevent her from leaving the facility unsupervised. -However, the resident returned from the hospital on 3/27/25 and the note was not written until 4/2/25, six days after the resident's return to the facility. The 4/2/25 psychiatry evaluation and management progress note documented Resident #16 was diagnosed with bipolar disorder. Resident #16 was currently on Seroquel (an antipsychotic medication) that was prescribed during her hospitalization on 3/16/25. The resident was reporting better sleep and a good appetite. The 4/29/25 CTT progress note documented Resident #16's mood appeared more stabilized and she reported being hopeful. It documented there were no recent attempts of suicide. It documented Resident #16 no longer had a wanderguard or video camera in the room. Resident #16 said she had discussed it with the NHA and it had been collaboratively decided to remove them. -The note failed to identify what intervention was put in place of the wanderguard and camera to monitor and keep the resident safe. -The documentation provided by the licensed clinical social work mentor after the survey exit additionally failed to reveal documentation to indicate Resident #16 was seen by her behavioral health care provider on 2/14/25, after her first hospitalization for suicide attempt, as was documented in the 2/13/25 hospital discharge summary (see record review above).

Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for two (#51 and #6) of four residents out of 32 sample residents. Specifically, the facility failed to: -Provide Resident #51 with privacy and dignity when receiving care, and, -Respond to Resident #51 and Resident #6's call light timely. Findings include: I. Facility policy and procedure Answering the Call Light policy, revised September 2022, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:50 p.m. It read in pertinent part, Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. When answering, knock on the room door, identify yourself and address the resident by his/her name. The Quality of Life-Dignity policy, February 2020, was provided by the NHA on 5/22/25 at 2:51 p.m. The policy read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Staff are expected to knock and request permission before entering residents' rooms. Staff speak respectfully to residents at all times. Procedures are explained before they are performed. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedure. II. Resident #51 A. Resident status Resident #51, age 65, was admitted [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Steele-[NAME]-[NAME] syndrome (a rare neurodegenerative disease that affects balance, eye movement, speech and swallowing), progressive supranuclear ophthalmoplegia (inability to move one's eyes at will), limitation of activities due to disability, muscle weakness, repeated falls, cognitive communication deficits, abnormalities of gait and mobility, other frontotemporal neurocognitive disorder (changes in behavior, personality and language) and history of falls. The 2/17/25 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. Resident #51 required extensive assistance with transfers and toilet use. B. Observation On 5/19/25 at 10:10 a.m. Resident #51's door was open. He was in bed with only a t-shirt on. The call light was on the floor behind his headboard. Resident #51 rolled to the edge of the bed to reach the call light. He pushed the call light for assistance to reposition himself. An unidentified certified nurse aide (CNA) responded, without knocking or identifying herself, asked from the doorway what Resident #51 wanted. Resident #51 was difficult to understand (see communication care plan below). The unidentified CNA asked if he wanted water and said she would be back with water. The resident slowly repositioned himself. -The unidentified CNA did not knock, identify herself or get close enough to the resident to hear his request. On 5/22/25 at 9:31 a.m. Resident #51's door was open. He was standing with his back to the door. CNA #2 walked in without knocking or identifying herself. C. Resident interview Resident #51 was interviewed on 5/19/25 at 10:10 a.m. Resident #51 said he felt he was not treated with respect and dignity by the staff. He said during care the staff spoke to him in an aggressive voice and did not always wait for a response. He said he felt that the staff lacked compassion. The resident said he liked his privacy and the staff often left the door open when providing personal care for him which made him feel uncomfortable. He said that many times staff just walked in without knocking. -The call light log revealed the call light was not answered for one hour and twenty six minutes on 5/14/25 at 11:33 a.m. D. Resident representatives interview Resident #51's representative was interviewed 5/21/25 at 10:51 a.m. The resident's representative said that they started to have concerns with Resident #51's care and the resident had requested a camera. She installed a camera in plain sight and posted a sign stating a camera was in use. She said the camera was pointed at the bed and door and was motion activated. The resident's representative said she had witnessed the resident's door being left open on several occasions when he was not wearing clothes and during care. She said she witnessed staff not being patient with the resident. Resident #51's representative said the resident had to wait for long periods of time until his call light was answered. She said on 5/14/25 she entered Resident #51's room before lunch, the door had been left open, the resident was not wearing any clothes, the room was freezing and the sheets were stained with urine. She said she pushed the call light and waited an hour and half before anyone responded. Resident #51's representative said during that time she walked to the nurses'station and requested assistance. E. Record review Resident #51's activities of daily living (ADL) care plan, dated 9/7/23 revised on 5/14/25, revealed the resident had an ADL self-care performance deficit related to progressive supranuclear ophthalmoplegia and impaired balance and mobility. Pertinent interventions included providing Resident #51 with assistance with dressing and toileting The communication care plan, dated 10/4/23 revised 5/14/25, indicated Resident #51 had a hearing deficit, stuttered and slurred his words, was slow to respond, and had difficulty with word finding. Pertinent interventions included allowing the resident adequate time to respond, do not rush the resident, requesting clarification to ensure understanding, facing the resident when speaking, asking yes/no questions, using simple, brief and consistent words and cues, using alternative communication tools as needed, speaking to the resident on an adult level, speaking clearly and slower than normal and validating the message by repeating aloud. The facility's call light system data for Resident #51 was provided by the NHA on 5/21/25 at 12:24 p.m. The log from 5/1/25 to 5/21/25 revealed the following: Staff response time to Resident #51's call light was greater than 20 minutes 18 times out of 66 calls or 39.3%. Staff response time to Resident #51's call light was greater than 60 minutes 18 times out of 66 calls or 39.3%. E. Staff interviews CNA #2 was interviewed on 5/22/25 at 9:25 a.m. CNA #2 said when she was providing care to a resident, she pulled the curtain and closed the door for privacy. She said she talked to residents during care and if a resident did not respond to the care she would leave, after the resident was safe, and returned with a different approach within a few minutes. CNA #2 said Resident #51 was not combative or resistant to care, but preferred to do things his way. She said that it was important to answer call lights as soon as possible. CNA #1 was interviewed on 5/22/25 at 11:15 a.m. CNA #1 said when she was providing care she closed the door and pulled the curtain for privacy. She said she talked to residents while she provided care and if a resident was combative or resistant to care she said she explained the care that was needed in a calm voice, but that she did not force a resident to accept care. CNA #1 said Resident #51 was not combative or resistant to care and if staff explained what needed to be done, he worked with staff. CNA #1 said she tried to answer call lights as soon as possible but sometimes it was difficult if she was helping another resident. She said she tried to get to a room at least within 10 minutes. The director of nursing (DON) was interviewed 5/22/25 at 2:30 p.m. The DON said she expected call lights to be answered within 10 minutes, but sometimes that was difficult depending on what was happening with other residents or if it was during a meal. She said everyone was responsible for answering the call lights. She said residents who were at a high risk for falls should be a priority when answering call lights. The DON said she expected that residents were treated with respect and dignity. She said the staff were provided education on these topics. She said she investigated immediately if there was a concern about respect and dignity. The DON was interviewed on 5/22/25 at 4:07 p.m. The DON said the call light system was an electronic banner that hung on the two units. She said that there was one computer, located at the west nurses'station, that had the room number and the wait time posted. She said she would get an alert, by email from the system, if a call light had been on longer than 30 minutes. The DON said if she was in the building she went to the nurses' unit to investigate why there was a long call light response. She said if she was not in the building, she waited until the next business morning to investigate the long response time. The DON said she used to review call light response time daily but has not done that lately. 48112 III. Resident #6 A. Resident status Resident #6, age [AGE] years, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included multiple sclerosis (chronic progressive disease of the central nervous system), depression, peripheral vascular disease (blood circulation to the body's tissue is restricted due to blocked blood vessels), contracture of muscle in multiple sites, psychotic disturbance, mood disturbance and left elbow contracture. The 2/18/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for toileting, showering, dressing and personal hygiene. The assessment revealed she had an impairment to one upper extremity and an impairment to both lower extremities. B. Resident interview and observation Resident #6 was interviewed on 5/20/25 at 11:02 a.m. The call light was clipped on the left side of her shirt. She said she used the call when she needed toileting assistance. She said sometimes it felt pointless to use the call light because the staff did not come for a long time. The resident said she kept her window open because sometimes she was left soiled and she did not want her room to smell bad. C. Resident representative interview Resident #6's representative was interviewed on 5/20/25 at 10:40 a.m. She said the resident's call light was frequently left unanswered for a long time period. She said when the resident had to wait a long time for staff to respond to her call light the resident called the representative. The representative said she called the facility to check on the resident. The resident's representative said the resident told her she felt he said felt helpless. D. Observation Resident #6 resided on the west unit. On 5/22/25 at 1:20 p.m. an electric banner hung on the wall in the east unit that was used to display the activated call lights. On 5/22/25 at 1:28 p.m. an electric banner hung on the wall in the west unit, and a tablet was observed in the west unit nurse's station. E. Record review The facility's call light system data for Resident #6, from 3/1/25 to 5/21/25, was provided by the NHA on 5/22/25 at 11:04 a.m. The call light data revealed the following: Staff response time to Resident #6's call light was greater than 30 minutes 57 times out of 233 calls, or 24.4% of the time. The call light response time ranged from 30 minutes to 266 minutes. F. Staff interviews CNA #4 was interviewed on 5/22/25 at 1:20 p.m. She said she should answer call lights as quickly as possible, typically within 30 seconds to one minute. She said it was important to respond to call lights quickly because she never knew what the resident needed. She said it was important to make the resident feel heard, seen and to acknowledge their needs. She said it was hardest to answer call lights when she was helping another resident shower, when she was assisting residents with meals in the dining room and when she was in another resident's room. She said the only way she could see if a resident's call light was on was by looking at the electric banner that hung on the wall in each unit. She said she was not provided direction on what to do when it was hard to answer the call lights. She said the nurses or other staff did not help answer call lights. She said the residents were frustrated when they needed to wait a long time for someone to respond to their call light. She said, she did not know if Resident #6 was frustrated waiting a long time for staff to respond to her call light. Registered nurse (RN) #1 was interviewed on 5/22/25 at 1:28 p.m. She said she should answer call lights as soon as possible. She said the nurses and the CNAs were responsible for answering the call lights. She said it was important to answer call lights because the resident could have an emergency. She said it was hardest to answer the call lights right before breakfast because everyone liked to eat breakfast in the dining room and wanted their showers before they had breakfast. She said it was not hard to answer the call lights in a timely manner if the staff knew the resident's daily routine. She said the residents became frustrated if they had to wait a long time. She said one resident had their family call the facility if the resident had to wait a long time. She said there were two ways to see if a resident's call light was on. She said one way was the electric banner above the hallway in each unit and the other way was a computer tablet that was in the nurse's station. She said Resident #6 sometimes was frustrated when she had to wait for someone to respond to her call light. The DON was interviewed on 5/22/25 at 3:59 p.m. She said everyone in the building was responsible for responding to call lights. She said staff should respond to call lights within 10 to 15 minutes. The DON said meal time was a time of day that was hard to respond to call lights in a timely manner. She said she heard of residents' complaints about call lights in the past and she said it was due to agency staff. The DON said she reviewed the call light records. She said she was not aware Resident #6 was frustrated with the call light response time. The DON said she received an email for any call light that was on for more than 30 minutes. She said she identified that residents waited the longest during meal time, during change of shift in the morning and after dinner. The DON said she did not have an immediate plan to reduce the call lights.

