Every finding on record at Royale Gardens Health & Rehabilitation Center

Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 3 sampled residents (#2) reviewed for unsafe discharge. This placed residents at risk for unsafe discharges. Findings include:Resident 2 was admitted to the facility in 6/2026 with diagnoses including vascular dementia. Resident was discharged from the facility on 7/4/26. Review of a progress note dated 7/4/26 at 9:51 AM, indicated Resident 2 was discharged from the facility to home with discharge orders and a medication release form. Resident 2's clinical record from 6/29/26 through 7/4/26 found no documented evidence a discharge summary was completed for the resident's discharge on [DATE]. In an interview on 7/14/26 at 11:20 AM, Staff 1 (Administrator) stated no discharge summary was completed for Resident 2's discharge to home.

Based on interview and record review it was determined the facility failed to provide a safe discharge for 1 of 3 sampled residents (#2) reviewed for unsafe discharge. This placed residents at risk for the lack of a safe and orderly discharge. Findings include:Resident 2 was admitted to the facility in June 2026 with diagnoses including vascular dementia. Review of a hospital Discharge summary dated [DATE] indicated Resident 2 was admitted to the hospital for cognitive impairment, failure to thrive and the inability to care for herself/himself after being found at home disoriented. The resident was diagnosed with a urinary tract infection and treated with antibiotics. The discharge summary also indicated the resident was not safe to return to independent living and was discharged to the facility. Review of Resident 2's Progress Notes indicated the following: -On 6/29/26 at 5:22 PM, indicated the resident was admitted to the facility. The resident was alert and oriented but could not remember why she/he went to the hospital. -On 7/1/26 at 4:29 PM, indicated the resident lived at home with their spouse who was the resident's caregiver. The resident's spouse was not able to provide support for the resident due to an illness. -On 7/4/26 at 9:51 AM, indicated the resident was discharged from the facility to home with discharge orders and medication release forms. Resident 2's BIMS assessment dated [DATE] indicated she/he had a score of 10 out of 15 (moderate impairment of cognition). The assessment indicated the resident was unable to report the correct year, month or day of the week. Review of a progress note dated 7/4/26 at 9:51 AM, indicated the resident was discharged from the facility to home with discharge orders and medication release forms. Review of a social service note dated 7/6/26 at 2:16 PM, indicated the facility contacted the local sheriff's department to do a wellness check on the resident. In an interview on 7/14/26 at 11:20 AM, Staff 3 (Social services) stated the resident had no support at home and did not want the resident to leave the facility. Staff 3 was not at the facility on 7/4/26 when the resident discharged . Staff 3 was able to set up the resident with Meals on Wheels and had the local Sheriff's department do a wellness check on the resident on 7/6/26. Staff 3 stated the resident's spouse was at another nursing facility recovering from an illness and was not at home. Staff 3 stated she had concerns about the resident's cognition and ability to take care of herself/himself. The facility did not contact anyone at the residence to ensure the resident was safe to go home. In an interview on 7/14/26 at 11:57 AM, Witness 1 (Neighbor) stated on 7/4/26 Resident 2 came to her house, about a mile away from the resident's home, and told her she/he was going to the store to get food for her/his cats. Witness 1 was concerned because the outside temperature was 98 degrees and the resident was walking outside. Witness 1 took the resident into her home and gave the resident water. Witness 1 took the resident home and visited the resident on 7/5/26 and found the resident lived with over 100 cats. The resident's home smelled of cat urine and was covered in cat feces. Witness 1 stated the resident was observed in the kitchen where burnt toast filled the house with smoke. Witness 1 stated the resident had little food in the house and called 911. On 7/6/26 and the resident was taken to a local hospital. Witness 1 stated she called the facility and left a voicemail, but no one responded. Witness 1 stated she did not know why the facility discharged the resident home. In an interview on 7/14/26 at 12:19 PM, Resident 2, who was pleasantly confused, stated she/he did not remember being at the facility. Resident 2 stated she/he remembered walking to Witness 1's house who suggested she/he go to the hospital. Resident 2 stated she/he was still at the hospital and was doing ok with no serious injuries. In an interview on 7/14/26 at 2:32 PM, Staff 4 (LPN) indicted on 7/4/26 a local transport company showed up to the facility to pick up Resident 2. Staff 4 was not informed of the resident's discharge and called the unit manager to confirm. The unit manager confirmed the resident's discharge, and she gave the resident a medication list and discharge orders. Staff 4 stated the resident was excited to go home, and Staff 4 was told family was waiting for the resident at home. In an interview on 7/15/26 at 8:05 AM, Staff 1 (Administrator) acknowledged the resident was not discharged in a safe and orderly manner.

Based on interview and record review it was determined the facility failed to administer antibiotics for 1 of 1 sampled resident (#78) reviewed for hospitalization. As a result, Resident 78 was admitted to the hospital with a diagnosis of UTI. Findings include: Resident 78 was admitted to the facility in 1/2026 with a diagnosis of cancer. Resident 78's Progress Notes revealed the following:-1/6/26 Resident 78 had yellow/pink tinged urine in her/his Foley catheter drainage bag. Orders were received to hold Resident 78's blood thinner and blood work was to be obtained. -1/7/26 Resident 78's physician History and Physical Note revealed Resident 78 had cancer, and Resident 78 reported she/he hoped to live one year so she/he could return home. Resident 78 reported she/he did not want heroic effects and would elect hospice services if outlook was futile. -1/8/26 Resident 78's Foley catheter drained dark red urine. -1/9/26 Resident 78 had 500 ccs of bloody urine, she/he was alert and oriented, and she/he was transported to the hospital for evaluation and treatment. Resident 78's 1/9/26 hospital Emergency Department note revealed she/he was evaluated for blood in her/his urine. A urine sample was obtained and revealed the urine was cloudy, had blood present, white blood cells, and many bacteria. The note indicated the urine sample results demonstrated compelling evidence of infection. Resident 78 was discharged back to the facility, and the facility was to administer Ceftin (antibiotic) BID for two weeks. Resident 78's clinical record including her/his 1/2026 MAR revealed she/he was not administered antibiotics as prescribed from 1/9/26 through 1/13/26.Resident 78's Progress Notes revealed the following:-1/9/26 Resident 78 did not have blood in her/his urine-1/10/26 Resident 78 was alert, oriented, and did not have a Foley catheter. -1/11/26 and 1/12/26 Resident 78 did not have bloody urine.-1/13/26 Resident 78 was assessed to have a low blood pressure, increased heartrate, and had difficulty breathing. Resident 78 was transported to the hospital for evaluation. Resident 78's 1/17/26 hospital Discharge Summary revealed she/he was admitted to the hospital with evaluation and management of complicated UTI. Resident 78's admission diagnosis was UTI. On 3/12/26 at 11:20 AM, Staff 5 (LPN) stated when new orders were received, one nurse entered the orders into the resident's clinical record, and the unit manager was to verify the orders were entered correctly. On 3/13/26 at 8:29 AM, Staff 22 (LPN) stated he worked on 1/9/26 when Resident 78 returned from the emergency department with orders for an antibiotic. Staff stated he faxed Resident 78's orders to the pharmacy, but the orders were not transcribed into her/his clinical record. On 3/13/2026 11:01 AM, Staff 23 (Physician) stated Resident 78 had multiple comorbidities (distinct medical conditions or diseases occurring simultaneously in an individual making diagnosis and treatment more complicated) but the facility not administering her/his antibiotic likely contributed to her/his 1/13/26 hospitalization. On 3/12/26 at 1:14 PM, Staff 2 (DNS) stated staff did not correctly inter the 1/9/26 antibiotic order and the oncoming nurse did not look in the order box to ensure all orders were entered.

Based on observation it was determined the facility failed to ensure the kitchen was kept in a sanitary manner in 1 of 1 kitchen reviewed for food service. This placed residents at risk for foodborne illness. Findings include:On 3/11/26 at 12:19 PM, during an observation of the kitchen, a swamp cooler located above the stove and food preparation area had a visible buildup of dust. A black pipe extending from the ceiling near the swamp cooler appeared greasy with dust accumulation. On 3/11/26 at 12:20 PM, Staff 29 (District Manager) and Staff 30 (Dietary Manager) confirmed the swamp cooler should have been clean.