Based on interviews and record review, the facility failed to maintain a system of documenting grievances and demonstrating prompt actions for one (#6) of two residents out of 32 sample residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to individual grievances for Resident #6. Findings include: I. Facility policy and procedure The Grievance policy and procedure, revised 5/8/23, was provided by the regional director of clinical services (RDCS) on 5/22/25 at 5:44 p.m. It read in pertinent part, The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ten working days of the filing of the grievance or complaint. II. Resident #6's representative interview Resident #6's representative was interviewed on 5/20/25 at 10:40 a.m. She said she had filed several grievances since the beginning of May 2025 with the facility. She said the facility had not told her the resolution. She said she was frustrated with one of the grievances because it had to do with how one of the staff members communicated with the resident. She said Resident #6 told her it did not make her feel well when the staff member cared for her. The resident's representative said the other grievance that was important to her to resolve was about the resident's head support. She said it was important for the staff to position the resident correctly due to the resident's comorbidities. The resident's representative said she did not know who at the facility was responsible for resolving grievances. III. Observation On 5/22/25 at 12:35 p.m. Resident #6 in her room leaning to her right side in her wheelchair. The director of nursing (DON) asked certified nurse aide (CNA) #2 to help readjust the resident. IV. Record review Two grievance forms completed by Resident #6's representative were provided by the nursing home administrator (NHA) on 5/20/25 at 4:30 p.m. The first section of the form revealed who the complaint or concern report was received from, the name of the resident, the name of the person reporting the concern, the relationship to the resident, the date and time of of the report, and the nature of the concern and a line for employee signature and a date line. The second section was the response given or action taken at the time of the report. The first grievance form, dated 5/8/25, revealed the family/legal representative completed the form. It revealed the nature of the concern was the new CNA did not speak English, so the resident could not communicate with her. The form documented the representative requested the CNA to use a translation system so the two of them could communicate. -The rest of the form was left blank. There was no documentation showing what steps were made to reach out to the resident's representative and to resolve the grievance. The second grievance form, dated 5/10/25 at 12:44 p.m., revealed the family/legal representative completed the form. It revealed the nature of concern was the resident's head support was not fastened to the right side of the wheelchair and she was positioned poorly, causing her to be slouched to the right side all day. The form documented the representative visited the facility at 2:30 p.m. and used the headrest to straighten the resident into a more upright position. The form documented the resident spent most of her day poorly positioned and the headrest should be used on her chair properly. -However, the rest of the form was left blank. There was no documentation showing what steps were made to reach out to the resident's representative and to resolve the grievance. V. Staff interviews The DON was interviewed on 5/22/25 at 3:46 p.m. The DON said Resident #6 had a small pillow that attached to the wheelchair for head support. She said this was not apart of the resident's care plan and was not on the Kardex (an abbreviated care plan), but it needed to be. She said the nursing staff was not trained on how to position the resident's head after Resident #6 filled the grievance on 5/10/25. The NHA was interviewed on 5/22/25 at 4:51 p.m. The NHA said anyone could fill out a grievance form, including the residents and their representatives. She said the staff could help a resident or a resident's representative complete a grievance form. She said the social services director (SSD) was the grievances coordinator, but the SSD was new so the NHA and the DON were helping review grievances. The NHA said she reviewed grievances in the morning meeting with the department managers. The NHA said during the morning meeting she determined who was responsible for following up on the grievance. The NHA said the department manager talked to the resident or the resident's representative, completed the appropriate steps, found an appropriate resolution and asked the resident or the resident's representative if the resolution satisfied their concern. The NHA said depending on the grievance, the department manager had 72 hours to resolve the complaint. The NHA said if the grievance required training, it might take longer than 72 hours for a resolution. The NHA said she was aware of the two two grievances submitted by Resident #6's representative and she would find out why the grievance form was not completed in its entirety. VI. Facility follow-up The facility provided an updated copy of the two grievance forms (5/8/25 and 5/10/25) grievance on 5/23/25 at 2:25 p.m. It revealed both forms were signed on 5/22/25 (during the survey) by facility staff and there was a handwritten line that said agrees to grievance resolved resident with the resident's signature and date. -However, the grievance forms were submitted by the resident's representative, not the resident. There was no documentation indicating the resident's representative was notified or approved the resolutions on the grievance forms she submitted in May 2025.

Based on interviews the facility failed to ensure one (#51) of five residents were free from abuse out of 32 sample residents. Specifically, the facility failed to protect Resident #51 from verbal and physical abuse from two staff members. Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 5/19/25 at 10:38 a.m. It read in pertinent part, Residents have the right to be free from abuse. This includes verbal, mental or physical abuse. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Employees have a unique position of trust with the vulnerable residents. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff or other agencies serving the residents. II. Resident #51 A. Resident status Resident #51, age [AGE], was admitted [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Steele-[NAME]-[NAME] syndrome (a rare neurodegenerative disease that affects balance, eye movement, speech and swallowing) progressive supranuclear ophthalmoplegia (inability to move one's eyes at will), limitation of activities due to disability, muscle weakness, repeated falls, cognitive communication deficits, abnormalities of gait and mobility, other frontotemporal neurocognitive disorder (changes in behavior, personality, and language) and history of falls. The 2/17/25 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. Resident #51 required extensive assistance with transfers and toilet use. B. Resident interview Resident #51 was interviewed on 5/19/25 at 10:10 a.m. Resident #51 said he felt he was not treated with respect and dignity by the staff. He said during care the staff spoke to him in an aggressive voice and did not always wait for a response. He said he felt that staff lacked compassion. He said during care the staff handled him roughly by shaking and pulling him. C. Resident #51's representatives interview Resident #51's representative was interviewed on 5/21/25 at 10:51 a.m. Resident #51's representative said she started to have concerns with Resident #51's care and the resident had requested a camera in his room. She said she installed a camera in the resident's room in plain sight and posted a sign stating a camera was in use. She said the camera was pointed at the bed and door and was motion activated. She said she witnessed staff not being patient with the resident, pulling on his arms and using an aggressive tone when speaking with the resident. Resident #51's family member said on 5/13/25 two certified nurse aides (CNA), CNA #5 and CNA #6, were abusive towards the resident. She described what she saw on the video. Resident #51's representative said she witnessed the two CNAs providing assistance to the resident via video recording. She said CNA #5 pulled Resident #51's arm to sit him up in bed and then pulled on both of his arms to have him stand up. She said once as he stood up, CNA #6 got in his face and aggressively yelled a few times at the resident to sit down in his wheelchair. She said CNA #5 said she was going to leave if he did not listen to her. She said CNA #6, who was behind Resident #51, without saying anything yanked on his t-shirt, pulled him backwards and he sat roughly in his wheelchair. D. Record review Resident 51#'s activities of daily living (ADL) care plan, initiated 9/7/23 and revised 5/14/25, revealed the resident had an ADL self-care performance deficit related to progressive supranuclear ophthalmoplegia and impaired balance and mobility. Pertinent interventions included providing Resident #51 assistance with dressing and toileting The communication care plan, initiated 10/4/23 and revised 5/14/25, indicated Resident #51 had a hearing deficit, stuttered and slurred his words, was slow to respond and had difficulty with word finding. Pertinent interventions included allowing the resident adequate time to respond, do not rush the resident, requesting clarification to ensure understanding, facing the resident when speaking, asking yes/no questions if appropriate using simple, brief and consistent words and cues, using alternative communication tools as needed, speaking on an adult level, speaking clearly and slower than normal and validating message by repeating aloud. III. Staff interviews CNA #2 was interviewed on 5/22/25 at 9:25 a.m. She said she talked to residents during care and if a resident did not respond to the care she would leave, after the resident was safe, and returned with a different approach within a few minutes. CNA #2 said Resident #51 was not combative or resistant to care, but preferred to do things his way. CNA #1 was interviewed on 5/22/25 11:15 a.m. She said she talked to residents while she provided care and if a resident was combative or resistant to care she said she explained the care that was needed in a calm voice, but that she did not force a resident to accept care. CNA #1 said Resident #51 was not combative or resistant to care and if staff explained what needed to be done, he worked with staff. The DON was interviewed on 5/22/25 at 2:30 p.m. The DON said she expected that residents were to be treated with respect and dignity. She said staff was provided education on these topics. She investigated immediately if there was a concern about respect and dignity. IV. Facility follow-up The NHA was notified of the abuse allegation on 5/21/25 at 11:00 a.m. The NHA said the facility started an investigation and reported the allegation of abuse to the State Agency. She said CNA #5 and CNA #6 were suspended pending investigation, she said the police were notified. The facility investigation documented a family member had provided a video recording of two CNAs assisting Resident #51. The video showed two staff members assisting a resident with the door open and no privacy curtain. The two CNAs were assisting with ADL care, dressing and transferring the resident from the bed to the wheelchair. Staff were giving directions in a loud manner and telling him to' sit down' . When the resident did not, one of the CNAs grabbed the resident's shirt and pulled him back towards the wheelchair, causing the resident to abruptly sit in the wheelchair. The resident immediately stood up and was trying to put shoes on while standing. The facility notified the local law enforcement department. The facility substantiated the allegation of physical abuse by CNA #5 and CNA #6 toward Resident #51.

Based on observations, record review and interviews the facility failed ensure residents were free from chemical restraints for one (#18) of five residents out of 32 sample residents. Specifically, the facility failed to ensure Resident #18, who was on an antipsychotic medication, received appropriate and timely monitoring before and after the resident developed signs and symptoms of tardive dyskinesia (involuntary movements). Findings include: I. Professional reference According to the National Institute of Health (NIH) National Library of Medicine's Impact of A Pharmacist-Driven Tardive Dyskinesia Screening Process (7/16/21) retrieved on 6/3/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC8287863/#s1, Tardive dyskinesia is defined as involuntary movements that can develop with prolonged antipsychotic use. Regular monitoring using the Abnormal Involuntary Movement Scale (AIMS) is recommended to be conducted every 3 (three) to 6 (six) months for early recognition, although the AIMS is underused. Several studies have investigated risk factors that may be associated with tardive dyskinesia, including age, sex and long-term antipsychotic use. II. Facility policy and procedure The Psychopharmacological policy and procedure, undated, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:29 p.m. It read in pertinent part, The licensed nurse completes a baseline Abnormal Involuntary Movement Scale (AIMS) on admission, quarterly and as needed if the resident has orders for antipsychotic medications and/or as ordered by the primary care physician or psychiatrist. III. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included depression, vascular dementia, neuroleptic induced parkinsonism (medications side effects that cause symptoms similar to Parkinson's disease a movement disorder) and drug induced subacute dyskinesia (a movement disorder characterized by involuntary repetitive movements). The 4/1/25 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. She required supervision with toileting, personal hygiene, bed mobility, transfers and required set-up assistance with eating. B. Observations On 5/19/25 at 1:40 p.m. Resident #18 was sitting in her wheelchair and constantly smacking her lips together. C. Record review The antipsychotic medication care plan, initiated 6/4/21, revealed Resident #18 was on antipsychotic medications for the diagnoses of major depression. Interventions included administering psychotropic medication as ordered, AIMS assessment quarterly or as needed, consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly, educating and informing the resident of current medication regimen, observing/documenting and reporting any adverse reactions of psychotropic medication, which included unsteady gait, tardive dyskinesia, shuffling gait, rigid muscle, shaking, frequent falls, refusal to eat, sedation, difficulty swallowing, dry mouth, depression weight gain, edema, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, constipation, muscle cramps, nausea, vomiting and behavioral symptoms. The 9/2/24 AIMS assessment documented the resident had minimal, may be extreme normal facial muscle movement, lip and perioral movement, jaw movement, tongue movement, upper and lower extremity movement, minimal neck, shoulder and hip movement. It documented minimal severity of abnormal movements. Review of Resident #18's electronic medical record (EMR) revealed the facility did not complete any further AIMS assessments (a period of eight months) until 5/20/25 (during the survey), despite the resident exhibiting symptoms of tardive dyskinesia (see below). -Review of Resident #18's May 2025 medication administration record (MAR) and treatment administration record (TAR) revealed there was no documentation regarding monitoring the resident for any adverse reactions or side effects. The May 2025 CPO revealed a physician's order to refer Resident #18 to psychiatry for mouth/lip snacking movements. The physician's order identified the resident was diagnosed with neuroleptic induced parkinsonism with an onset of 3/16/2020 and was currently on Zyprexa (an antipsychotic medication), ordered 4/14/25. The 4/10/25 physician progress note documented possible lip smacking movements were observed which were possibly related to her dementia or antipsychotic medication side effects. Resident #18 had a history of neuroleptic induced parkinsonism would refer to psychiatry for evaluation. The 4/15/25 nursing progress note documented information was provided to the facility's scheduler for an appointment to made for Resident #18 in regards to the referral for mouth/lip smacking movements. The 5/1/25 psychiatric/behavioral health progress documented Resident #18 was on the lowest effective dose of her current antipsychotic medications and the benefits outweighed the risks for the prescribed psychoactive medications. It documented a dose reduction of the medication at that time would only exacerbate the resident's existing symptoms and place the resident at unacceptable risk for harm to self or others. -The note did not address monitoring for worsening tardive dyskinesia. The 5/20/25 AIMS assessment documented the resident had mild facial movement, moderate kp and perioral movement, moderate jaw movement, severe tongue movement, minimal extremity and trunk movement, moderate incapacitation due to abnormal movements. The May CPO failed to reveal an order for antipsychotic medication side effect monitoring. IV. Staff interviews The director of nursing (DON) was interviewed on 5/22/25 at 2:20 p.m. The DON said AIMS assessments should be completed every three months or once a quarter for residents that were on antipsychotic medications. The regional director of clinical services (RDCS) was interviewed on 5/22/25 at 2:55 p.m. The RDCS said AIMS assessments should be completed quarterly (every three months) for anyone on antipsychotropic medications and it was the responsibility of nursing staff to complete the assessments. He said once antipsychotropic medication side effects were identified it should be discussed and addressed with the physician and documented. The DON was interviewed again on 5/22/25 at 4:30 p.m. The DON said AIMS assessments were done quarterly and it was her responsibility to ensure that these were completed. She said the EMR system usually would alert staff when the AIMS assessments were due, but Resident #18's EMR had not alerted staff for the last quarter that the resident's AIMS assessment was due. She said she was currently completing audits on other residents who were on antipsychotic medications to make sure all residents were current with their AIMS assessments. She said it was important to evaluate and monitor residents for side effects of antipsychotic medications and, when concerns were identified, to report those concerns to the physician.

Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents out of 32 sample residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to ensure preventative measures were put into place for Resident #6's right foot. Findings include: I. Facility policy and procedure The Restorative Nursing Services policy and procedure, revised July 2017, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:52 p.m. It read in pertinent part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Restorative goals may include, but are not limited to supporting and assisting the resident in adjusting or adapting to changing abilities; developing, maintaining or strengthening his/her physiological and psychological resources; maintaining his/her dignity, independence and self-esteem; and participating in the development and implementation of his/her plan of care. II. Resident #6 A. Resident status Resident #6, age [AGE] years, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (chronic progressive disease of the central nervous system), depression, peripheral vascular disease (blood circulation to the body's tissue is restricted due to blocked blood vessels), contracture of muscle in multiple sites, psychotic disturbance, mood disturbance and left elbow contracture. The 2/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) assessment score of 15 out of 15. She was dependent on staff for toileting, showering, dressing and personal hygiene. The assessment revealed she had an impairment to one upper extremity and an impairment to both lower extremities. The assessment revealed she received a restorative nursing programs, including passive range of motion and splint or brace assistance five days a week. B. Resident interview and observation Resident #6 was interviewed on 5/20/25 at 11:02 a.m. The resident was in her wheelchair in her room with socks on her feet. There were two soft heel boots on a chair next to the resident's bed. She said she did not wear boots on her feet because the staff did not know how to put them on correctly. She said two staff members put them on correctly, but when the other staff put them on it caused her pain. C. Observations On 5/21/25 at 12:49 p.m. the resident was in her room. She was in her wheelchair with socks on her feet. There were two soft heel boots observed on a chair next to the resident's bed. On 5/22/25 at 12:41 p.m. the resident was in her room. The director of nursing (DON) offered to place the right boot on the resident's foot. The resident declined. The DON offered to place a pillow under both feet and the resident accepted. The resident said she was comfortable. D. Record review The restorative nursing care plan, initiated on 11/6/24, revealed the resident had the potential to benefit from participation in restorative nursing related to limited range of motion and to maintain current function. Interventions included monitoring the resident's tolerance to the restorative program, providing occupational therapy and physical therapy as needed for evaluation and treatment and reviewing progress toward goals and participation on a monthly basis -The care plan did not include documentation indicating the use of the foot drop boot for the right lower extremity. Review of Resident #6's May 2025 CPO revealed the following physician's order: Foot drop boot to the right lower extremity for contracture management and range of motion per physical therapy, ordered 6/1/24. -Review of the December 2024, January 2025, February 2025, March 2025, April 2025 and May 2025 (5/1/25 to 5/22/25) medication administration record (MAR) and treatment administration record (TAR) did not reveal documentation that the the foot drop boot was administered according to the physician's orders. -Review of the resident's electronic medical record (EMR) revealed there was no documentation that the foot drop boot was administered or refused according to the physician's orders. III. Staff interviews Registered nurse (RN) #1 was interviewed on 5/22/25 at 10:00 a.m. She said there was a restorative certified nurse aide (certified nurse aide) who trained the nurses and the CNAs on restorative nursing services. She said about half of the nursing staff were trained to provide restorative nursing services to residents. She said she knew what the resident's restorative program was based on the resident's care plan and the physician's orders. She said the restorative CNA knew what care to provide based on the Kardex (an abbreviated care plan) and the EMR. She said Resident #6 had a physician's order for a foot drop boot but she did not know why it was not showing up on the MAR or TAR for the staff to administer. She said she looked closer and the order was not scheduled. She said if it was not scheduled, then the order would not show up on the MAR and TAR. She said restorative services were important to provide to residents because it prevented further contractures and it helped the resident continue their independence and mobility. The DON and the regional director of clinical services (RDCS) were interviewed together on 5/22/25 at 12:17 p.m. The DON said the restorative CNA trained the staff to complete the restorative nursing services. The DON said the restorative CNA and another CNA provided restorative nursing services. She said the CNA mostly provided functional maintenance services like placing and removing splints and braces. She said the therapy department made restorative nursing recommendations and trained the CNAs. The RDCS said the nurses knew what restorative services a resident received based on the physician's orders. She said the restorative CNA and the CNAs knew restorative services based on POC. The RDCS said the care plan triggered the Kardex that was transferred to the POC. The DON said Resident #6's restorative nursing services were passive range of motion, left splint for her upper extremity and transfer wheelchair sit-ups. The DON said the foot drop boot was a passive ankle stretch and the nursing staff were responsible for providing the boot to the resident. The DON said she did not know Resident #6 had two boots in the resident's room and went to the resident's room to look at them after the interview (see observations above). The DON and the RDCS were interviewed together again on 5/22/25 at 3:36 p.m. The DON said since the physician's order for the foot drop boot did not have a frequency, the foot drop boot was not administered per the physician's order because it did not show up on the nurse's daily MAR and TAR. The DON said if the resident refused the foot drop boot in the future, an alternative could be offering a pillow if the physician and the rest of the interdisciplinary team agreed to the intervention.

Based on observations, record review and interviews, the facility failed to ensure one (#18) of three residents out of 32 sample residents received dental services timely. Specifically, the facility failed to arrange a referral for a dental surgical appointment to remove the permanent implants on Resident #18's lower gums so she could be fitted with new lower dentures. Findings include: I. Facility policy and procedure The Dental Services policy and procedure, revised December 2016, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:29 p.m. It read in pertinent part, Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. Direct care staff will assist residents with denture care, including removing, cleaning and storing dentures. II. Resident #18 A. Resident status Resident #18, age 78, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included depression, vascular dementia and hypertension. The 4/1/25 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. She required supervision with toileting, personal hygiene, bed mobility, transfers and required set-up assistance with eating. The assessment did not indicate if the resident had dentures, loose fitting dentures or had difficulty with chewing. B. Resident interview and observation Resident #18 was interviewed on 5/19/25 at 1:50 p.m. Resident #18 said her lower dentures did not fit correctly and were snap-in dentures. She said she needed fixative for her upper dentures because they would not stay in place. She said she had been seen by the dentist but her insurance would not cover the cost to get the dental implant screws removed from her lower jaw so that she could be fitted with new dentures. She said not having lower dentures made it more difficult to chew. Resident #18 was sitting in her wheelchair in her room. Two screws were permanently implanted into her lower gums. The resident had lower dentures in her mouth. Resident #18's upper dentures were loose and the resident had to continuously adjust them back onto her upper jaw. Resident #18 was interviewed a second time on 5/21/25 at 10:00 a.m. Resident #18 said the facility gave her some fixative for her upper dentures so they would not keep coming loose. C. Record review The dental/oral health care plan, initiated 6/24/21, documented Resident #18 was edentulous (did not have any natural teeth). Interventions included coordinating arrangements for dental care, transportation as needed (initiated 6/24/21), providing diet as ordered and consulting with the dietitian (initiated 6/24/21), offering mighty shakes (initiated 8/8/24), observing and reporting any signs of oral or dental problems needing attention (initiated 6/24/21) and the resident was refused a mechanically altered diet (initiated 8/8/24). -A comprehensive review of the care plan failed to reveal any follow up for the resident's lower dentures or a plan to replace her snap-in dentures. The 3/5/25 dental provider progress note documented Resident #18's upper and lower dentures were made [AGE] years ago and the resident no longer wore the lower denture. The note documented Resident #18 had significant bone loss and the dental implants were sticking out of her gum tissue. The resident complained the dental implants hurt her and she wanted them removed and new dentures made. The note indicated the plan was to refer Resident #18 to a specialty dental clinic to have the dental implants removed. -A comprehensive review of Resident #18's electronic medical record (EMR) failed to reveal documentation of communication with the specialty dental clinic to have the dental implants removed. -The resident's EMR failed to reveal communication to Resident #18's representative to coordinate a plan of care for Resident #18's dentures. III. Staff interviews The licensed clinical social work mentor was interviewed on 5/20/25 at 12:15 p.m. The licensed clinical social work mentor said the facility did not currently have a social work director and had recently hired a social work assistant. She said Resident #18 did not like her dentures. She said after she reviewed Resident #18's EMR she said Resident #18 had been seen by a dentist and had been referred to a specialty dental clinic to remove the lower gum implants for the old dentures so she could be refitted for new ones. She said she would follow up to see if an appointment was made. The social services assistant (SSA) was interviewed on 5/21/25 9:30 a.m. The SSA said she had called the dentist on 5/20/25 to verify Resident #18's referral to the dental specialty clinic and had a phone call out to the dental specialty clinic on 5/21/25 to make an appointment for the procedure. The licensed clinical social work mentor was interviewed again on 5/22/25 at 2:15 p.m. The licensed clinical social work mentor said when there was a referral there should be documentation of the communication between the provider and the facility. She said the SSA made a call on 5/21/25 to the specialty dental clinic regarding getting Resident #18's implants removed. She said she would follow up with the SSA and find out if the clinic had called back with an appointment time.

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services for two (#48 and #38) of four residents reviewed for hospice care services out of 32 sample residents. Specifically, the facility failed to: -Establish a communication process, including how the communication would be documented between the facility and the hospice provider for Resident #48 and Resident #38; and, -Ensure hospice agency staff notes were easily accessible to the facility staff and have consistent documentation of hospice care visits in Resident #48 and Resident #38. Findings include: I. Facility policy and procedure The Hospice Care policy and procedure, revised 2/29/24 was provided by the nursing home administrator (NHA) on 5/22/25 at 2:52 p.m. It read in pertinent part, When a facility resident elects to have hospice care, the facility staff communicates with the hospice agency to establish and agree upon a coordinated plan of care that is based upon an assessment of the resident's need and living situation in the facility. Hospice communication will be reviewed and added to the medical record. II. Resident #48 A. Resident status Resident #48, age less than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Huntington's disease (a neurodegenerative disorder affecting movement, thinking and emotional control), drug induced parkinsonism (neurological syndrome causing slow movements, tremors and rigidity) and type 2 diabetes mellitus. The 4/9/25 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long-term memory problems and her cognitive skills for daily decision making were severely impaired. The assessment revealed the resident received hospice services. B. Resident's representative interview The resident's representative was interviewed on 5/19/24 at 2:04 p.m. She said she was frustrated with the communication between the facility staff and the hospice staff. She said it was important for the resident's Broda chair (specialized wheelchair) to be replaced. She said the chair was broken for the past three weeks. She said the durable medical equipment company sent a chair last week but the facility said they could not locate the chair. The resident's representative said it was important to replace the chair to make sure the resident was comfortable. She said she visited the resident often but she wanted to visit the resident and not constantly check with the facility to see if things were being done like the chair being replaced. C. Observations On 5/19/25, between 11:30 a.m. and 12:25 p.m. hospice registered nurse (HRN) #1 was observed talking to Resident #48's representative and other residents and staff in the dining room. -However, the facility did not have documentation of HRN #1's visit with the resident (see record review below). D. Record review The hospice care plan, revised 8/27/24, revealed the resident received additional support services through hospice secondary to advanced Huntington's. Interventions included a hospice nurse visiting one to two times per week, a hospice certified nurse aide (CNA) visiting twice weekly to assist with showering and bathing, grooming and hygiene, hospice staff participating in care, referring to the hospice care plan and collaborating with hospice staff regarding resident care. The skin integrity care plan, revised 8/2/24, revealed the resident had potential for skin integrity problems due to choreatic movements (irregular movements), impaired mobility, incontinence and fall risk. Interventions included hospice providing a new wheelchair, initiated 5/9/25. Review of Resident #48's May 2025 CPO revealed the following physician's order: Admit to hospice with Huntington's disease, ordered 10/15/24. -However, a review of Resident #48's electronic medical record (EMR) revealed no documentation of visits from the hospice provider from 4/2/25 to 5/22/25. The 5/9/25 interdisciplinary (IDT) note revealed the resident bumped her head on her chair. The new interventions put in place was hospice to provide a new wheelchair. -However, there was no further documentation that a new chair was delivered by hospice. III. Resident #38 A. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included chronic atrial fibrillation, chronic embolism and thrombosis, dementia, psychotic disturbance, mood disturbance and anxiety. The 4/28/25 MDS assessment revealed the resident was cognitively impaired with a BIMS score of four out 15. The assessment revealed the resident received hospice services. B. Record review The hospice care plan, initiated 11/24/23 and revised 5/22/25 (during the survey), revealed the resident received additional support through hospice secondary to advanced Huntington's disease. Interventions included a hospice nurse visiting one to two times per week, a hospice CNA visiting twice weekly to assist with showering and bathing, grooming and hygiene, hospice participating in care, referring to the hospice care plan and collaborating with hospice staff regarding resident care. Review of Resident #38's May 2025 CPO revealed the following physician's order: admitted to hospice with Huntington's disease, ordered 10/15/24. -A review of Resident #38's eEMR revealed no documentation of visits from the hospice provider from 4/11/25 to 5/22/25. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 5/22/25 at 9:46 a.m. She said she knew a resident was on hospice services through the end of the shift report and in the resident's medical record under special instructions. She said sometimes the hospice staff checked in when they visited the resident and sometimes they did not check in with her. She said it depended on the type of visit. She said the hospice staff did not document on paper when they visited the residents. RN #1 said the designated hospice coordinator was the social services director (SSD), but the SSD was new so the director of nursing (DON) helped. RN #1 said h Resident #48 was on hospice services. She said she did not work 5/19/25 and she was not told the hospice nurse made a visit on 5/19/25. She said she did not have a way to check if the hospice nurse made a visit. She said hospice was responsible for all of the durable medical equipment Resident #48 needed. She said when a new piece of medical equipment was needed, the unit nurse told the hospice nurse and the hospice nurse facilitated the resident's need. She said the Broda chair had been broken for a long time. She said the hospice staff had taken a long time to replace the chair. She said the Broda chair was important for Resident #48 because it kept her comfortable with her Huntington's disease. RN #1 said h Resident #38 was on hospice services. She said the hospice nurse visited twice a week. HRN #1 was interviewed on 5/22/25 at 11:10 a.m. She said when she visited residents who were receiving hospice care, she tried to check in with the unit nurse first, if they were busy, she tried to see if the assistant director of nursing (ADON) or the DON. She said there was a binder for each resident in the DON's office. She said the DON's office was often locked so she was unable to sign in the binder. She said she should leave a progress note but she was not consistent. She said she always gave a verbal report to the unit nurse after she saw her hospice residents. She said the hospice office was responsible for sending hospice visit notes, the hospice's plan of care, hospice certification and hospice orders by fax. She said Resident #48 and Resident #38 were her hospice residents. She said she would ask the hospice agency to send any notes to the facility going forward. HRN #1 said she visited Resident #48 on 5/19/25 around lunchtime. HRN #1 said the hospice agency was responsible for the resident's medical equipment. She said she was aware of the issues with Resident #48's Broda chair. She said it had been a nightmare the past couple of weeks trying to find out what happened with replacing her chair. She said the Broda chair had been broken for a couple of weeks. She said the hospice agency first sent one Broda chair but the facility refused it because it was too small. She said the durable medical equipment company did not coordinate with the facility when they delivered the chair. She said she talked to the durable medical equipment company and the hospice agency. She said the durable medical equipment company changed their delivery process. She said the company now required a signature when they delivered medical equipment. She said a signature would be helpful because it would track down who signed for the DME. She said it was important for Resident #48 to have a working Broda chair because she did not like to be in her room. She said Resident #48 liked going to the dining room and going outside. The DON and the regional director of clinical services (RDCS) were interviewed on 5/22/25 at 12:03 p.m. The DON said the staff knew if a resident was on hospice services based on the physician's orders and during shift reports. The RDCS said under the payor and special instructions section of the resident's EMR it specified if the resident was on hospice services. The DON said the hospice staff checked in and out with the unit nurse when they visited a resident. The DON said the care plan said how often hospice staff visited. She said the SSD was the hospice coordinator but she was new so the DON was helping. The DON said the hospice staff documented their visit in their own EMR system and sent their notes every two weeks. She said the nurses should be able to look at the hospice notes in the resident's EMRs. The DON said Resident #48 and Resident #38 received hospice services. She said the hospice agency was responsible for the resident's medical equipment. She said she knew the medical equipment company delivered one Broda chair, but it was too small. She said she was not aware Resident #48 was still waiting for a replacement. The RDCS said it was important to have a communication process documented to ensure the resident's needs were addressed and met 24 hours per day.