Based on observation and interview it was determined the facility failed to ensure their call light communication system functioned independently for each resident in a shared room for 4 of 4 sampled residents (#s 14, 22, 61, and 68) reviewed for call lights. This placed residents at risk for unmet needs. Findings include:1. Resident 14 was admitted to the facility in 1/2021 with diagnoses including pain.On 3/10/26 at 3:44 PM, Staff 32 (CNA) tested Resident 14's call light. When Staff 32 turned off Resident 14's call light, the roommate's call light also turned off.2. Resident 22 was admitted to the facility in 6/2024 with diagnoses including pain and repeated falls.The 12/19/25 Quarterly MDS revealed Resident 22 was cognitively intact.On 3/9/26 at 12:31 PM, Resident 22 stated it took staff approximately 20 minutes to answer her/his call light. Resident 22 stated she/he believed something was wrong with her/his call light because it would shut off by itself. Resident 22 further stated she/he reported this to staff; however, no follow-up occurred.On 3/10/26 at 3:42 PM, Staff 32 (CNA) stated Resident 22 reported multiple times that her/his call light was not working. However, she initially believed the resident was mistaken and did not address it. Staff 32 tested Resident 22's call light and confirmed it was not functioning properly because when Staff 32 turned off Resident 22's call light, the roommate's call light also turned off.On 3/11/26 at 10:24 AM, Staff 25 (CNA) stated she observed the issues with the call light system for several years. Staff 25 stated she informed staff about the call lights not functioning properly, but the concerns had not been resolved.3. Resident 61 was admitted to the facility in 1/2024 with diagnoses including stroke and diabetes.On 3/10/26 at 3:42 PM, Staff 32 (CNA) tested Resident 61's call light. When Staff 32 turned off Resident 61's call light, the roommate's call light also turned off.4. Resident 68 was admitted to the facility in 1/2023 with diagnoses including heart disease.On 3/10/26 at 3:50 PM, Staff 32 (CNA) tested Resident 14, Resident 22, Resident 61 and Resident 68's call lights with Staff 1 (Administrator) present. Staff 1 confirmed each resident's call light should operate independently.

Based on interview and record review it was determined the facility failed to ensure x-rays were obtained timely for 1 of 6 sampled residents (#10) reviewed for accidents. This placed residents at risk for delayed treatment. Findings include: Resident 10 was admitted to the facility in 5/2020 with a diagnosis of heart disease. Resident 10's Progress Notes revealed the following:-11/4/25 staff responded to Resident 10's call for help. Resident 78 was found on the floor and reported bilateral feet pain. knee pain, and hip pain. The note indicated x-rays were obtained. Resident 10's 11/4/26 Order Details revealed left ankle, right ankle, left toes, right toes, left knee, right knee, hips and pelvic x-rays were orders. Resident 10's clinical record revealed results of her/his 11/4/25 right foot/ankle x-rays results were not in her/his clinical record. Resident 10's Progress notes revealed the following: -11/7/25 Resident 10 had bruising and swelling to her/his right foot.-11/9/25 Resident 10 was offered to be transported to the hospital for evaluation but declined.-11/11/25 Resident 10 had unrelieved pain and her/his physician was notified-11/28/25 Resident 10 had a discolored swollen area to the right lower shin, foot and inner ankle. Resident 10's physician was notified and right ankle x-rays were ordered. Resident 10's 11/28/25 x-ray report revealed her/his right ankle was fractured. On 3/11/26 at 5:15 PM, Staff 24 (LPN) stated she was at the facility when Resident 10's 11/4/25 x-rays were obtained. The x-ray technician did not ask for staff assistance with positioning and when the technician left, he did not indicate any of the ordered x-rays were not obtained. Staff 24 stated if she would have been notified the x-rays were not completed as ordered, she would have notified Resident 10's physician. On 3/11/26 at 12:42 PM, Staff 3 (LPN Unit Manager) stated Resident 10's right foot x-rays were not obtained as ordered on 11/4/25. On 3/13/26 at 2:20 PM, Staff 2 (DNS) stated the x-ray t technician did not report he did not obtain the ordered 11/4/25 right ankle x-rays. When Resident 10's physician reviewed all the x-rays, it was not noted the right foot x-rays were not completed.

Based on interview and record review it was determined the facility failed to ensure the resident and resident representative were included in the care planning process for 1 of 3 sampled residents (#5) reviewed for care planning. This placed residents at risk for insufficient involvement in care decisions. Findings include: Resident 5 was admitted to the facility in 11/2023 with diagnoses including brain damage and heart failure. A 10/17/23 legal Petition for Appointment or a Temporary Guardian and Permanent Guardian of An Adult revealed Witness 2 (Family Member) was Resident 5's legal guardian. A 2/17/25 IDT (Interdisciplinary Team) Care Plan Conference/Welcome Meeting Form revealed Resident 5 and Witness 2 attended the meeting and were involved in the care planning development. The 11/17/25 Annual MDS indicated Resident 5 was unable to participate in her/his BIMS assessment. On 3/9/26 at 2:52 PM, Witness 2 stated he was not included in any recent care planning process and had questions about Resident 5's therapy and nutrition. On 3/10/26 at approximately 4:30 PM, Staff 8 (Regional Director of Clinical) confirmed Resident 5's last care conference was on 2/17/25. On 3/12/26 at 11:29 AM, Staff 5 (Director of Social Services) stated she was recently hired and was working to address the lack of timely care conferences for residents. Staff 5 expected care conferences to occur quarterly and annually, family needed to be invited to care conferences, and acknowledged Resident 5's last care conference was a long time ago.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed to self-administer medications for 1 of 4 sampled residents (#10) reviewed for accidents. This placed residents at risk for an adverse medication regimen. Findings include: Resident 10 was admitted to the facility in 5/2020 with a diagnosis of heart disease. Resident 10's 8/11/23 Self-Administration of Medication form revealed Resident 10 wanted to self-administer medications, did not have visual impairment, was alert and oriented, and was assessed to be safe to self-administer mediations. The form did not list which medications Resident 10 was safe to administer. Resident 10's 2/28/26 Quarterly MDS revealed she/he was cognitively intact. Resident 10's 3/2026 MAR revealed she/he was able to self-administer artificial tears BID. The MAR also revealed Resident 10 administered the medication BID. On 3/9/26 at 1:00 PM, observation revealed fluconazole (an antifungal medication) nasal spray, an over the counter hair growth supplement, an over the counter weight loss medication, and a non-medicated eye drop on Resident 10's bedside table. On 3/10/26 at 12:16 PM, Staff 12 (LPN) stated if a resident had medications at the bedside, staff were to first assess the resident to ensure they were capable of medication self-administration. Staff 12 also stated the medications were to be stored in a safe manner such as in a lock box. Staff 12 stated Resident 10 had orders for the self-administration of eye drops, but did not have orders for the fluconazole, weight loss medication, or hair growth supplement. On 3/10/26 at 12:34 PM, Staff 2 (DNS) stated no residents were currently identified to be able to self-administer medications. Staff 2 stated staff should have identified the medications were at the bedside and assessed Resident 10 to ensure she/he was capable of self-medication administration. On 3/11/26 at 11:54 AM, Resident 10 stated she/he had the medications at her/his bedside forever.

Based on interview and record review it was determined the facility failed to ensure residents received showers for 1 of 4 sampled residents (#36) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 36 was admitted to the facility in 12/2025 with diagnoses including a below knee amputation of the right leg and a diabetic ulcer of the left foot.A 12/31/25 admission MDS indicated Resident 36 was cognitively intact with a BIMS score of 14. A 1/5/26 Care Plan for Resident 36 lacked information regarding bathing/showering. On 3/9/26 at 2:22 PM, Resident 36 stated she/he did not receive showers as frequently as was her/his preference, and she/he was told by CNAs this was due to lack of staff to help with showers.The Kardex (abbreviated care plan for CNAs) as of 3/10/26 for Resident 36 did not include the level of assistance required by Resident 36 for bathing.According to the Documentation Survey Report for 2/2026 and 3/2026, Resident 36 received three out of eight showers during the month of 2/2026. On 3/11/26 at 9:24 AM, Resident 36 stated frustration with the lack of opportunities to shower and stated, It's not like I need help; I just need to be wheeled in there and wheeled out after.On 3/11/26 at 10:16 AM, Staff 13 (CNA) stated when CNAs were short-handed, showers were frequently not completed. On 3/12/26 at 7:42 AM Staff 39 (CNA) confirmed evening shift CNA staff often ran out of time in their shift to provide showers to residents. On 3/12/26 at 4:13 PM, Staff 2 (DNS) indicated that a shower schedule was posted at the nurse's station with two scheduled showers per week per resident, unless a resident preferred one. Staff 2 confirmed the number of showers Resident 36 received failed to meet facility expectations. Staff 2 acknowledged CNA staff voiced difficulty completing assigned care and scheduled showers.

Based on observation, interview, and record it was determined the facility failed to provide meaningful activities for a dependent resident for 1 of 2 sampled residents (#5) reviewed for activities. This place residents at risk for lack of social interaction and isolation. Findings include:Resident 5 was admitted to the facility in 11/2023 with diagnoses including brain damage and heart failure. The 11/17/25 Annual MDS indicated Resident 5 was unable to participate in her/his BIMS assessment and her/his activity preferences were completed by staff. Staff indicated Resident 5 liked to listen to music and attend group activities. The Activities CAA revealed appropriate activities were needed to help protect the resident from social isolation and loneliness. A 2/27/26 revised Care Plan indicated Resident 5 required assistance to activity functions, she/he preferred to socialize with staff members and was able to sit in her/his chair to watch movies. Resident 5's preferred activities including watching comedy in her/his chair. Resident 5's care plan did not indicate any music as a preference. The 3/10/26 CNA Task: Activity Involvement report revealed on 2/16/26 Resident 5 received a single one to one conversation during the last 30 days. No other activities were indicated.On 3/10/26 at 10:57 AM, Resident 5 was observed in bed with her/his television on and no engagement with staff. On 3/10/26 at 1:59 PM, Resident 5 was observed in bed awake and looking at that wall.On 3/10/26 at 2:39 PM, Staff 14 (CNA) stated Resident 5's family visited infrequently. On 3/11/26 at 11:04 AM, Resident 5 was in her/his bed with the television on and no social engagement. On 3/11/26 at 10:50 AM, Staff 4 (Activities Assistant) stated he was instructed to engage cognitively impaired residents once each month and believed the requirement for Resident 5's activities were met. Staff 4 was not aware Resident 5's family visited infrequently and stated residents who had infrequent family interactions were to have increased interaction. Staff 4 stated he lacked training to address the needs of cognitively impaired residents and was currently the only staff working in the activities department. On 3/11/26 at 1:09 PM, Staff 17 (CNA) stated Resident 5 rarely was in her/his chair and only Staff 9 (CNA) was successful to ensure the resident did not get agitated when assisted into her/his chair. ON 3/11/26 at 3:34 PM, Staff 9 stated he did not care for Resident 5 often and was able to motivate Resident 5 with her/his preference for music and conversation during care. Staff 5 stated he played Resident 5's music preference on his own equipment because music was not set-up in the resident's room. On 3/11/26 at 5:46 PM, Staff 3 (Unit Manger-LPN) stated staff required additional training. Staff 3 expected staff to assist and offer daily activities to residents who were bedbound and acknowledged Resident 5's care plan required updated information to include her/his preference for music.

Based on interview and record review it was determined the facility failed to provide adequate ROM services for 2 of 3 sampled residents (#s 5 and 45) reviewed for position and mobility. This placed residents at risk for compromised mobility and pain. Findings include:1. Resident 5 was admitted to the facility in 11/2023 with diagnoses including brain damage and heart failure. A 4/30/24 Restorative Nursing Program Plan indicated Resident 5's restorative treatment was to occur one to three times each week and interventions included bilateral upper and lower extremity exercises to her/his shoulder, elbow, wrist, hand, hip, knee and ankle. The 11/17/25 Annual MDS indicated Resident 5 was unable to participate in her/his BIMS assessment and received ROM services for five out of seven days during the review period with no therapy services. The 1/1/26 through 3/8/26 Restorative Program log for Resident 5 revealed from 1/10/26 through 1/20/26 (11 days) and 2/15/26 through 2/21/26 (seven days) ROM services were NA (not available). The 2/17/26 Quarterly MDS revealed Resident 5 received ROM services one day out of seven during the review period. A 2/27/26 revised Care Plan indicated Resident 5 was non-verbal and had a performance deficit due to impaired mobility and bilateral upper extremity ROM impairment. The nursing and rehabilitation active ROM program was to maintain progress from therapy and be conducted one to five times each week. On 3/10/26 at 2:39 PM, Staff 14 (CNA) stated she provided ROM exercises to residents in the past but, during the last two months, she no longer provided ROM to residents. Staff 14 stated if CNAs were not trained to provided ROM exercises, CNAs were not to perform the task. On 3/10/26 at 3:49 PM, Staff 12 (LPN) stated she no longer saw staff provide ROM services for Resident 5 until 3/2026 when therapy began to work with Resident 5's hands. On 3/11/26 at 9:18 AM, Staff 18 (Director of Therapy) stated Resident 5 was re-evaluated in 10/2025 and she expected CNAs to provide ROM services if a designated restorative aide was unavailable. Staff 18 stated Resident 5 required ongoing ROM services. On 3/13/26 at 8:27 AM, Staff 19 (PT) acknowledged, over the last two to three months, ROM services for residents had declined despite the need for ROM services to assist residents with therapy maintenance. Staff 19 stated Resident 5's lack of consistent ROM services impacted her/his ease with transfers. On 3/13/26 at 3:01 PM, Staff 2 (DNS) stated a decision was made to remove restorative aide hours from the schedule to CNA hours during the last two months. Staff 2 expected ROM services to be consistent for Resident 5 and other residents who required ROM services. 2. Resident 45 admitted to the facility in 11/2020 with diagnoses including pain and contractures of muscle of left and right hand. The 10/14/25 ADL Care Plan indicated Resident 45 had a self-care performance deficit related to contractures. Staff were to provide restorative therapy consisting of active range of motion exercises to the bilateral upper extremities for 10 repetitions per extremity using a 3-pound weight, and active range-range-of motion exercises to the bilateral lower extremities for 10 repetitions while the resident's seated in a wheelchair. The 12/30/25 Quarterly MDS revealed Resident 45 was cognitively intact, had impairment on all four extremities, was dependent on staff for ADLs, and received range of motion services three days out of seven during the review period. Review of Resident 45's clinical record found no documented evidence a restorative program was being provided. On 3/9/26 at 3:21 PM, Resident 45 stated she/he previously received restorative therapy but was told they did not have enough staff to continue providing restorative services. Resident 45 reported restorative therapy helped strengthen her/his arms, shoulders, and hands, and stated since the therapy stopped, she/he had experienced increased tightness in her/his arms. On 3/11/26 at 10:24 AM, Staff 25 (CNA) stated Resident 45's hands were contracted. Staff 25 confirmed the facility did not have a restorative program for more than three months because staff were pulled from the floor. Staff 25 further stated Resident 45 had previously participated in the restorative therapy program and she/he asked whether the services would be continued. On 3/11/26 at 11:50 AM, Staff 26 (CNA) stated the facility had not had restorative services for some time. On 3/11/26 at 2:28 PM, Staff 27 (CNA) stated the facility had not had a restorative aid program for the past six months. On 3/12/26 at 10:20 AM, Staff 28 (Physical Therapy) stated the facility had not had a restorative program the past few months. Staff 28 further stated when services were provided, Resident 45 actively participated and benefited from the services. On 3/12/26 at 11:49 AM, Staff 1 (Administrator) acknowledged the facility did not have a restorative program and expected restorative services be provided.

Based on observation, interview and record review the facility failed to ensure the resident's clinical record accurately reflected the resident's resuscitation wishes for 1 of 4 sampled residents (#44) reviewed for ADLs. This placed residents at risk for not having their resuscitation choices followed. Findings include: Resident 44 was admitted to the facility [DATE] with a diagnosis of chronic heart failure. A review of the resident's clinical record revealed a POLST (Portable Order of Life-Sustaining Treatment) dated [DATE] indicating the resident elected a designation of Do Not Attempt Resuscitation (DNR).A review of the resident's IDT Care Plan Conference revealed the resident elected to be designated as DNR.A review of the resident's Clinical Resident Profile revealed the resident was to receive CPR. On [DATE] at 6:55 AM, Staff 11 (LPN) stated nurses are responsible for entering the resident's CPR/DNR status into the residents' clinical record. Staff 11 confirmed Resident 8's Clinical Resident Profile revealed the resident elected to receive CPR but her/his POLST revealed a status of DNR. Staff 11 stated if a resident was found unresponsive staff would look at the Clinical Profile to know whether or not to attempt CPR. On [DATE] at 3:17 PM, Staff 2 (DNS) stated her expectation was the clinical record would reflect the resident's elected resuscitation status.

Based on observation and interview, it was determined the facility failed to ensure drinks were stored in accordance with professional standards for 1 of 2 resident refrigerators and failed to ensure water dispensers were properly sanitized for 1 of 1 water dispensers observed. This placed residents at risk for cross-contamination. Findings include:1. On 1/16/26, the State Survey Agency received a public complaint indicating the filtered water stations had pink slime and were not replaced or cleaned. On 1/27/26 at 8:11 AM, the water dispenser across the hall from the main nurses' station was observed with an orangish buildup on the cold-water outlet and a gray to black buildup on the hot-water outlet. On 1/27/26 at 10:17 AM, Staff 8 (LPN) confirmed both water outlets on the dispenser had a buildup on the ends. On 1/28/26 at 8:44 AM, Staff 40 (Housekeeping Manager) stated the housekeeping department was responsible for cleaning and sanitizing the outside of the dispenser but not the outlets or the inside of the dispenser. On 1/28/26 at 9:19 AM Staff 44 (Maintenance Director) stated there was no cleaning schedule or documentation showing the water dispenser outlets were regularly cleaned. On 1/28/26 at 10:16 AM, Staff 1 (Administrator) stated he expected staff to complete the necessary activities for their job as required. 2. On 1/27/26 at 8:13 AM, the resident's snack refrigerator was observed to have three clear pitchers: one with a red liquid and two with yellow liquid. None of the pitchers had labels indicating when they were placed in the refrigerator or when they should be removed. On 1/27/26 at 10:17 AM, Staff 8 (LPN) confirmed the pitchers were not labeled. On 1/28/26 at 9:19 AM, Staff 39 (Dietary Manager) confirmed the pitchers of juice in the resident's snack refrigerator should have date labels. On 1/28/26 at 10:16 AM, Staff 1 (Administrator) stated he expected staff to complete the necessary activities for their job as required.