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 on one of two units. Specifically, the facility failed to: -Ensure housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas; -Ensure housekeeping staff were trained appropriately on housekeeping procedures; -Ensure housekeeping staff changed cleaning rags between different sides in a double occupancy resident room; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident bathrooms; and, -Ensure housekeeping staff performed appropriate hand hygiene with glove changes. Findings include: I. Professional reference According to Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. (2021 Jul);113:104-114 was retrieved on 5/26/25 from https://pubmed.ncbi.nlm.nih.gov/33744383/, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures (5/4/23) was retrieved on 5/26/25 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails; -IV (intravenous) poles; -sink handles; -bedside tables; -counters; -edges of privacy curtains; -patient monitoring equipment (keyboards, control panels); -call bells; and, -door knobs. According to the CDC ' s Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 5/26/25 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. II. Facility policy and procedure The Cleaning and Disinfecting Resident Rooms policy and procedure, revised August 2013, was provided by the nursing home administrator (NHA) on 5/22/25 at 3:08 p.m. It read in pertinent part, Clean all high-touch personal use items (lights, phones, call bells, bedrails) with disinfectant solution. Perform hand hygiene after removing gloves. III. Observations During a continuous observation on 5/22/25, beginning at 9:38 a.m. and ending at 10:35 a.m., housekeeper (HK) #1 was observed exiting room [ROOM NUMBER] and removing her gloves. She pushed the cleaning cart to room [ROOM NUMBER]. She entered room [ROOM NUMBER] and washed her hands in the bathroom. She returned to the cleaning cart and put gloves on. HK #1 removed a cleaning tray from the cart which contained disinfectants and a toilet brush. She placed the cleaning tray on the bathroom floor in room [ROOM NUMBER]. She sprayed the sink, the toilet, and poured cleaner into the toilet bowl. She emptied the trash in the bathroom and the bedroom. After two minutes, HK #1 returned to the bathroom and scrubbed the inside of the toilet with the toilet brush, flushed the toilet and placed the toilet brush back in the holder on the cleaning tray. She sprayed the toilet rim and under the seat. She removed a yellow rag and washed the inside of the sink, around the sink, the base of the sink and the hand rails. She wiped the alcohol based hand sanitizer dispenser and the paper towel dispenser. HK #1 proceeded to use a black rag to wipe the rim of the toilet, the bottom of the seat, the top of the seat, the toilet lid, the toilet tank and the top of the toilet tank. She used a second black rag to repeat the process. She returned the cleaning tray to the cart and disposed of the soiled rags in a trash bag hanging on the side of the cart. She removed her gloves and entered the bathroom to wash her hands. -HK#1 failed to disinfect the toilet from top to bottom and clean to dirty. HK#1 put on clean gloves and sprayed the door handles in the room and both residents ' overbed tables and night stands. She used a yellow rag to wipe down the top of bed A's overbed table, the base of the overbed table and then the top again. Using the same yellow rag, HK #1 moved to bed B and wiped that resident ' s night stand top and front, then moved to bed A's night stand and repeated the process a second time with the same rag. HK #1 placed the soiled rag back into the bag for soiled rags, removed a clean yellow rag from the cart and wiped the door knobs of the bedroom and bathroom doors. She removed linens from behind the door and placed them in a plastic bag and into the laundry cart. She removed her gloves and put on clean gloves, without performing hand hygiene. She placed multiple trash bags into the two trash cans. She removed the dust mop from the cart and swept the room. She swept under the night stands and beds. She swept the debris to the entrance and used a broom and dust pan to pick up the debris. She placed the broom and dust pan back onto the cart. HK #1 then mopped the room, removed the mop pad and discarded it and placed the mop handle on the cart. She removed her gloves and pushed the cart to room [ROOM NUMBER] without performing hand hygiene. -HK #1 failed to disinfect high touch areas such as the bed remotes, the call lights and the light switches. -HK #1 failed to use a separate clean rag to clean bed B's side of the room after cleaning Bed A ' s side of the to prevent cross contamination. -HK #1 failed to perform hand hygiene after removing her gloves and putting on new glove and after exiting the residents ' room. IV. Staff interviews HK #1 was interviewed on 5/22/25 at 10:35 a.m. HK #1 said she washed her hands when she finished cleaning the bathroom and when the room was finished being cleaned. She said she did not know she needed to wash her hands every time she removed her gloves and put on clean ones. She said the high touch areas that she needed to clean were the door knobs, overbed table and the night stands. She said when she cleaned the toilet, she cleaned it from bottom to top. The housekeeping supervisor (HKS) was interviewed on 5/22/25 at 10:41 a.m. The HKS said HK #1 should have performed hand hygiene after cleaning the bathroom, with any gloves changes and when exiting the room. He said high touch areas included door knobs, call lights, light switches, bedside tables, night stands and bed remotes, which should be disinfected daily. He said HK #1 should have used a separate clean rag for each side of the room in a double occupancy room to prevent the spread of germs. He said the toilet should always be cleaned from top to bottom or clean to dirty. He said he would immediately retrain housekeeping staff on the correct process for cleaning resident rooms. The infection preventionist (IP) was interviewed on 5/22/25 at 3:37 p.m. The IP said the toilet should always be cleaned from top to bottom and a separate cleaning cloth should be used for each side of the residents ' room. She said high touch areas included door knobs, call lights, light switches, bedside tables, night stands and bed remotes, which should be disinfected daily. The IP said hand hygiene should be performed with any glove changes. The director of nursing (DON) was interviewed on 5/22/25 at 4:23 p.m. The DON said toilets should be cleaned from clean to dirty, starting at the top of the toilet. She said hand hygiene should be performed with any glove changes and a different rag should be used to clean each side of the room. She said high touch areas included door knobs, call lights, light switches, bedside tables, night stands and bed remotes, which should be disinfected daily. The DON said it was important for the HKs to follow the correct cleaning procedure to prevent the spread of infection. E. Facility follow up: The HKS provided the inservice, dated 5/22/25, of retraining the house keeping staff on the process of cleaning and disinfecting resident rooms.