Based on interview and record review, it was determined the facility failed to inform the resident prior to the initiation of a psychotropic medication for 1 of 3 sampled residents (#3). This placed residents at risk for not being informed of the side effects of a medication and not participating in their treatment. Findings include:Resident 3 admitted to the facility in 2/2025 with a diagnosis of seizures. Resident 3's Physician Order Details revealed she/he was administered the following psychotropic medications between 2/12/25 and 6/16/25:- Asenapine (prescribed to treat bipolar disorder)- Buspirone (prescribed to treat anxiety).- Lamotrigine (prescribed for seizures (can also be used for bipolar)). - Abilify (prescribed to treat bipolar). There was no documented evidence to show the resident was informed of the side effects of these medications prior to being administered.On 7/21/25 at 11:48 AM, Staff 14 (SSD) confirmed Resident 3 was not informed for the listed medications prior to the medication being administered. 7/23/25 at 10:45 AM, Staff 16 (Administrator), Staff 15 (DNS), and Staff 17 (Regional Nurse) were notified of the findings of Resident 3 not being informed, and no additional information was provided.

Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 3 sampled residents (# 6) reviewed for abuse. This placed residents at risk for mental anguish and abuse. Findings include:Resident 6 admitted to the facility in 2024, with diagnoses including diabetes and below the knee amputation.Resident 6's 6/25/25 Quarterly MDS revealed Resident 6 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident 7 admitted to the facility in 2023, with diagnosis including cognitive communication deficit. Resident 7's 6/10/25 Quarterly MDS revealed Resident 7 had a BIMS score of 15, which indicated the resident was cognitively intact.On 6/16/25 a public complaint was filed which alleged Resident 7 made sexual contact with Resident 6 with a food item. On 7/16/25 at 9:47 AM, Resident 7 stated she/he gestured toward Resident 6 with a doughnut. Resident 7 did not recall saying anything afterward. Resident 7 stated Resident 6 had avoided her/him since the incident. On 7/17/25 at 9:46 AM, Witness 2 confirmed Resident 7 swiped a doughnut between Resident 6's legs. On 7/17/25 at 9:58 AM, Witness 1 stated her/his back was turned but Resident 6 was unable to speak, and the activities director was mad something happened. On 7/17/25 at 10:06 AM, Resident 6 stated she/he was sitting with two other residents and Staff 7 (Activity director) in the activity room eating doughnuts and drinking coffee. Resident 6 stated she/he playfully made a joke that she/he had touched all the doughnuts when Resident 7 reached for one. Resident 7 then took a doughnut, wiped it in her/his crotch area, ate it, and then stated now she/he had touched them all. Resident 6 stated, for a while after the incident she/he would check and see where Resident 7 was to avoid her/him. Resident 6 stated she/he was triggered by Resident 7's presence for at least a week after the incident. On 7/17/25 at 1:03 PM, Staff 7 (Activities Director) confirmed Resident 6 stated Resident 7 rubbed a doughnut between my legs. Staff 7 recalled Resident 6 turning white and getting quiet. Staff 7 confirmed an unwanted sexual incident occurred. On 7/18/25 at 8:37 AM, Staff 9 (CNA) stated after the incident Resident 6 was not herself/himself for about a week. Staff 9 indicated Resident 6 was angry about what happened. On 7/18/25 at 10:14 AM, Staff 13 (CNA) stated Resident 6 was angry and upset after the incident occurred. On 7/22/25 at 8:53 AM, Staff 18 (LPN) stated Resident 7 grabbed a doughnut and put it near Resident 6's private area. Staff 18 stated that Residents 6 and 7 were separated. Staff 18 confirmed the incident occurred.

Based on interview and record review it was determined the facility failed to ensure sufficient nursing staff to ensure timely incontinent care and resident showers were completed for 6 of 6 sampled residents (#s 5, 8, 12, 14, 15, and 16) reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: The facility's 1/2025 Resident Council Notes revealed concerns related to short staffing and having care needs met. The facility's 3/2025 Resident Council Notes revealed resident showers were not completed as scheduled. Review of the assigned showers on 4/20/25 revealed Resident 5, Resident 12, Resident 14, Resident 15, and Resident 16 did not receive their showers. The CNA staff documented, not attempted due to environmental limitations, refused, or NA. Resident 8's 4/2025 Shower Record revealed she/he did not receive a shower on 4/23/25 and 4/25/25. On 4/30/25 at 5:40 PM, Resident 8 stated the facility was often short staffed, call lights were not answered timely and she/he did not always get her/his scheduled showers. On 4/30/25 at 6:00 PM, Staff 18 (CNA) stated staffing shortages over the past few months caused residents to miss showers and not receive timely incontinent care. On 4/30/25 at 6:10 PM, Staff 19 (CNA) stated he was unable to meet the care plan needs of his assigned residents including showers and had come on shift to find residents soaked in urine. On 4/30/25 at 7:08 PM, Staff 4 (Licensed Nurse) and Staff 5 (Licensed Nurse) stated there was not enough CNA staff to provide residents with their scheduled showers, including Resident 8. On 5/1/25 at 8:23 AM, Staff 17 (CNA) stated on 4/20/25 the facility was short seven CNAs for day shift; showers were missed, incontinent care was not timely, residents did not get out of bed and call lights were not answered timely. Staff 17 stated the facility was short staffed and it was common for residents to miss showers and not get timely incontinent care. On 5/1/25 at 10:00 AM, Staff 10 (CNA) stated the facility was often understaffed, she was unable to complete the assigned resident showers, and incontinent care was not completed timely. On 5/1/25 at 10:07 AM, Staff 9 (CNA) verified Resident 8 was not always offered showers. On 5/1/25 at 10:17 AM, Staff 11 (CNA), Staff 20 (CNA) and Staff 21 (CNA) all stated staffing was terrible and chaotic and resident showers were frequently missed. On 5/1/25 at 12:15 PM, Staff 15 (CNA) confirmed on 4/20/25 resident showers were not completed due to low staffing levels and stated she documented this as refused and NA. On 5/1/25 at 12:27 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated the facility was short staffed for CNAs in 4/2025 and acknowledged resident showers did not occur for Residents 5, 8, 12, 14, 15 and 16 on 4/20/25.