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 at the facility. Specifically, the facility failed to; -Ensure housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (light switches and door handles); -Ensure housekeeping staff performed hand hygiene when appropriate; -Clean the mechanical lift and vitals machine between each use with a resident; -Perform hand hygiene during medication administration; -Offer hand hygiene to each resident before meals; and, -Perform hand hygiene between each resident when assisting with meals. Finding include: I. Housekeeping practices and disinfection of environmental surfaces A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. (2021 Jul);113:104-114 was retrieved on 4/30/24 from https://pubmed.ncbi.nlm.nih.gov/33744383/ revealed, in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures (5/4/23) was retrieved on 4/30/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs. According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 4/30/24 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. B. Facility policy and procedure The Cleaning and Disinfecting Resident Rooms policy and procedure, revised August 2013, was provided by the clinical consultant (CC) on 4/24/24 at 5:13 p.m. It read in pertinent part, Clean all high-touch personal use items (lights, phones, call bells, bedrails) with disinfectant solution. Perform hand hygiene after removing gloves. C. Observations On 4/22/24, during a continuous observation beginning at 2:00 p.m. and ending at 2:24 p.m., housekeeper (HK) #1 was observed cleaning a room on the east unit. HK #1 put on gloves before entering the room. HK #1 sprayed the bathroom sink, toilet, and handrail with the disinfectant spray. HK #1 exited the bathroom and sprayed the drawer pulls, remotes for the bed and television (TV) and the bedside table. After four minutes, HK #1 began wiping the drawer pulls, remotes, bedside table, nightstand and refrigerator. She proceeded to remove the trash bag from the receptacle near the resident's bed and put new bags in the trash can. -HK #1 failed to disinfect high touch areas such as the light switches and the door handles in the room. HK #1 removed her gloves, took a pen out of the drawer and wrote the temperature of the refrigerator on the log on the door of the refrigerator. HK #1 put new gloves on, sprayed the bathroom with disinfectant spray again and began wiping down the sink, the grab bar, the top of the toilet and the shelf. -HK #1 did not perform hand hygiene prior to putting on the new pair of gloves. HK #1 proceeded to clean the inside of the toilet, the sink and wiped the toilet seat last. -HK #1 failed to clean the toilet in a sanitary manner by wiping the toilet seat after she had cleaned the inside of the toilet. HK #1 exited the bathroom and swept the entire floor. -HK #1 failed to change her gloves and perform hand hygiene prior to using the broom to sweep the resident's floor. HK #1 mopped the living area and the bathroom floor before exiting the room. -At 2:24 p.m. HK #1 entered the next resident's room, went to the sink in the resident's bathroom and washed her hands for six seconds using soap and water. -HK #1 failed to wash her hands for the appropriate amount of time. HK #1 returned to the cart, put gloves on and entered the room to begin cleaning. D Staff interviews HK #1 was interviewed on 4/22/24 at 2:25 p.m. HK #1 said she was trained by the maintenance director (MTD) when she was hired. She said housekeepers should perform hand hygiene between each glove change and clean all the high touch areas in the residents' rooms, which included remotes and call lights. The director of nursing (DON) was interviewed on 4/23/24 at 2:32 p.m. The DON said proper hand hygiene consisted of using hand sanitizer or washing hands with soap and water for at least 20 seconds. She said if hands were visibly dirty staff should use soap and water to sanitize them. The DON said hand hygiene should be performed before and after care of residents, before and after gloving, and between different cares for residents. The MTD was interviewed on 4/24/24 at 12:45 p.m. The MTD said housekeeping staff were trained by the MTD. He said staff should perform hand hygiene before entering the room, put on gloves, spray all high touch areas and let it sit for 45 seconds. He said housekeeping should start in the bathroom, cleaning all surfaces and the toilet, perform hand hygiene and change gloves before moving to the next part of the room. The MTD said staff should clean the light switch and door handles, exit the room and remove their gloves. He said staff could go into the next resident's room to wash their hands at the sink and then put on gloves. The MTD said staff should wash their hands for 20 seconds with soap and water. 50315 II. Staff hand hygiene failures during resident assessment and resident care, use of shared equipment and medication administration A. Professional references According to the Centers for Disease Control and Prevention (CDC) (January 2021) Hand Hand Hygiene in Healthcare Settings, retrieved on 4/30/24 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. The risk of healthcare provider colonization or infection caused by germs acquired from the patient. When to perform hand hygiene: immediately before touching a patient, after touching a patient or the patient's immediate environment, after glove removal. According to Medline (October 2022) Cleaning medical equipment that's shared: Who's responsible?, retrieved on 4/30/24 from https://www.medline.com/strategies/infection-prevention/cleaning-shared-patient-care-devices-best-practice/#:~:text=Bacteria%20can%20grow%20on%20this,%2Fresidents%2C%20leading%20to%20HAIs.&text=Establishing%20disinfection%20practices%20for%20shared,establishing%20daily%20room%20disinfection%20practices. Bacteria can grow on this medical equipment and be transferred among patients/residents, leading to HAIs (health associated infections). Establishing disinfection practices for shared patient/resident devices and equipment is as important as establishing daily room disinfection practices. B. Facility policy The Hand Hygiene policy, revised August 2019, was received from the corporate director of clinical services (CDCS) on 4/24/24 at 5:13 p.m. It documented in pertinent part, This facility considers hand hygiene the primary means to prevent spread of infections. Use an alcohol-based hand rub or soap and water for the following situations: before and after direct contact with residents, after contact with resident's intact skin, after handling contaminated equipment, after contact with objects in the immediate vicinity of the resident, after removing gloves and before and after entering isolation settings. C. Vital signs equipment 1. Observations Certified nurse aide (CNA) #6 was observed on 4/22/24 at 8:50 a.m. CNA #6 was taking vital signs on residents using an automatic vital signs machine. She unplugged the machine from the nurses station and took it into the first resident's room. -CNA #6 did not sanitize the vital signs machine prior to obtaining the first resident's vital signs nor did she perform hand hygiene. CNA #6 completed the task of taking vital signs on the resident and recorded the vital signs on a clipboard. -Without sanitizing the vitals signs equipment or her hands, CNA #6 took the vitals machine into the next resident's room, obtained the resident's vitals signs and recorded the results. After obtaining the second resident's vital signs, CNA #6 proceeded to take the vital signs machine to a third resident's room and took the resident's vital signs. -CNA #6 did not sanitize her hands or the vital signs machine after obtaining the third resident's vital signs. CNA #6 proceeded to a fourth resident's room with the vital signs machine and obtained the resident's vital signs. After obtaining the fourth resident's vital signs, took the vital signs machine back to the nurses station and plugged it in. -CNA #6 did not sanitize her hands or the machine after plugging the vital signs machine in CNA #8 was observed on 4/22/24 at 2:42 p.m. CNA #8 unplugged the vital signs machine from the nurses station and proceeded to a resident's room to obtain the resident's vital signs and record the results on a clipboard -Without sanitizing the vitals signs equipment or her hands, CNA #8 took the vital signs machine into the next resident's room and obtained the resident's vital signs and recorded the results. -After obtaining the second resident's vital signs, and without sanitizing the vital signs machine or her hands, CNA #8 obtained a third resident's vital signs. CNA #8 proceeded to a fourth resident's room and obtained the resident's vital signs. -CNA #8 did not sanitize the vital signs machine or her hands prior to obtaining the fourth resident's vital signs. CNA #8 took the vital signs machine to a fifth resident's room and obtained the resident's vital signs. -CNA #8 did not sanitize the vital signs machine or her hands after obtaining the fifth resident's vital signs. 2. Staff interviews CNA #8 was interviewed on 4/22/24 at 3:02 p.m. CNA #8 said hand hygiene should be performed before resident care, between changing gloves and after resident care. She said shared resident equipment should be cleaned between use with different residents. The director of nursing (DON) was interviewed on 4/23/2024 at 1:30 p.m. The DON said that all medical equipment should be cleaned and sanitized in between each use. D. Mechanical lifts 1. Observations On 4/22/24 at 3:26 p.m. the Spruce Hall unit was observed with three mechanical lifts. Each of the mechanical lifts were heavily soiled and the push-handles were all soiled with a dried brown substance. CNA #7 took one of the mechanical lifts, without cleaning the device, to a resident's room and proceeded, with another CNA, to get the resident back into bed using the lift. -After getting the resident in bed, CNA #7 placed the mechanical lift back in the hall without sanitizing the device. The push handles were still soiled with the dried brown substance. At 3:37 p.m., CNA #7 returned to get the mechanical lift to put another resident back into bed. -CNA #7 did not sanitize the mechanical lift before using it with the second resident. -The mechanical lift was used an additional two times with different residents. The CNAs failed to sanitize the lift in between use with any of the residents. 2. Staff interviews CNA #1 was interviewed on 4/23/2024 at 2:00 p.m. CNA #1 said all shared medical equipment, including the mechanical lift, must be sanitized before and after each use. CNA #1 said the CNAs the purple top disinfecting wipes to disinfect the equipment. The director of nursing (DON) was interviewed on 4/23/2024 at 1:30 p.m. The DON said the staff should have sanitized the mechanical lift in between each use with a resident. E. Medication administration 1. Observations On 4/22/24 at 10:51 a.m., RN #3 was preparing to administer medication to a resident on enhanced barrier precautions (EBP), which required wearing a gown, gloves and a mask. RN #3 walked inside the resident's room with only a mask on for precautions and listened to the resident's heart and lungs and measured his blood pressure. She brought the stethoscope and blood pressure cuff back to her cart and set the equipment down on her cart. RN #3 returned to the resident's room, put on a procedure gown and gloves and administered medications through the resident's feeding tube. -RN #3 changed her gloves but did not perform hand hygiene between handling the resident's feeding tube and administering eye drops to the resident. -RN #3 did not clean the blood pressure cuff or stethoscope after resident use and before storing it in the medication cart. 2. Staff interview The DON, the nursing home administrator (NHA), and the CDCS were interviewed on 4/24/24 at 11:14 a.m. The DON said nursing staff were to perform hand hygiene before and after resident care. She said staff should perform hand hygiene during resident care if gloves were changed. She said the importance of hand hygiene was for infection control purposes. The DON said shared resident equipment should be cleaned between use with different residents for infection control purposes. 41032 F. Meal service 1. Observations On 4/21/2024 at 11:13 a.m. the lunch meal was observed. Some residents were already in the dining room finishing up an activity and some residents arrived just before meal service began. At 11:28 a.m., staff started to serve beverages to the residents however, no hand hygiene was offered to any resident after the activity ended and before beverages and meals were served to residents. The first meal was served to a resident at 11:41 a.m. -At 12:02 a.m., staff started to offer residents the opportunity to perform hand hygiene, however, most residents had already started eating and some were finished with their meals by the time staff offered them a squirt of antibacterial hand sanitizer to clean their hands. A couple of residents were offered hand sanitizer just before they started eating. At 12:03 p.m. an unidentified woman was standing by a resident at the assisted table talking to one of the residents. The woman had been in the dining room since the start of the meal service. Once the meals were served, the woman went to three different tables talking to three different residents. As she talked to the residents she offered each resident assistance to fork up or spoon up food for them then handed them their fork or spoon for them to eat. Additionally, the woman handed the residents their napkins and/or drinking cups. -In between assisting the residents in this manner, the woman did not perform hand hygiene and frequently stuck her hand into the pocket of her winter coat that she wore throughout the meal service. The woman's winter coat was light beige and was visibly soiled with black smudges by the pockets and on the back of the coat. There were several CNAs and members of the facility's leadership team present in the dining room during the meal service. -None of the facility staff addressed the unidentified woman's behavior or made an attempt to educate her to perform hand hygiene in between assisting the residents with their meals. At 12:32 p.m. the business office manager (BOM), the director of medical records (DMR), the maintenance director (MTD) and dietary aide (DA) #1 were interviewed to see if they knew who the woman in the beige coat was. -None of the staff had noticed the woman and did not know who she was. The BOM approached the woman, returned and said the woman was a hospice volunteer for one of the residents in the facility. -However, none of the residents the woman assisted during the meal was the resident she was assigned to visit. On 4/23/2024 at 11:44 a.m. the lunch meal service was again observed. -None of the residents in the dining room were offered the opportunity to perform hand hygiene during the meal service. 2. Staff interviews The DON was interviewed on 4/23/24 at 1:30 p.m. The DON said the staff should wash their hands in between serving residents their meals, before assisting residents with their meals and in between moving from resident to resident to provide meal assistance. The DON said the staff should have offered the residents an opportunity to clean their hands before they ate their meals. 42193

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored according to professional standards in one of three medication carts, one of two medication treatment carts and one of two medication rooms. Specifically, the facility failed to ensure medication rooms and medication/treatment carts were locked properly when unattended by a licensed nurse. Findings include: I. Facility Policy The Storage of Medication policy, revised November 2020, was received from the corporate director of clinical services (CDCS) on 4/24/24 at 5:13 p.m. It documented in pertinent part, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control. Only persons authorized to prepare and administer medications have access to locked medications. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. II. Observations On 4/21/24 at 9:10 a.m. the medication room on the Aspen hallway was unlocked. -The room contained prescription medications for multiple residents and the medication nurse did not maintain direct line of sight to monitor the resident medications. Additionally, a treatment cart, which contained medicated treatment supplies, was next to the medication room and was unlocked. -The treatment cart was not in direct line of sight from the licensed nurse responsible for the cart's contents. On 4/22/24, medication pass was performed on the Aspen hall by registered nurse (RN) #3. The following was observed: -At 10:03 a.m., RN #3 left the medication cart, which contained several medications for multiple residents, unlocked and unmonitored, to go check on a resident in their room. The cart was left in the hall without supervision from the licensed nurse responsible for the cart's contents. The RN came back to the cart at 10:04 a.m. At 10:20 a.m., RN #3 walked away from the medicion cart to deliver a nutritional shake to a resident down the hall. Prior to walking away from the medication cart, RN #3 pushed the cart's locking mechanism to lock the cart. However, two of the drawers to the medication cart were not closed all the way when the cart was locked, leaving them unlocked and accessible to anyone walking by the medication cart. The drawers contained prescription medication and medical supplies. -RN #3 did not return to the cart until 10:25 a.m. (five minutes after initially leaving the medication cart unattended and improperly locked). -RN #3 left the cart and returned to it two more times. Each time she left the cart she closed the push lock mechanism but did not ensure the drawers were fully closed and secured. -Despite locking the push lock the drawer was easy to open and the medications inside were accessible. On 4/23/24 at 12:57 p.m. the Aspen hall medication cart, which contained several resident prescription medication cards for residents, was outside the dining room without supervision from the licensed nurse responsible for the cart's contents. The cart's locking mechanism had been engaged, however, there were a couple of drawers that had not been closed completely when the cart was locked and were accessible to residents and staff. -At 1:02 p.m. the director of nursing (DON) was notified that the medication cart was unlocked and the drawers could not be secured without the key to unlock the locking mechanism and fully close the open drawers. The DON arrived on the unit and tried to lock the cart but was unable. The DON walked down the hall and retried with RN #3 at 1:03 p.m. to reset the locking mechanism so the open drawers could be re-engaged and locked. III. Interviews The DON, the nursing home administrator (NHA) and the CDCS were interviewed on 4/24/24 at 11:14 a.m. The DON said medication rooms, medication carts and medication treatment carts containing medications were to be closed and locked properly when the licensed nurse in charge of the carts and resident medications was not in direct line of sight of the medication/treatment cart or the medication room. The DON said it was important to ensure medication/treatment carts and medication rooms were locked because only licensed nurses should have access to medications.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, temperature and texture. Findings include: I. Resident interviews Resident #35 was interviewed on 4/21/24 10:20 a m. Resident #35 said the food was either served cold or was bland and unseasoned which made it taste terrible. Resident #20 was interviewed on 4/21/24 at 10:46 a.m. The resident said the food was just okay and was often served cold. Resident #209 was interviewed on 4/21/24 at 10:54 a.m. Resident #209 said the food was terrible because it was almost always served cold. She said because the food was served cold it did not taste good (cross-reference F585 for failure to respond to grievances). The family representative for Resident #56 was interviewed on 4/21/24 at 2:33 p.m. The representative said Resident #56 did not like a lot of the food prepared by the facility and was unable to say she did not like the food she was being served. When the resident was served foods she did not like she would stop eating. If the resident did not like the food she was served the staff would not always offer her something else to eat. The representative said since she knew what kinds of foods the resident liked she tried to come in every other day and order Resident #56' s meals in advance. She said it was hard when agency staff who did not know the resident well tried to feed her. II. Observations On 4/21/24 at 11:30 a.m. meal service was observed several residents only ate half or less of their meal and no staff inquired about why the resident(s) were not eating nor did they offer the residents an alternative meal choice. On 4/23/24 at 12:29 p.m. a test tray for a regular diet was evaluated by five surveyors immediately after the last resident had been served their room tray for lunch The test tray consisted of seafood alfredo, garlic bread, green beans and spice cake with icing: -The shrimp in the seafood alfredo was mushy and had a strong flavor of fish; -The noodles in the seafood alfredo were tough and chewy; -The green beans were waxy, flavorless and chewy; and, -The iced spice cake was dry. III. Record review A request was made for the food committee notes on 4/24/24. The food committee notes were not received during the survey process. IV. Staff interviews The dietary manager (DM) was interviewed on 4/24/24 at 1:29 p.m. The DM said the food committee met once a month to go over concerns the residents had regarding the food. She said the facility used a new distributor for food and had never bought the shrimp that was served on the test tray before. She said, due to budget constraints, it was difficult to accommodate all the requests from the residents but she did the best she could. The DM said she had noticed in the past that food tray delivery took a long time and she was working with the facility administrator to find a solution. She said residents had complained that the noodles served in the facility were chewy and unappetizing multiple times in the past. She said when any concerns were raised at the food committee meetings, the facility would do the best they could best to accommodate the requests. She said the residents were encouraged to order off of the ala carte menu that included items such as burritos, pizza and hamburgers.