Based on interviews and record review, it was determined the facility failed to treat, assess, and monitor wounds for 3 of 3 sampled residents (#s 101, 102, and 103) reviewed for wound care. This placed residents at risk for worsening wounds and infections. Findings include: 1. Resident 101 admitted to the facility on ,d+[DATE], with diagnoses including mononeuropathy of the bilateral lower limbs (damage or dysfunction of two or more peripheral nerves in both legs), second degree burns of the right foot (2nd and 3rd toes) and second degree burns to the left foot and toes. Resident 101's 2/13/25 Hospital Discharge Orders indicated to continue local dressing changes daily with Xeroform and a dry sterile dressing. Resident 101's 2/13/25 Nursing Admission/Readmission Evaluation included the following skin observation: -Right toe(s): burns, blisters -Left toe(s): burns, blisters No additional information related to the wounds was found such as: description, measurements, which toes were involved, or the condition of surrounding tissues. The skin evaluation did not contain any information related to the burn wound on the upper aspect of the left foot. Resident 101's 2/15/25 Nursing Admission Skin & Wound Evaluation indicated she/he had a second degree burn on the right dorsum, 2nd digit (toe) with no evidence of infection. There was no Skin & Wound Evaluation found for the left foot. On 2/24/25 at 4:24 PM, Witness 1 (Hospital Social Worker) reported Resident 101 sustained burns to both feet from a space heater at home. The resident discharged from the hospital to the nursing home on 2/13/25 with orders to change the Xeroform and sterile dressings (inner and outer dressings) daily. Witness 1 stated that on 2/20/25, the facility wound nurse observed that the resident had smelly discharge, discoloration to the left great toe, as well as pain and swelling. Resident 101 was readmitted to the hospital on 2/20/25, and reported to the hospital podiatrist that the nursing facility staff had not changed the Xeroform dressing on her/his wounds for four of the seven days she/he was at the facility. On 2/24/25, while at the hospital, Resident 101 had debridement performed on both feet and the removal of second and third toenail beds of the right foot. Resident 101's 2/2025 TAR indicated the resident's wound orders of 2/13/25 was not initiated until 2/15/25, two days after the resident's admission to the facility. A review of Resident 101's TAR for 2/2025 revealed the order for the wound care was not transcribed onto the TAR until 2/15/25 or two days after admission. On 2/28/25 at 9:58 AM, Staff 4 (Wound Nurse/RN) stated nursing staff did not transcribe Resident 101's wound orders, there was no documentation showing that nursing staff implemented the resident's wound care during the first two days of admission, and staff did not monitor the resident's wounds. Staff stated the resident's Admission Nursing Assessment - Skin/Wound section did not assess the resident's wounds to her/his toes and foot. The resident was sent out to the hospital on 2/20/25 due to an infection. On 2/27/25 at 1:17 PM, Staff 2 (DNS) and Staff 4 (Wound Nurse/RN) acknowledged the lack of treatment and monitoring of Resident 101's wounds on 2/13/25 and 2/14/25, and was unable to provide documentation of wound care to the resident's other foot for 2/15/25. On 2/28/25 at 11:53 AM Resident 101 stated the nurses at the facility told her/him they did not receive an order for wound care so they would have to leave her/his wounds alone. About five days went by before the wound care nurse came and addressed the wound, but the wound had started to stink. Resident 101 state she/he knew her/his feet were infected and she/he almost lost a toe. Resident 101 stated staff never offered to change the bandages on the first day she/he was admitted and she/he never refused wound care. Resident 101 stated that she/he pleaded with staff to perform wound care because she/he knew she/he got infections easily. On 2/28/25 at 3:39 PM, Witness 2 (Wound Clinic Physician) indicated Resident 101 was his patient prior to and after her/his stay at the facility. On 2/20/25 the resident told him the facility had not completed wound care for four of the seven days the resident was at the facility and they only changed the outer dressing not the inner dressing. Witness 2 stated the resident had pain during dressing changes but never refused dressing changes. Witness 2 also stated burn wounds have a different physiology than other types of wounds. Infection was the main concern, and a lack of wound care can contribute to the development of an infection in the wound. 2. Resident 102 was admitted to the facility in 2/2025, with diagnoses including fractured right femur and need for orthopedic aftercare (care following a fracture repair such as, physical therapy, pain management, and wound care). Resident 102's 2/4/25 Nursing Progress Note indicated the resident admitted to the facility at approximately 2:10 PM, with a right femur fracture above the knee which was wrapped and a brace in place. Resident 102's Care Plan dated 2/11/25 indicated the resident was at risk for skin breakdown and pressure injury related to immobility from a recent femur fracture. Staff was to follow facility policies and protocols for the prevention and treatment of skin breakdown. On 2/27/25 the care plan was revised to include monitor the surgical incision to right knee and thigh for signs and symptoms of infection such as, increased pain, drainage, redness, odor, fever. Wound care provided every shift and notify nurse and MD if signs and symptoms occur. Resident 102's 2/2025 TAR included an order for staff to monitor surgical incision to the right knee and thigh for signs and symptoms of infection, increased pain, drainage, redness, odor, fever. Notify nurse and MD if symptoms occurred, every shift, for wound care. The order was dated 2/27/25, 23 days after the resident's admitted [DATE]. Resident 102's electronic medical record revealed weekly skin evaluations were not completed, and had the following evaluations for the resident's three surgical sites as follows: -2/28/25: Skin & Wound Evaluation - front right knee (4 sutures) -2/28/25: Skin & Wound Evaluation - front right-side knee (3 sutures) -2/28/25: Skin & Wound Evaluation - front right thigh (2 sutures) On 2/27/25 at 10:36 AM, Staff 2 (DNS) and Staff 4 (Wound Nurse/RN) reviewed Resident 102's documentation and acknowledged the monitoring of the resident's surgical site did not begin until 2/27/25. Staff 4 indicated they were having trouble with hospitals not providing wound care instructions for residents and they were working to address the issue. 3. Resident 103 was admitted to the facility in 2/2025, with diagnoses including fractured femur with a surgical site on the hip with staples. Resident 103's care plan dated 2/20/25 included the resident had potential for impairment to skin integrity related to surgical site on the hip with 13 staples. Staff were to monitor the hip for any changes to skin integrity. On 2/24/25 the care plan was revised to include staff were to monitor for pain, redness, and swelling to the site and report to nursing and MD. Resident 103's 2/2025 TAR included an order for staff to monitor the resident's right hip incisions for signs and symptoms of infection, BID. The order was dated 2/27/25, 9 days after the resident's admitted . On 2/27/25 at 10:36 AM, Staff 2 (DNS) and Staff 4 (Wound Nurse/RN) reviewed the resident's documentation and acknowledged the monitoring of the resident's surgical site did not begin until 2/27/25. Staff 4 indicated they were having trouble with hospitals not providing wound care instructions for residents and they were working to address the issue.

Based on interview and record review it was determined the facility failed to assess the effectiveness of interventions and provide adequate resident supervision to prevent falls for 1 of 3 sampled residents (#s 102) reviewed for accidents. This placed residents at risk for recurring falls. Findings include: Resident 102 was admitted to the facility in 2024 with diagnoses including dementia, and repeated falls. Resident 102 had a BIMS score of 5 which indicated severe cognitive impairment. The resident had a total of 27 falls during the two months she/he was at the facility. Resident 102's care plan dated 9/30/2024 indicated the resident was a two person extensive assist with bathing/showering, transferring, and locomotion. Resident 102's 10/7/24 Fall Risk Care Plan instructed staff to anticipate and meet the resident's needs, keep the call light within reach, encourage use of the call light, educate the resident about safety reminders, ensure commonly used items were within reach, wear appropriate footwear, keep the bed in a low position,and a PT consult for strength and mobility. A review of the facility's fall Incident Reports revealed Resident 102 had 27 falls while at the facility from 10/3/24 through 12/1/24. There were 7 falls with staff assist to the ground or while staff were assisting the resident, 8 falls were witnessed, and 12 falls were unwitnessed. A review of the 27 Fall Incident Reports for Resident 102 from 10/3/24 through 12/1/24 revealed: -For 21 of the incident reports indicated Resident 102's care plan interventions at the time of the fall were frequent rounding, call light within reach, and staff-provided care. -The 10/4/24 a report included a gait belt was in place at the time of the intervention. The resident was ambulating alone in the hall. -The 11/14/24, 11/26/24, and 11/27/24 reports did not contain what interventions were in place at the time of falls. -The 11/28/24 report indicated Resident 102 was using the proper wheelchair at the time of the fall, which as not listed as a fll intervention on the resident's care plan. -The 10/13/24 and 11/6/24 the report indicated an intervention as the resident's walker was nearby which was not listed as an intervention on the resident's care plan, -The 10/13/24 and 10/14/24 incident reports also included an intervention to use visual reminders to ask for assistance which was not listed as an intervention on the resident's care plan. There was no documented evidence the facility conducted an analysis of the resident's falls to evaluate if her/his fall interventions were effective or appropriate. On 1/14/25 at 3:38 PM, Witness 2 (family member) stated the resident was at high risk for falls and required two-person assistance for transfers and showers. The resident had many falls while at the facility. On 12/1/24 the facility staff called the family and told them the resident fell in the shower and was sent to the hospital. The resident was diagnosed with damage from previous falls and a new brain bleed. On 1/16/24 at 8:55 AM, Witness 4 (LCSW/Veteran's Administration) stated Resident 103 had multiple falls while at the facility. Witness 4 further stated she has met with the Ombudsman and facility staff because the resident was having frequent falls and felt the facility did not have good fall interventions in place as the resident continued to fall. On 1/21/24 at 2:02 PM, Staff 5 (CNA) stated she was the CNA who assisted Resident 102 in the shower on 12/1/24 and had heard the resident had two falls earlier in the morning. Staff 5 stated Resident 102 needed one to one care because of the frequent falls but the facility did not have the staff to provide that level of care. On 1/21/25 at 2:23 PM, Staff 6 (CNA) stated Staff 5 completed a shower with the resident and she called for help because the resident became unresponsive. Staff 6 further stated the facility was often under staffed and when they were not staffed adequately they were unable to monitor residents who high fall risks. On 1/15/25 at 9:12 AM, Staff 12 (Nurse) stated Resident 102 was sent to the hospital often for falls. Staff 12 stated she had warned staff and the resident's family that the fall interventions in place were not adequate and did not work. Staff 12 further stated there was not enough staff to monitor Resident 102 who had sundowning behaviors and was impulsive. Staff 12 stated the resident needed one-to-one caregiver during waking hours. On 1/22/25 at 4:14 PM, Staff 1 (Administrator) stated they felt Resident 102's care plan was followed for both falls on 12/1/24. Staff 1 did not address how the care plan was followed for the resident's unwitnessed fall. Staff 1 was unable to address why Resident 102 had 27 falls in two months or why there was no assessment of the effectiveness or appropriateness of Resident 102's fall interventions.

Based on interview and record review it was determined the facility failed to provide timely pharmaceutical services for 3 of 7 sampled residents (#s 198, 21, and 78) reviewed for medication administration, and failed to ensure narcotic medication management systems were in place to account for and reconcile narcotics for 2 of 5 narcotic books reviewed for medication administration. This placed residents at risk for untimely medications and diversion. Findings include: 1. Resident 198 admitted to the facility in 10/11/24 with a history of seizures. The 10/2024 MAR instructed staff to administer lacosamide (antiseizure medication) two times a day for seizures, with a start date of 10/11/24. From 10/11/24 through 10/21/24 the MAR referred the reader to progress notes. Administration Notes revealed the following for lacosamide administrations: -10/11/24 waiting for delivery. -10/12/24 at 7:37 AM waiting for medication delivery. -10/12/24 at 7:17 PM the medication was unavailable. -10/13/24 at 8:44 AM the medication was unavailable. -10/14/24 at 10:01 AM an Administration Note revealed the medication was unavailable in the facility's automated electronic medication dispensing unit. At 7:40 PM the Administration Note indicated the medication was unavailable. -10/15/24 at 8:01 AM and 7:13 PM the medication was unavailable. -10/16/24 at 7:23 AM and 7:58 PM the medication was unavailable. -10/17/24 at 10:03 AM and 7:53 PM the medication was ordered and not available. -10/18/24 at 8:39 AM the medication was still not in the facility. -10/19/24 at 8:05 AM and 9:33 PM the medication was unavailable. -10/20/24 at 8:11 AM and 7:21 PM the medication was unavailable and nurse was aware. The 10/14/24 Encounter Provider Note revealed nursing indicated the pharmacy was unavailable to deliver the lacosamide for Resident 198's seizures. The 10/21/24 at 11:06 AM Nursing Note indicated the facility received signed orders for lacosamide and the pharmacy was faxed. No documentation was found in Resident 198's clinical record the facility contacted the pharmacy to follow up on the medication. On 10/24/24 on 1:31 PM Resident 198 stated lacosamide was the only antiseizure medication she/he took, and when she/he had a seizure it felt like an out of body experience, and she/he had a history of grand mal (type of seizure which involves a loss of consciousness and violent muscle contractions). Resident 198 stated she/he always took her/his seizure medication. Resident 198 stated she/he felt shaky and had an electrical current feeling form at the base of her/his skull to the top of her/his head and had headaches everyday lately. Resident 198 was unaware she/he was not receiving her/his antiseizure medication until notified by the survey team. On 10/24/24 at 2:04 PM Witness 5 (Pharmacy Technician) stated on 10/11/24 the pharmacy sent a request for Resident 198's lacosamide to her/his physician. The pharmacy was not provided a new prescription until 10/21/24. On 10/24/24 at 2:50 PM Staff 2 (DNS) stated she was not aware there were issues with Resident 198's admission medications. Staff 2 indicated the process was for the admission nurse to notify the pharmacy if a medication was not delivered, and every shift was to follow up with the pharmacy until the medications arrived. Staff 2 acknowledged the process was not followed. 2. Resident 21 admitted to the facility in 9/2024 with diagnoses including high blood pressure and lung disease. A 9/27/24 physician order indicated staff were to administer Atorvastatin (for high cholesterol) once a day at bedtime. The 10/2024 MAR indicated Resident 21 missed doses of her/his medication on 10/1/24, 10/2/24 and 10/3/24. The MAR referred the reader to the Nursing Progress Notes. Nursing Progress Notes dated 10/1/14 through 10/5/24 revealed the medication was unavailable. No documentation was found which indicated the physician or the pharmacy were notified of the unavailable or missed doses of Atorvastatin. On 10/24/24 at 2:50 PM Staff 2 (DNS) indicated the process was for the admission nurse to notify the pharmacy if a medication was not delivered, and every shift was to follow up with the pharmacy until the medications arrived. 3. Resident 78 admitted to the facility in 9/2024 with diagnoses including respiratory failure. a. An 10/14/24 physician order indicated Resident 78 was to receive dexamethasone (for seizures) two times a day. The 10/1/24 MAR indicated the following: -Resident 78's dexamethasone was to be administered twice a day at 8:00 AM and 8:00 PM. -On 10/14/24 and 10/15/24 the MAR referred the reader to Nursing Progress Notes. Nursing Progress Notes dated 10/14/24 through 10/15/24 indicated dexamethasone was not available, No documentation was found which indicated the physician or the pharmacy were notified of the unavailable and missed doses medications. b. An 10/17/24 physician order indicated staff were to administer Advair (used in the treatment of chronic obstructive pulmonary disease) aerosol powder inhaler BID. Review of the 10/2024 MAR indicated Resident 78 missed doses of her/his inhaler on 10/18/24 10/19/24, and 10/20/24. On 10/21/24 and 10/22/24 Resident 78 missed two doses of her/his inhaler. The MAR referred the reader to Nursing Progress Notes. Progress Notes from 10/8/24 through 10/22/24 revealed the Advair inhaler was unavailable. No documentation was found which indicated the physician or the pharmacy were notified of the unavailable or missed doses of the inhaler. On 10/24/24 at 2:50 PM Staff 2 (DNS) indicated the process was for the admission nurse to notify the pharmacy if a medication was not delivered, and every shift was to follow up with the pharmacy until the medications arrived. 3. On 10/23/24 at 12:38 PM the narcotic reconciliation records were reviewed with Staff 2 (DNS) for the two narcotic books on the B and G halls. The reconciliation records revealed many blank signature areas. Staff 2 stated staff should sign the narcotic reconciliation book at every shift change when narcotic medications were counted. Staff 2 acknowledged the blank signature areas and acknowledged the expected process was not followed.

Based on interview and record review it was determined the facility failed to accurately assess, care plan, implement, follow and maintain pressure ulcer treatments and care plans for 1 of 1 sampled resident (#191) reviewed for pressure ulcers. Resident 191 developing an avoidable unstageable (obscured full-thickness skin and tissue loss) pressure ulcer. Findings include: Resident 191 admitted to the facility in 6/2024 with diagnoses including kidney failure. The 6/17/24 Admission MDS indicated Resident 191 had pressure ulcer and was at risk for pressure ulcers due to incontinence and decreased mobility. Resident 191 admitted with a Stage 2 (shallow open wound) pressure ulcer to the coccyx. A public compliant was received on 6/25/24 which indicated Resident 191 discharged from the hospital on 6/12/24 with a Stage 2 (shallow open wound with red or pink base) pressure ulcer on her/his coccyx (tailbone) measuring 2 cm by 0.1 cm. Resident 191 returned to the hospital on 6/19/24 with worsening wounds to her/his coccyx. The 6/27/24 care plan indicated Resident 191 had potential for skin impairments related to fragile skin. Staff were to identify and document potential causative factors, and resolve them when possible. The 6/12/24 Skin and Wound Evaluation indicated the resident had a Stage 2 pressure ulcer, but did not identify where the wound was located. The picture of the resident's pressure wound in the electronic record revealed the wound bed had slough (a layer of dead tissue on the base of a pressure wound) which indicated an unstageable (covered by necrotic tissue making it impossible to determine the depth of the wound) pressure ulcer. A 6/16/24 Nursing Progress Note indicated Resident 191 had a new open area to her/his right buttocks. No Skin and Wound Evaluation or incident report was found in the resident's electronic record. A 6/18/24 Nursing Progress Note indicated Resident 191's right buttock had a wound that was open, dark red, moist, and had purple bruising surrounding the wound. Resident 191 complained the wounds were painful and burning. No documentation of the wounds or incident report was found in the resident's electronic record. The 6/24/24 Skin and Wound Evaluation indicated Resident 191 had a Stage 2 pressure ulcer to the coccyx upon admission, but there was no documentation or description of the wound or wound care treatment. Resident 191's new pressure ulcer was an unstageable pressure wound to the buttocks, not the coccyx. There was no documented description or treatment for the unstageable pressure ulcer. On 10/27/24 at 1:25 PM Staff 12 (RN) stated she remembered the resident and the pressure wound she/he had. Staff 12 stated the resident admitted to the facility with a Stage 2 pressure ulcer to her/his coccyx which became worse and she/he returned to the hospital. Staff 12 stated the resident also acquired an unstageable pressure ulcer to her/his buttocks which never should have happened. Staff 12 stated the treatments were not working, nurses were not documenting on the Skin and Wound Evaluation documents, and the doctor was not notified. On 10/29/24 at 10:45 AM Staff 2 (DNS) stated wound measurements are part of the admission process. The admission nurse did not complete a Skin and Wound Evaluation, for the initial coccyx wound. Staff 2 stated the physician was not notified of the resident's acquired and worsening unstageable pressure ulcer to her/his buttocks and should have been before the wound became worse.

Based on interview and record review it was determined facility staff failed to provide necessary treatment and services to prevent pressure ulcers for 1 of 3 sampled residents (#6) reviewed for pressure ulcers. Resident 6 developed an unstageable (wound covered by necrotic (dead) tissue or thick, brown or black scab or crust that covers the wound) ulcer on 12/20/23. Findings include: The facility's policy and guidelines for Skin Integrity dated 3/2023, stated the facility would provide care and services consistent with professional standards of practice to promote the healing of pressure ulcers or injuries and individualized interventions would be implemented to prevent development of pressure ulcers or injuries. Resident 6 admitted to the facility in 9/8/23 with diagnosis including Sepsis (an overall body infection which can be life threatening). Resident 6's initial nursing assessment noted she/he had wounds on her/his left hand, both thighs, right side of her/his face and pink skin above her/his coccyx (the small bone located above the sacral area, which is the area on the back located between the right and left hip bones). A nursing note written on 9/26/23 by Staff 9 (LPN) noted the resident was observed with two small, blanchable open sores on her/his buttocks. There was no documentation the facility physician or unit manager was notified of this change until 9/28/23, when the resident had a telehealth visit with the facility provider and told the provider she/he had experienced pain due to the wound. The 9/2023 TAR did not reflect any orders for treatment of the sores observed on Resident 6's buttocks. Resident 6's initial care plan dated 9/16/23 indicated she/he was at risk for skin breakdown related to impaired mobility and bowel and bladder incontinence. No updates were made to the care plan after the open sores on the resident's buttocks were observed on 9/26/23. Skin and wound assessments for 9/2023 and 10/2023 were reviewed and there was no documentation of any assessment for the wounds on Resident 6's coccyx/sacral area. A nursing note written on 11/22/23 by Staff 8 (LPN/Wound Care) noted an alert due to red blanchable skin developing over the resident's coccyx. New orders were input on 11/23/23 to cleanse the skin over the coccyx, apply barrier cream and foam dressing to the sacral area daily. The 9/2023 TAR reflected the dressing was not changed on 9/25/23. A progress note written by Staff 12 (LPN) on 11/25/23 noted the dressing had been changed the day before. A nursing note written on 12/13/23 by Staff 8 noted red skin over the resident's coccyx with a small open area. A provider note written on 12/18/23 noted Resident 6 had no skin issues. A nursing note written on 12/20/23 by Staff 8 noted during todays dressing change a deep unstageable pressure ulcer was discovered, skin split around wound. Photo uploaded .new wound care orders in place. Resident is on an air mattress, MD notified. No risk management report was initiated by the facility for the resident's unstageable pressure ulcer and no investigation was initiated. On 1/19/24 at 5:47 PM, Staff 1 (DNS) acknowledged no risk management report or investigation had been completed by the facility for the unstageable pressure ulcer.