Based on interviews and record review, the facility failed to ensure prompt action was taken to honor a request for the resident's personal and medical records by the resident and legal representative for one (#52) of one resident reviewed for medical records requests out of 33 sample residents. Specifically, the facility failed to allow Resident #52 and the resident's legal representative the right to obtain a copy of the resident's medical records or any portions of the electronically maintained record upon request and within two (2) working days of a verbal or written request for the resident's medical records. Findings include: I. Resident #52 A. Resident status Resident #52, under the age of 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included bipolar disorder (a mental illness that causes unusual shifts in the person's behavior), anxiety disorder and cerebrovascular disorder (a condition that affects blood flow to the brain). The 3/15/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive assistance with bathing, dressing and personal hygiene. The resident did not have any behaviors or rejection of care. B. Record review A medical durable power of attorney (MDPOA) for healthcare decisions, signed on 1/6/24 by Resident #52, read in pertinent part: I hereby authorize all physicians and psychiatrists who have treated me, and all other providers of health care services or treatment, including hospitals, nursing homes, and any other facilities or treatment centers or programs to release to my agent all information or photocopies of any record which my agent may request. B. Resident and legal representative interview Resident #52 was interviewed on 4/22/24 at 2:30 p.m. Resident #52 said she made her sister her MDPOA and wanted her MDPOA to make all her medical decisions because she did not understand medications and medical matters and she needed help to make good decisions. Resident #52 said it made her anxious and worried when the nursing staff tried to discuss medical issues with her and asked her to make medical decisions on her own without her MDPOA present. Resident #52's MDPOA was interviewed on 4/23/24 at 10:42 a.m. The MDPOA said she had filed a couple of requests for Resident #52's medical records asking for specific information. She said it took the facility approximately 30 days to respond to the first request for medical records and she did not get all of the documents she had requested. She said, additionally, the facility did not provide an explanation of why the facility had not provided all of the requested documents. She said a grievance form was filed and the facility did not provide a written response on how they resolved the grievance. The MDPOA said the failure to provide medical records as requested was not resolved (cross-reference F585 for failure to respond to grievances). The MDPOA said, in addition to the request made on 3/5/24, she made an additional request for records on 4/21/24 and she still had not received the records. She said the facility returned the request to her because she had attached a page explaining the types of documents requested. She said the facility told her she needed to rewrite the request because the request needed to be written on one sheet of paper and if she needed more space she could write on the back of the form. The MDPOA was interviewed again on 4/24/24 at 5:12 p.m. The MDPOA said she still had not received the medical records documents she requested on 4/21/24. C. Records review A review of a grievance form dated 3/18/24 revealed Resident #52 and her MDPOA requested medical records on 3/5/24 and they had not received the requested documents by 3/18/24. When the resident's representative complained the facility requested the representative fill out a new request form. The grievance form documented that the requested medical records were sent to the MDPOA by email and the grievance was resolved. -However, the MDPOA disagreed with the grievance finding and said that she did not receive all of the requested documents. The MDPOA provided a copy of a records request sent to the facility by email on 4/22/24 at 7:18 a.m. The requested documents included documentation of resolutions for all grievances forms filed with the facility from 11/2/21 through 4/22/24, all speech therapy and any other therapy notes and evaluations from 1/1/24 through 4/22/24 and laboratory results from 4/11/24 through 4/22/24. The facility responded by email on 4/23/24 at 10:07 a.m. The email read in pertinent part, I received your request, unfortunately, I will need you to fill out another request. The dates are required to be provided on the form. If there is not enough room on the sheet, can you please provide additional information on the back of the form. -However, the facility did not permit the resident and the MDPOA the right to clarify the medical records request verbally. D. Staff interviews The nursing home administrator (NHA) was interviewed on 4/24/24 at 1:10 p.m. The NHA said the facility had some difficulty with records management and it was taking longer than usual to process records requests. The NHA said the facility had hired a new director of medical records (DMR) and a records request should take approximately 10 days to process. The NHA said they had received the records request for Resident #52 and would process the request as soon as possible. -However, the resident/ resident representative had the right to request copies of the resident's medical records verbally or in writing and receive the requested records within two working days with advance notice to the facility.

Based on record review and interview, the facility failed to ensure two (#209 and #52) of two residents out of 33 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to: -Ensure Resident #209' s complaint about meals not being served at a palatable temperature; -Support Resident #52' s right to file any grievance (written or verbally) without the fear of feeling retaliation; -Ensure that all written grievance decisions included the date the grievance was received, a summary statement of the resident' s grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident' s concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was provided to the resident; -Ensure Resident #209 and Resident #52 received written responses to verbal and written grievances; and, -Establish a grievance policy that included all required elements per the regulations. Findings include: I. Facility policy and procedures The Grievances Policy, dated [DATE], was provided by the corporate director of clinical services (CDCS) on [DATE] at 5:13 p.m. It read in pertinent part, To provide residents and responsible party with information on the facility grievance procedure. To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form. A resident, family member, staff member or visitor may file a grievance at any time with an appropriate staff member or supervisor regardless of cognitive status, mental health diagnosis, or physical disability. There is no set time frame or minimum amount of time in which it must be filed except for those required under Elder Justice Law (see Abuse Policy). The administrator may assign the responsibility of investigating grievances and complaints to the appropriate department. Upon the receipt of a Grievance and Complaint Report or Complaint Concern form, the Social Services Director or designee will begin an exploration into the allegations/concerns. The appropriate department director will be notified of the nature of the complaint and that follow up is necessary. The investigation and report will include, as each may apply the date and time the incident took place, the circumstances surrounding the incident, where the incident took place, the names of any witnesses and their account of the incident, the resident' s account of the incident, the employee' s account of the incident, accounts of any other individuals involved ( employee' s supervisor) and recommendations for corrective action if not already remedied . The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ten (10) working days of the filing of the grievance or complaint. -The grievance policy failed to include the resident's right to file a grievance in writing or orally, file a grievance anonymously and obtain the review in writing. II. Resident #209 A. Resident status Resident #209, age 67, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included bipolar disorder (mental illness that causes unusual shifts in the person's behavior) and generalized anxiety disorder. The [DATE] 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. She was independent for eating. She required partial/moderate assistance for oral hygiene and was dependent on staff for toileting. B. Resident interviews Resident #209 was interviewed on [DATE] at 10:54 a.m. She said she had recently been admitted to the facility and had noticed the food was served cold for most meals. Resident #209 said she had filed grievances about the concern but it was never resolved and she was still receiving cold food at meals (cross-reference F804 for failure to serve food that was palatable in temperature). Resident #209 was interviewed again on [DATE] at 1:53 p.m. She said her food was still arriving cold and she had only had two fairly warm meals over the past week. C. Record review A grievance, filed by Resident #209 on [DATE], revealed she had a concern with her meals being served cold. The food and nutrition manager (FNM) documented the concern was passed on to the dietary manager (DM). The DM documented the food was being made at the proper temperature and recommended the resident eat in the dining room for faster service. -Resident #209' s preference to eat in her room was not taken into account and there was no action taken to address the resident's complaint of food being served cold and unpalatable food. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on [DATE] at 2:12 p.m. She said breakfast trays were served late that morning because there were only two CNA' s on the floor and they were providing care for a resident that required care in pairs. CNA #4 said one resident did not get her breakfast until after 9:30 a.m. and then had to order a special breakfast because the tray had sat for so long it was cold. The DM was interviewed on [DATE] at 1:29 p.m. The DM said the kitchen served the residents in the dining room first and then the room trays were sent out for delivery to residents who ate in their rooms. The DM said there were a lot of room trays so it sometimes took the kitchen staff time to plate and get all the trays for the units on the food delivery carts. The DM said the kitchen was working on fixing the room tray deliveries and it could sometimes take a long time for the trays to get delivered by the nursing staff depending on what other duties they had to complete. The DM could not provide evidence the facility had resolved Resident #209' s grievance regarding cold food in a manner that was satisfactory to the resident. 41032 III. Resident #52 A. Resident status Resident #52, under the age of 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included bipolar disorder (a mental illness that causes unusual shifts in the person's behavior), anxiety disorder and cerebrovascular disorder (a condition that affects blood flow to the brain). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required extensive assistance with bathing, dressing and personal hygiene. The resident did not have any behaviors or rejection of care. B. Resident and resident representative interview Resident #52 was interviewed on [DATE] at 2:30 p.m. Resident #52 said she was very nervous and worried about speaking to anyone because she was worried what she said would be used against her. Resident #52 said the nursing home administrator (NHA) once told her she was a mandated reporter. The resident said she was worried that meant the NHA would use her status as a mandated reporter to stop her sister from being her legal representative and also stop her sister from visiting me if she said too much or complained. Resident #52 said one night last month ([DATE]), she woke up and her room was very cold. Resident #52 said she asked one of the certified nurse aides (CNA) to adjust the heat and the CNA would not adjust the heat and instead piled a bunch of blankets on top of her. The CNA then told her that was good enough. Resident #52 said she complained to the facility staff about the encounter and the social services director (SSD) came to her room to talk to her about her complaint. Resident #52 said after she spoke to the SSD, the previous director of nursing (DON) came to talk to her about her grievance but did not explain how they planned to resolve the staff's refusal to honor a request like turning the heat up a couple of degrees. She said after the DON spoke to her, the NHA came to her room and told her the matter had been resolved but did not tell her how it was resolved. Resident #52 said after she voiced her grievance about the CNA's response to her request to turn up her heat, facility leadership responded by imposing care in pairs, which meant that any time a staff member came to her room there needed to be two staff present to provide any assistance so the staff had a witness for the interactions. Resident #52 said she worried that the staff would stick together and no one would believe anything she said. Resident #52 said she wanted a witness for herself. Resident #52 said that was the reason she did not want to discuss care issues or make medical decisions without her legally designated representative being present. Resident #52 said the facility's response to her grievance was upsetting and made her very anxious. She said if staff were to come in to discuss concerns with her and ask her to make decisions about her daily care she wanted her legal representative to be present. Resident #52 said the facility's leadership staff was bossy. The resident said she brought things to the facility's attention and the staff did not listen to everything she had to say. She said the leadership staff would end the conversations by saying That is all I am going to say. Resident #52 said she did not feel listened to. The resident's representative was interviewed on [DATE] at 2:30 p.m. The resident's representative said she and Resident #52 had voiced several grievances to facility staff on numerous occasions. She said most of the time the grievances were verbally communicated and the facility failed to provide a written response of actions taken to resolve the concerns. The resident's representative said most of the time she tried to talk to facility leadership privately about their concerns because talking about the grievances in front of Resident #52 was upsetting to the resident and made Resident #52 very anxious. The resident's representative said she filed a records request for the grievance action reports filed by her and Resident #52 and some other medical records information on [DATE] but had yet to receive the responses (cross-reference F573 for failure to provide residents the right to access/ purchase copies of records). The resident's representative said she and Resident #52 did not feel their grievances were resolved fully or to their satisfaction. She said the facility kept changing the way they resolved their concerns and she and Resident #52 wanted the facility's resolutions provided in writing. C. Record review Resident #52's grievance report dated [DATE] documented Resident #52 voiced a concern regarding the temperature of her room on the night of [DATE]. The concern form documented Resident #52 said she activated her call light and requested the CNA to turn the heat up to 75 degrees when she noticed the heat had been turned down to 73 degrees and she was freezing. The resident requested the CNA to turn up the heat. The grievance form documented the resident reported the CNA refused to turn up the heat and said she was unable to access the heater controls. The CNA got the resident extra blankets. The resident said she was unable to go back to sleep. The resident said she did not want extra blankets but instead wanted the heat turned up and she needed assistance from staff to reach and access the heater controls. The grievance form documented the action taken by the facility to ask the resident if she got someone who could help her and the resident said yes. -However, per Resident #52, the staff who came to help the resident refused to honor her request. The grievance form documented that the facility interviewed the CNA who responded to Resident #52's call light on the night she requested her heat be turned up; the CNA said she provided the resident blankets and did not adjust the heat as providing the resident with blankets would be the same as the turning the heat up. The CNA said after the staff left the room, the resident screamed for the heat to be fixed. The CNA said she explained to the resident that screaming was disruptive and Resident #52 said she did not care. The CNA said she asked Resident #52 not to speak to her that way. -The grievance report documented how the CNA made a decision to disregard the resident's request and implemented her own solution rather than work with the resident to come up with an agreeable solution. Additionally, the report failed to document how the facility planned to ensure that the resident's request would be accommodated in the future, or if it was not possible to accommodate the resident's request, how the staff would work with the resident to come up with an agreeable resolution. -According to the grievance report, the resident did not agree with the resolution and declined to sign the finalized report. The [DATE] grievance form submitted by Resident #52 revealed the resident was concerned because she signed a medical records release form on [DATE] and had received a menu instead. The resident was told she had to submit a new medical records release form. The facility's response on the form documented the facility had 30 days to get the information to the resident. The resident and her representative said the information was supposed to be provided within two days. The form documented the concern would be addressed with the NHA. The follow-up action documented an email was sent by medical records confirming the records were sent. -However, the response did not document the date the records were sent to the resident and the resident's representative. The form documented the resolution was reviewed verbally with the resident's legal representative and was resolved on [DATE]. -However, the resident and her representative did not feel the concern had been addressed because they had not received the medical records. III. Staff interviews The social services director (SSD) was interviewed on [DATE] at 12:16 p.m. The SSD said he was the grievance officer and managed grievances and complaints. The SSD said staff were asked to complete a grievance form when a resident voiced a concern. The SSD said, as the grievance officer, he would check and pick up all concern forms from the hallway grievance box a couple of times a day. The SSD said he also received written grievance forms directly from staff and residents. He said once a grievance form was accepted, he handed it over to the manager responsible for the area related to the concern for them to investigate and issue a resolution. He said the manager had 72 hours to respond to a resident's grievance and get the form back to the resident to see if they agreed to the resolution. The SSD said if the resident agreed and it was fully resolved, the grievance was filed in the facility's grievance binder. He said if the resident did not agree and the concern was not resolved, the grievance was turned back to the program manager to attempt another resolution. He said the grievances that came in over the weekend should be reported directly to a member of the leadership team in case it required urgent attention. The SSD said food grievances were directed to the DM. He said the facility had a lot of concerns with room trays and the facility was looking into those concerns and addressing the identified issues with leadership and the food committee monthly. The SSD said he was trending grievance concerns and it was rare to receive a concern about long call lights but most nursing related complaints were about agency staff not knowing residents' care. The facility had a few grievances about missing items that were usually located after a search. The SSD said the facility was usually able to resolve concerns quickly and when concerns were not resolved, they made a call to the ombudsman to see if the ombudsman could speak with the resident to see if they could assist with a resolution as a neutral person. The NHA was interviewed on [DATE] at 1:10 p.m. The NHA said she had many discussions with Resident #52 and her representative and had tried to resolve their concerns. The NHA said the facility had made several adjustments in the residents' care to try to meet the resident's and the resident representatives' requests but the resident's representative still had unresolved concerns that the facility continued to address. The NHA said with regard to the heater incident, the facility staff did not adjust the heat as the resident requested because the heat was already reading in the 70's and the staff did not think it needed to be turned up higher. The NHA considered that the grievance was resolved.