Based on interview and record review it was determined the facility failed to prevent a fall with significant injury for 1 of 3 sampled residents (#4) reviewed for falls and the facility failed to ensure appropriate mechanical lift equipment was available for transferring bariatric residents for 1 of 1 facility reviewed for accidents. The failure to prevent falls resulted in Resident 4 sustaining a fall with a fractured hip and required hospitalization . Both failures placed residents and staff at risk for falls and significant injuries. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses including a right hip fracture, unspecified dementia and atrial fibrillation (irregular heartbeat that can lead to blood clots). A 9/13/23 hospital discharge orders revealed the resident was admitted to the hospital on 9/4/23 with a right hip fracture and required surgical repair on 9/5/23. The orders indicated activity instructions were weight bearing as tolerated on the right lower leg. A 9/13/23 PT Discharge Summary revealed Resident 4 had potential for falls, weight bearing precautions (weight bearing as tolerated) and total hip precautions. Mobility recommendations revealed the resident had a decreased awareness of precautions and her/his deficits. The resident was noted to self correct mobility errors with cues and good awareness of safety. A Nursing Admission Evaluation on 9/13/23 at 4:23 PM indicated Resident 4 required the extensive assistance of one staff for toileting and the extensive assistance of two staff to turn and reposition in bed and when transferring. The evaluation revealed the resident had an unsteady gait (manner of walking) and generalized weakness. Resident 4's 9/13/23 initial care plan revealed safety interventions included: - One staff assistance with a four-wheeled walker and gait belt for transfers and - One staff assistance with locomotion. A 9/13/23 incident report revealed Resident 4 was found on the floor in her/his room at 9:00 PM next to the bed. The resident stated she/he was sitting on the bedside commode, tried to get up on her/his own and fell . The report indicated the resident reported intense left hip pain and was transferred to the hospital for evaluation. According to a 9/13/23 ED (Emergency Department) visit note, X-rays revealed the resident had a (new) left hip fracture and the previous right hip fracture repair was intact. A 9/16/23 hospital discharge report revealed Resident 1 had left hip repair surgery on 9/14/23. Discharge orders included: weight bearing as tolerated for her/his left and right lower extremities and hip precautions for the right hip. During an interview on 1/18/24 at 12:24 PM Witness 10 (Complainant) stated during the intake process on 9/13/23, a nurse indicated the resident should not be left alone or get out of bed for the first 24 hours. Witness 10 stated she was called by the facility at approximately 9:00 PM to notify her the resident had fallen. Witness 10 indicated the facility staff told her the resident convinced them she/he wanted to get up to the commode, the resident was left without supervision and while attempting to clean herself/himself, she/he fell and broke the other hip. On 1/18/24 evidence of a facility investigation was requested for the resident's 9/13/23 fall. Staff 2 (Unit Manager) provided an undated document that indicated the resident used a [NAME] lift (Hoyer lift - a mechanical assistive device used for transfers). The investigation revealed the fall was unavoidable because care plan interventions were in place: call light within reach, using a bedside commode and the resident attempted to transfer without assistance. The resident's care plan revealed the fall interventions identified in the 9/13/23 investigation were not initiated until 9/16/23 and 9/20/23, when the resident was readmitted to the facility after the second fall. On 1/23/24 at 2:13 PM Staff 18 (LPN/Unit Manager) confirmed she completed the incident report and investigation for Resident 4's 9/13/23 fall. Staff 18 revealed the resident did not use the call light to request help while she/he was on the commode. Staff 18 stated the fall was unavoidable because care plan interventions were in place and abuse and neglect were ruled out because no one had intentions for having [the resident] fall. On 1/24/24 at 3:20 PM Staff 1 (DNS) revealed when Resident 4 was on the commode the CNA did not remain near her/him to provide privacy. Staff 1 stated the resident tried to clean herself/himself and fell , and staff were not close enough to assist her/him. Staff 1 indicated the resident's discharge orders were weight bearing as tolerated. Staff 1 stated it was difficult to get all the critical evaluations done within 24 hours and acknowledged a fall risk assessment was not completed before Resident 4 fell . On 1/25/24 at 10:40 AM Staff 27 (Former Staff - RN) stated she remembered Resident 4's initial evaluation was done in her/his room with Witness 10 present, but she was unable to recall the specific conversation. Staff 27 stated she remembered the resident because she/he fell and broke the other hip on the same day she/he was admitted to the facility. Staff 27 stated she was not at the facility when the fall occurred and Witness 10 indicated she noticed during the initial evaluation, the resident did have some dementia. 38139 2. On 1/18/24 at 2:45 PM Witness 4 (Medical Professional) indicated the facility had 10 bariatric residents but did not have the correct size or configuration Hoyer mechanical lifts to transfer the residents safely. Witness 4 said the Administrator had been trying for the past four months to get the needed Hoyer lifts but had been ignored. Witness 4 stated the CNA staff were standing on the Hoyer lifts so they would not topple when the lifts were used to transfer bariatric residents and Witness 4 said it was not safe for the residents or the staff. On 1/18/24 at 3:06 PM Staff 4 (LPN) indicated they did not have appropriate Hoyer lifts for the bariatric residents. They had one 600 lb Hoyer that did not work properly but their corporation would not spend the money to fix the issue or get new equipment. Staff 4 said there was an issue two weeks ago with Resident 16. The resident needed to go to the hospital for fluid overload (too much fluid in your body which can cause swelling, high blood pressure and potential heart problems) but the Hoyer was not adequate to get the resident out of bed. It took 3-5 EMTs (Emergency Medical Technicians), 3 CNAs and a couple of nurses to drag the resident off the bed, into the hallway and onto a gurney. It took over 25 minutes to get the resident up and out for transport to the hospital. On 1/18/24 at 4:16 PM Staff 1 (DNS) acknowledged the facility needed new Hoyer lifts to accommodate bariatric residents. She tried to get at least one from a sister facility but had not managed to ensure it would be possible. The facility needed newer equipment such as two of the higher capacity Hoyers with a better configuration in the lifting arm to provide the safest care for their bariatric residents. In a follow up interview on 1/23/24 at 2:09 PM Resident 14 indicated there had been an issue with her/his transfer to the hospital and she/he was concerned about the facility's ability to transfer her/him. Resident 14 said there had been some rough transfers recently including transfers with staff having a CNA stand on the Hoyer lift so it would not tip over. The resident did not think that was the safest thing to do for her/him or the CNAs. Resident 14 stated she/he had to go to the hospital a lot lately and she/he was worried about what might happen each time and what they would do if there was a fire.