Based on observation, record review and interviews, the facility failed to ensure one (#13) of one resident reviewed out of 33 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to: -Ensure Resident #13 was assisted and encouraged to shower and maintain personal hygiene; and, -Ensure Resident #13's care plan addressed his refusals of showers and provided person-centered interventions to ensure the resident had appropriate hygiene. Findings include: I. Facility Policy The Bath, Shower/Tub policy and procedure, revised February 2018, was provided by the director of clinical services (DCS) on 4/24/24 at 5:13 p.m. It read in pertinent part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Notify the supervisor if the resident refuses the shower/tub bath. II. Resident #13 Resident #13, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included schizophrenia (a disorder that affects a person's ability to think and act clearly), type II diabetes mellitus, obsessive-compulsive disorder (unwanted thoughts and fears) and morbid obesity. The 4/3/24 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 MDS assessment identified the resident needed partial to moderate assistance with toilet hygiene and dressing and was independent with personal hygiene. The MDS assessment indicated the resident refused to shower or bathe during the assessment. III. Resident #13 interview Resident #13 was interviewed on 4/21/24 at 10:27 a.m. Resident #13 said he had not had a shower in over two weeks. He apologized multiple times for being disheveled and smelly. Resident #13 said he wanted a shower but he understood that things happened and he could not always get a shower when he wanted one. Resident #13 was interviewed again on 4/23/24 at 10:55 a.m. He said he preferred to have a male CNA assist him with showers. He said he had a fear of falling in the shower and preferred to have assistance. He said the male CNA that he preferred to have help him shower was not at the facility today. He said there was an agency CNA working instead. He said the agency CNA did not know him and he did not think he could trust her to keep him from falling so he did not want to get a shower today. IV. Observations On 4/21/24 at 10:27 a.m. Resident #13 was sitting on a bench across from the nurses station. The resident was wearing blue sweatpants, smelled strongly of urine and his scalp was dry and scaley. On 4/22/24 at 10:04 a.m. Resident #13 was sitting on a bench across from the nurses station. The resident was wearing the same blue sweatpants, smelled strongly of urine and his scalp was dry and scaley. On 4/23/24 at 10:55 a.m. Resident #13 was sitting on a bench across from the nurses station. Resident #13 was wearing the same blue sweatpants, smelled strongly of urine and body odor and had visibly dirty and matted facial hair. At 11:04 a.m. Resident #13 was observed in a conversation with the social services assistant (SSA). Resident #13 said he wanted to take a shower but he did not know when the certified nurse aide (CNA) that he trusted would be back to work. The resident told the SSA he was concerned of being sued by female CNAs if he allowed one of them to assist him in the shower (see SSA interview below). The SSA encouraged Resident #13 to continue to wait for a shower so he would be comfortable. On 4/23/24 at 11:12 a.m. Resident #13 was sitting on a bench across from the nurses station. Resident #13 was talking to another resident about how he wanted a shower and needed to shave his facial hair. Resident #13 said he knew he was not clean and needed a shower and other personal hygiene but he was not going to get anxious about it. V. Record review The activities of daily living (ADL) care plan, initiated on 4/29/14 and revised on 6/20/23, revealed Resident #13 had a self-care performance deficit related to weakness, impaired balance and activity intolerance. The interventions included providing the resident a shower on Sundays and providing the resident towels and washcloths when he frequently declined showers so he could wash himself at his bathroom sink. -A review of Resident #13's comprehensive care plan did not reveal person-centered interventions, such as consistent male caregivers, to encourage Resident #13 to shower and receive personal hygiene regularly. Resident #13's bathing record from 3/27/24 to 4/24/24 revealed the resident had refused showers on 3/27/24, 4/3/24, 4/10/24 and 4/17/24. -A review of Resident #13's shower records revealed the resident had not received a shower in at least 30 days. -A review of the resident's medical record did not reveal the resident was reapproached or person-centered interventions were implemented to encourage Resident #13 to take a shower. VI. Staff interviews The SSA was interviewed on 4/23/24 at 11:10 a.m. The SSA said Resident #13 needed a shower. The SSA said he was aware Resident #13 had a preference for who he would allow to assist him in the shower. He said he did not know if that CNA was still employed at the facility and if he was on the schedule anytime soon. He said Resident #13 was embarrassed about staff seeing his body and was worried about female staff being alone with him and suing him. The SSA said he would look into what needed to happen for the resident to get a shower. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed together on 4/23/24 at 2:45 p.m. The DON said Resident #13 had paranoia around females assisting him with a shower. The DON said the male CNA who was often able to assist Resident #13 in the shower per Resident #13's preference had called out sick and was going on leave so the resident would likely continue to refuse to shower. The ADON said Resident #13 had been offered wet wipes and would sometimes clean himself in his room. The DON said staff offered to help Resident #13 change his clothes, offered to have two staff members to assist with showers and offered to keep him partially covered in the shower but the resident continued to refuse. -However, review of the resident's medical record did not reveal these interventions had been attempted. The DON said she had told Resident #13 he had body odor and needed a shower. The DON said she had no idea what else the facility could do to get Resident #13 to take a shower. The DON said she felt the facility had tried everything. The medical director (MD) was interviewed on 4/24/24 at 10:11 a.m. The MD said Resident #13 had negative effects from years of poorly treated schizophrenia and it presented in his hygiene habits. The MD said he had a good relationship with Resident #13 and he needed to have a conversation with the resident regarding personal hygiene.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (#3) of five residents reviewed for ADL care assistance out of 33 sample residents. Specifically, the facility failed to assist and provide Resident #3 with her scheduled showers and wash her hair with the prescribed medicated shampoo. Findings include: A. Facility policy The Activities of Daily Living policy, revised March 2018, was received by the corporate director of clinical services (CDCS) on 4/24/24 at 5:13 p.m. The policy documented in pertinent part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. B. Resident status Resident #3, age 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis (disease disabling the brain and spinal cord), dementia and functional quadriplegia (complete immobility from physical disability). The 3/27/24 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required extensive assistance for transfers, toilet use, personal hygiene and bathing. The resident did not reject care. C. Resident interview Resident #3 was interviewed on 4/22/24 at 2:24 p.m. Resident #3 said she had not gotten a shower more than once a week for the past several weeks. She said she preferred taking two showers a week and the staff were too busy to give her more than one shower a week. She said this bothered her and her scalp got itchy. She said she got frustrated when she did not get the help she needed because she was dependent on staff for assistance. Resident #3 said she never refused showers when offered. She said she often felt dirty and did not want her skin to break down. She pointed out a bottle of [NAME] shampoo and [NAME] conditioner and said that was what the certified nurse aides (CNA) used to wash her hair when she received a shower. She said she did not go to the hair salon on a scheduled basis to get her hair washed anywhere else. During the interview Resident #3, was observed scratching her head every couple minutes. Her hair was messy, out of place and greasy. D. Record review According to the April 2024 CPO, Resident #3 had a physician's order to wash her hair with Selsun Blue Dry Scalp shampoo every Wednesday and Sunday, start date 1/24/24. -However, CNA #7, who said she showered the resident the most, said they used the pink shampoo from the resident's room during her showers and was not aware that the resident had an order for a medicated shampoo (see CNA #7's interview below). Review of Resident #3's record for the ADL task of bathing from 3/27/24 to 4/20/24 revealed Resident #3 received five showers (3/27/24, 4/3/24, 4/10/24, 4/17/24 and 4/20/24) out of eight shower opportunities during that timeframe. The bathing record documented Resident #3 refused her shower on 4/6/24 and 4/13/24. -However, the resident said she never refused staff offers to give her a shower (see resident interview above). -Additionally, 4/6/24 and 4/13/24 were Saturdays, not Sundays (see physician's order above). The bathing record documented the bathing task was not applicable on 3/30/24 (a Saturday, not a Sunday). -There was no further documentation for showers on the bathing record from 3/27/24 to 4/20/24. D. Staff interviews CNA #7 was interviewed on 4/29/24 at 3:02 p.m. CNA #7 said she had given Resident #3 several showers in the past two months and used the pink shampoo and conditioner that the resident purchased and kept in her room. CNA #7 pointed out the pink shampoo and conditioner in the clear bottles in the resident's room during the interview. She said she had never used a blue bottle of shampoo for Resident #3 or obtained a special shampoo from the nursing medication cart. CNA #7 said the resident was cooperative with showers and did not refuse care. She said in the charting system, the option for not applicable meant the staff did not have time to get the task completed. CNA #7 pointed out the CNA shower book and said Resident #3 was scheduled for showers on Wednesdays and Saturdays. -However, according to the physician's order dated 1/24/24, Resident #3 was to have her hair washed with the medicated shampoo on Wednesdays and Sundays. Registered Nurse (RN) #5 was interviewed on 4/24/24 at 2:30 p.m. RN #5 said Resident #3 did not refuse care, which included showering. RN #5 said in addition to assisting Resident #3 with showering, the CNAs were supposed to wash the resident's hair with the prescribed Selsun Blue Dry Scalp shampoo which they were supposed to get from the nurse. The director of nursing (DON), the nursing home administrator (NHA) and the CDCS were interviewed on 4/24/24 at 11:14 a.m. The DON said if a shower was refused by a resident, the nursing staff was to reapproach the resident later that same shift. If the resident continued to refuse the shower, the nursing staff were to get the charge nurse involved. The charge nurse was to educate the resident on showering, encourage the shower, and include it in the care plan. She said the nursing staff would document the refusal in the resident's chart. -The progress notes and care plan were reviewed and there was no documentation that the resident ever refused showering assistance. There was nothing documented in the care plan that the resident refused showers and no interventions for what to do if the resident were to refuse showering assistance.

Based on observations, record review, resident, family and staff interviews, the facility failed to ensure the environment was free from accidents as possible for three (#1, #2 and #3) of three sample residents for accident hazards. Specifically: --Resident #3 eloped from the facility and as a result sustained an injury resulting in amputation of all five of his toes on his right foot. --Resident #2 failed to have night stand relocated after a fall resulting in sutures to his head; and -- Failure to place appropriate restrictions on all doors for resident #1 who was assessed to be at risk for elopement Findings include: Resident Status: Resident #3 was admitted to the facility on [DATE]. According to the 4/14 Computerized Physician order [REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] documented a brief interview for mental status was not completed as the resident was rarely or never understood. The MDS coded the resident as having severely impaired decision making skills. The resident required total assistance on personal hygiene. The MDS indicated the resident required supervision with locomotion off of the unit. Colorado Department of Public Health and Environment received a complaint on 5/12/14 that resident #3 left the facility via electric wheel chair without the knowledge of the facility. Subsequently the resident's foot slipped off of the foot rest and he was found to have an injured foot. The paramedic report dated 4/30/14 5:01 p.m. documented, "...Witness state they saw pt traveling down street in his electric wheelchair. Witness state pt's (patient's) R (right) foot had slipped off the foot rest and was being drug on the street. Blood trail on street starts approx (approximately) 3 blocks away from location. Witness state pt did not appear to notice his injury. Pt is non verbal but answering questions with nods of his head ...lower extremity abrasions to superior side of 4/5 toes on R (right) foot, bone is visible with moderate bleeding ... " Review of the hospital report dated 5/8/14 documented the resident was admitted to the hospital on [DATE]. The resident's right foot had a degloving injury and posttraumatic osteo[DIAGNOSES REDACTED]. The bone biopsy showed osteo[DIAGNOSES REDACTED]. On 5/8/14 the resident underwent [REDACTED]. Failure to assess 1. Elopement risk --Review of the medical record failed to show the resident was assessed for elopement risk. Review of the policy documented all residents were to be assessed for elopement. Review of the nurses notes dated 4/30/14 documented the following: --At 2:20 p.m., the resident was observed to be in bed --At 3:45 p.m., the resident was assisted up into the electric wheel chair. --At 4:00 p.m., he was observed in his room --At 4:30 p.m., the resident's mother asked the whereabouts of the resident. The report investigation dated 4/30/14 documented the resident was not located in the building. The resident was located by the resident's mother blocks away where the paramedics were treating the resident for the injury. The facility was unable to conclude how the resident had eloped from the facility. The social service director (SSD) was interviewed on 5/16/14 at 11:28 a.m. via phone. The SSD stated that the resident was unable to maneuver his electric wheel chair independently. She stated that the resident was not assessed for elopement, as there was no indication from the hospital when he was first admitted that he was at risk for elopement. The nurse consultant (NC) was interviewed on 5/16/14 at 12:01 p.m. The NC stated all residents were to be assessed for elopement risk at admission. She stated that after the incident a full house audit and elopement assessments were completed on all residents. The elopement books which included resident pictures, and pertinent information was included for all residents at risk for elopement. 2. Electric wheel chair --Review of the medical record failed to show the resident was assessed for the use of the electric wheel chair. The care plan had not been updated to include the use of the electric wheel chair. The rehabilitation director (RD) was interviewed on 5/16/14 at approximately 11:00 a.m. The RD stated that the resident was not capable of using his electric wheel chair independently. She stated that the chair was set on the lowest setting and that a staff member had to direct the resident while he maneuvered the wheel chair. The RD stated the resident was not assessed for the use of the electric wheel chair. The RD stated the wheel chair was appropriate size for the resident and fit him appropriately. The RD stated the wheel chair was to be left in the off position when he was not using the chair. A certified nurse aide #2 (CNA #2) who cared for the resident was interviewed on 5/16/14 at 10:20 a.m. CNA #2 stated the resident's electric wheel chair was set on the lowest setting and that he needed assistance with controlling the wheel chair, as he would continue to go straight and not turn and could run into walls. She stated the chair needed to be in the off position when he was left unattended. The NC was interviewed on 5/16/14 at 12:01 p.m. The NC stated through the investigation it was found the resident had not been assessed for the electric wheel chair. She stated that all residents who have electric wheel chairs were assessed for the safe use of the wheel chair. The guardian was interviewed on 5/15/14 at 9:00 a.m. The guardian stated that the resident was currently in the hospital and being treated for [REDACTED]. The guardian stated on 4/30/14 the resident could not be located in the facility around 4:30 p.m. She stated that she asked the staff of his whereabouts and they were unable to locate him. She then went to her car and drove the surrounding blocks. She saw an ambulance and fire truck on one of the blocks and found that it was resident #3 who was being treated for [REDACTED]. The resident developed a bone infection related to the injury and had to have his toes amputated. She stated that the resident was able to use the wheel chair independently and that he was able to hit the automatic door opener. She stated that the wheel chair needed to remain in the off position and that a sign was in his room which indicated the w/c was to be turned off when left alone. The nursing home administrator (NHA) was interviewed on 5/16/14 at 3:00 p.m. The NHA stated that a investigation was completed regarding his elopement. The investigation failed to conclude how the resident had eloped from the facility. The NHA stated that all residents had an elopement assessment completed and also all residents with an electric wheel chair. She stated that only one resident had a wanderguard at present. She stated that staff were educated on the policy of the importance of assessments. 2. Resident #1, age 54, was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the most recent MDS assessment dated [DATE] the resident had a brief interview for mental status and scored a 6 out of 15 which indicated the resident had impaired decision making abilities. The resident was coded as requiring extensive assistance with personal hygiene. The MDS coded the resident for disorganized thinking. The resident exhibited during the assessment period wandering 1 to 3 days. Record Review: -Resident's initial assessment 1/11/13 indicated that he was at high risk for elopement. -The quarterly assessment conducted on 12/19/13: "(Resident) makes comments about leaving here to go to Colfax but has never attempted to due to (sic).... " -The social services note dated 1/24/14: "This author spoke with (Resident) about his attempts to leave the building. Discussed safety, alternate placement.... " -Social Services note dated 1/31/14: "This author arranged for companion services to ensure (Resident's) safety/ some agitation noted. Wander Guard in place for security. Father/guardian gave consent." -Review of the computerized physician orders [REDACTED]. -The CPO dated 3/11/14 had a physician order [REDACTED]. " -A physician telephone order dated 5/1/14 clarified, " Check wander guard for placement and function. " -The care plan dated 2/4/14 implemented a plan for Wandering/Elopement risk which included addition of a wander guard as of 2/4/2014. The care plan also identified the resident had an ability for locomotion on and off the unit with supervision. -Review of the 5/14 Medication Administration Record (MAR) showed the order for the wander guard to be checked one time a day. However, the MAR was blank and did not show the wander guard was checked for function. Interviews: --The registered nurse (RN #3) was interviewed on 5/16/14 at approximately 2:30 p.m. The RN #3 stated that the resident had a wander guard in place as he was at risk for elopement. She stated that when the resident was admitted he had attempted to leave the building unattended. He had used the front door and also a side door near his room. The resident had not attempted to elope for the past month and a half. --The social service director was interviewed on 5/16 at approximately 2:00 p.m. The SSD stated the resident was able to self propel and was able to reach door handles. The resident had made multiple elopement attempts out of the facility and the team determined that he needed a wander guard. The resident had not made an attempt recently to elope, and had expressed the desire to leave less. Observations of the doors of the facility The building was separated into four halls, Aspen, Maple, Oak, and Birch. There was one front door (door 1), one side door that led directly to the street (door 2), two doors that led from hallways into a courtyard on the south east side of the building (doors 3-4), two doors that led into a courtyard on the southwest and west sides of the building (doors 5 and 6) and three additional doors that led from a "discovery room" next to the dining room to the courtyard on the southwest/west sides. The courtyards were enclosed by a fence. The southeast courtyard had two gates (gates 1 and 2) that led to the street. The southwest courtyard had three gates (gates 3-5) led to the street. Observations revealed that only doors 1 and 4 were equipped with a wander guard. Door 2 was equipped with an alarm. Doors 3, 5, and 6 were not equipped with either an alarm or a wander guard and opened freely. The gates 1-5 from the courtyard were all unlocked and able to be opened from the courtyard and led directly to the street. Interviews: --Two residents who were out in the courtyard were interviewed on 5/15/2014 at approximately 2:20 p.m. The residents stated that the doors to the courtyard were open all the time even in the middle of the night. -CNA #1 was interviewed on 5/16/2014, at approximately 9:00 a.m. CNA #1 stated that residents were able to go into the courtyard any time they wanted. If residents were independent they could go outside at anytime. -CNA #2 was interviewed on 5/16/2014, at approximately 9:00 a.m. The CNA #2 confirmed that there were no alarms on the doors which lead to the courtyard. --The maintenance director (MD) was interviewed on 5/16/14 at 1:05 p.m. The MD stated that door #1 and door #4 were equipped with the wander guard system. He stated that the only door which had an alarm was door #2. The other three doors leading into the courtyards did not have an alarm, or a chime to alert staff that someone went out the door. The MD confirmed the gates from the courtyards were not locked and residents could leave the premises from the courtyard directly into the street. The doors leading to the courtyard were open 24 hours a day. 3. Resident #2, age [AGE] years old, was admitted to the facility on [DATE]. According to the 4/14 CPO [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the resident scored a 13 out of 15 for the brief interview for mental status. The resident required extensive assistance with activities of daily living. The resident was coded as not having good balance. The MDS indicated the resident had a fall since admission, and had a fall with a fracture within the past six months. Record Review: -Resident's initial care plan dated 3/17/14 read the resident was at risk for falls due to a history of falls, ambulation status, gait/balance, and existence of a condition that would predispose him to falls. -The care plan was updated on 5/2/14 to indicate that the resident's table would be moved due to risk for injury. -Review of the nursing notes dated 4/30/14 documented," ...At 0645, RN (registered nurse) was called into resident's room by a CNA staff who happened to be passing by the room and found resident on the floor by the entrance of his bathroom. Resident stated he tried to walk to the bathroom and fell . Resident was assessed and found to have two lacerations to the side of his head, he was cleansed with NS (normal saline) and TAO was applied and opened to air, bleeding stopped. Resident denied pain at the time. He was assessed again 30 minutes later and was found to be bleeding again and the bleeding couldn't (sic) stop. RN notified (resident's doctor) who gave the order to send resident out to hospital for sutures. Resident's father was also notified of incident. Before resident was sent out to (hospital), he was complaining of laceration area being tender, so Tylenol 650 mg PRN was given. Incident report completed and placed on 24 hour report as well. Neurological assessment has also been completed ... " -Nursing Note from 4/30/2014 11:04 p.m., " ...Resident came back from hospital with 4 sutures on his right frontal head ... " -An incident report dated 4/30/14 documented that on the morning of 4/30/14, the CNA on duty found the resident lying on the floor in his room by the door to the bathroom. Resident had sustained two lacerations (4.0 x 0.2 and 4.0 x 0.3) on the right frontal side of his head. The incident report documented that the facility would "move table resident fell on from entrance to the bathroom." -A post fall assessment report that was also completed on 4/30/14 stated that the action plan following the fall was to "move table resident fell on from his room." Observations: --On 5/15/14 at 1:00 p.m., two surveyors noted that the nightstand in the resident's room was located immediately to the right of the bathroom door. --On 5/15/14 at approximately 2:30 p.m., the room was observed with the director of nurses and also the MD. The nightstand continued to be located to the right of the bathroom door. --On 5/16/14 at approximately 1:30 p.m., the resident was observed to be lying in bed. The bed was low and a fall mat was in place. Interviews: --The resident was interviewed on 5/15/14 at 1:00 p.m. The resident stated that on 4/30/14, he had tried to get up to go to the bathroom and then fell and hit his head on the nightstand to the right of the bathroom door. The resident stated that it happened during the night, and that he did not put on his call light to request assistance. The resident said that no changes have been made to his bed, and that the nightstand that was currently sitting next to his bathroom door was the nightstand he had hit his head on. The licensed practical nurse was interviewed on 5/16/14 at approximately 1:45 p.m. The LPN #1 stated that the resident was at risk for falls and that he had a bed mat and a low bed because of falls. She stated that the resident had fallen prior to admission at home. --The RN #1 was interviewed on 5/15/14 at approximately 2:00 p.m. The RN #1 stated that she was notified by the CNA that she had found him on the floor and that there was blood on his head. The RN stated that there was a nightstand to the right of his bathroom door and that when he fell he hit his head while attempting to go to the bathroom. The RN #1 stated that the bleeding had not stopped for minutes and he was sent to the hospital. The RN said that she instructed the maintenance staff to remove the table, and that it had been removed. The RN stated that she had not been in the room since the incident.