Based on interviews, and record review it was determined the facility failed to protect the resident's right to be free from physical restraints for 1 of 3 sampled residents (# 12) reviewed for abuse. This failure resulted in Resident 12 experiencing psychosocial harm with suicidal ideation, increased depression symptoms, heightened anxiety, and fear of losing her/his home. Findings include: Resident 12 was admitted to the facility in 2015 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), contractures of the right and left hand, right elbow, and lower extremities (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the body part), and a history of traumatic brain injury. Resident 12 was dependent on a power wheelchair for her/his mobility. Resident 12's care plan dated 11/17/2020 indicated the resident had an ADL self-care deficit related to quadriplegia and contractures in both upper and lower extremities. The resident was dependent on two staff for assistance with bed mobility, toilet use and transferring. The resident was totally dependent on one staff for eating, filling a water cup and drinking fluids. A facility Incident Report dated 12/8/23 indicated Resident 12 and Staff 3 (Administrator) had an altercation in the doorway of the Administrator's office. Both Staff 3 and Resident 12 accused each other of yelling and physical contact. Staff 3 said Resident 12 ran into the back of his leg with her/his power chair and caused pain to his Achilles tendon. Resident 12 said Staff 3 tried to shut the office door on her/him and caused a small cut to her/his leg. There were no witnesses identified who heard either yelling or saw any physical contact. Law Enforcement responded but no arrest was made. On 12/8/23 at 9:30 PM a Nursing Note indicated staff were told the resident's power chair was to be removed from the room while an investigation was conducted, and a manual wheelchair was provided for the resident. An email dated 12/26/23 at 11:42 AM from Witness 18 (State Operations Policy Analyst) to Staff 3 (Administrator) requested Staff 3 provide confirmation, and response to a summary of details related to the incident with Resident 12. Witness 18 reiterated to Staff 3 it was important to ensure Resident 12's rights were not compromised and to ensure removal of the power chair was not considered a physical restraint. Witness 18 requested Staff 3 confirm and ensure the resident was provided with a 1:1 caregiver and staff had documented the 1:1 care was provided. Based on the resident's functionality/disability the facility may NOT take away mobility without ensuring she/he had a caregiver to assist 24 hours per day 7 days a week because she/he could not use the manual wheelchair by herself/himself. Witness 18 wrote if the facility did not ensure a 1:1 caregiver was assigned, removal of the electronic wheelchair would be considered a physical restraint. The timeline of events which occurred after the 12/8/23 incident between Staff 3 and Resident 12 and included the following: -Resident 12's care plan dated 11/17/20 indicated Resident 12 was a quadriplegic and the only means for having independence was the use of a power chair. -On 12/8/23 the resident was accused of intentionally hitting Staff 3 with her/his power chair. -On 12/8/23 the resident was informed the power chair would be removed from her/his room and use while the facility conducted an investigation. -On 12/8/23 the facility provided the resident with a manual wheelchair. Resident 12 was not physically able to use a manual wheelchair due to quadriplegia. -On Friday 12/8/23, Staff 3 was suspended from the facility for the duration of the investigation. -On 2/9/23 a 1:1 caregiver was provided for the resident. -On Monday 12/11/23, Staff 3 returned to work which indicated the end of the investigation. The power chair was not returned to Resident 12. -On 12/11/23 the 1:1 caregiver was discontinued. -On 12/12/23 the facility had the resident take a new driver's test which she/he passed. The resident did not get the chair back. -On 12/15/23 the facility told the resident to sign a contract before she/he could get the power chair back. The contract had a confession statement and indicated a determination of breach of the agreement would be at the sole discretion of the facility and the resident would then agree to an immediate voluntary discharge. The resident did not sign the contract. -On 12/17/23 Resident 12 had an unwitnessed fall and was found on the floor by her/his bed. The resident stated she/he had to yell for about 10 minutes before staff responded. No 1:1 caregiver was present. -On 12/19/23 Staff 3 asked the power chair company to turn the wheelchair power down to 1 mph (known as turtle mode) but was advised the resident was cognitively able to make the decision on appropriate speed and any decrease in speed by the company could be viewed as a restraint. -On 12/25/23 Resident 12 was not able to spend the Christmas holiday with her/his family because she/he did not have her/his power chair on 12/25/23. -On 12/26/23 Staff 3 received an email from Witness 18 (State Operations Policy Analyst) reminding him of the importance of having 1:1 caregiving provided to Resident 12 during the entire time the wheelchair was removed from her/his use or it would be considered physical restraint. Witness 18 requested verification the care was provided and documented in the resident's medical record. -On 12/26/23 a 1:1 caregiver was provided for the resident. -On 12/26/23 Resident 12 called the State Complaint line because the 1:1 was reinstated and she/he wanted to know why. Both facility Unit Managers were present and said they did not know. -On 12/27/23 the facility returned the resident's power chair and the 1:1 caregiver was discontinued. On 1/12/24 at 3:35 PM Staff 3 provided the timeline for the 1:1 caregiving they provided for Resident 12 when they removed the resident's power chair. The resident was placed on 1:1 effective 12/09 - 12/10. The 1:1 stopped on 12/11.(two days) The 1:1 commenced again on 12/26 and ended on 12/27. (one day) The resident received 1:1 care for 3 days out of the 19 days the facility withheld the power chair. Staff 3 (Administrator) said the reason the 1:1 caregiver was removed was due to staffing. In interviews on 1/8/24 and 1/24/24 Resident 12 stated she/he knew Staff 3 was retaliating against her/him for standing up to him. Resident 12 said Staff 3 was a bully. Resident 12 said taking her/his chair messed with her/him hardcore. The resident said she/he almost quit going to school and her/his participation in school dropped from 100 percent down to 20 percent because she/he was so depressed. The resident said she/he could not celebrate Christmas with family because she/he did not have the power chair and the facility did not offer to help. Resident 12 also said Staff 3 moved the CNAs around so she/he would not receive assistance from the CNAs she/he trusted and the facility knew she/he needed consistency with care. The resident also stated she/he knew Staff 3 wanted to get rid of her/him but if she/he had a choice she/he would at the facility stay to finish school. Resident 12 said she/he had lived at the facility since 11/2020, had no violent history and wanted to stay at the facility. Resident 12 said she/he knew she/he could not if Staff 3 was there. Documentation in the facility progress notes by nursing staff following the incident on 12/8/23 and removal of the resident's power chair indicated the resident expressed suicidal thoughts, hopelessness, anxiety, and fear. On 1/22/24 at 1:50 PM Staff 16 (Regional Director) acknowledged the power chair was removed on Friday 12/8/23 and returned on 12/27/23. Staff 16 indicated Staff 3 should have handled the situation differently. On 1/22/24 at 8:30 AM The District Attorney's office determined there was no evidence Resident 12 had assaulted or caused physical injury to Staff 3 and there was no evidence of any intention of Resident 12 to cause injury to Staff 3. The District Attorney's office declined to press charges for simple assault or for harassment even though Staff 3 was pushing for them to press charges against the resident and was angry they did not.

Based on interviews and record review it was determined the facility failed to protect the resident's right to be free from involuntary seclusion by facility administration for 1 of 3 sampled residents (# 12) reviewed for abuse. This failure resulted in Resident 12 experiencing psychosocial harm with suicidal ideation, increased depression symptoms, heightened anxiety, and fear of losing her/his home. Findings include: Resident 12 was admitted to the facility in 11/2015 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), contractures of the right and left hand, right elbow, and lower extremities (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the body part) and a history of traumatic brain injury. Resident 12 was dependent on a power wheelchair for her/his mobility. Resident 12's care plan dated 11/17/2020 indicated the resident had an ADL self-care deficit related to quadriplegia and contractures in both upper and lower extremities. The resident was dependent on two staff for assistance with bed mobility, toilet use and transferring. The resident was totally dependent on one staff for eating, filling a water cup and drinking fluids. A facility Incident Report dated 12/8/23 indicated Resident 12 and Staff 3 (Administrator) had an altercation in the Staff 3's office. Both Staff 3 and Resident 12 accused each other of yelling. Staff 3 also said Resident 12 bumped him with her/his power chair and caused pain to his Achilles tendon. Staff 3 claimed he was assaulted. Resident 12 said Staff 3 tried to shut the office door on her/him and caused a small cut to her/his leg and she/he did not hit Staff 3 with the power chair. There were no witnesses identified who heard either yelling or saw any physical incident. Law Enforcement responded but did not arrest the resident. Staff 3 told the officer he wanted to pursue charges but the District Attorney's office refused to charge the resident with assault as no one saw any physical contact, there was no proof of any injury and there was no intention to cause injury. Staff 3 then requested they arrest the resident for harassment but the District Attorney's office declined. On 12/8/23 at 9:30 PM a Nursing Note indicated staff were told the resident required the assistance of two staff for all care giving, her/his power chair was to be removed from the room while an investigation was conducted, and a manual wheelchair was provided for the resident. Resident 12 did not have the physical ability to use a manual wheelchair due to quadriplegia. On 12/9/23 at 7:22 AM a Nursing Note indicated an unnamed CNA reported Resident 12 told her they took away her/his power chair and said she/he assaulted Staff 3. The resident said she/he hated the facility and just wanted to die. If she/he got Covid she/he would just refuse treatment and oxygen. On 12/9/23 at 9:25 AM a Nursing Note indicated Resident 12 was made aware all cares were to be provided by 2 staff. The resident stated she/he was told it was to monitor for aggression, but a CNA told her/him they were not worried because she/he was not aggressive and they were not scared. Resident 12 said he thought it was just some bullshit to try to get rid of her/him. Then the resident said, What am I going to do? Refuse and not get any care? The resident was calm and polite with staff. On 12/9/23 at 1:52 PM a Nursing Note indicated Resident 12 again stated if I were to get Covid or a kidney infection I would just let the infection take me. As of right now, I'm going to call and cancel my school, all rehab appointments and cancel all future surgeries since I can't use my wheelchair. The resident was informed there was a manual wheelchair for appointments and so she/he could get up and leave the room. The resident stated she/he could not use the chair because she/he could not push it. Staff would need to push her/him around and they did not have time to push her/him around because there was not enough staff and it would take away from other residents getting care. Resident 12 was again informed she/ he could use a manual chair for appointments and rehab but she/ he refused because the pickup service could not push the wheelchair for her/him either. Resident 12 said, they are going to kick me out of here anyway. On 12/19/23 at 4:39 PM a Social Services Note indicated the resident was informed there was a contract written by the corporate office for her/him to sign to regain use of the power chair. The resident was informed the contract needed to be signed before she/he would be able to use her/his power chair. Staff 3 (Administrator) informed staff the chair needed to be removed from the resident's room and she/he could not use the chair until the contract was signed. On 12/20/23 at 5:32 PM a Social Services Note indicated she informed the resident the power chair had been put away in a safe place. Staff 3 informed Social Service staff the resident called the police regarding the chair being stolen. Resident 12 said the chair was stolen, they had no right to take it from the room and she/he would not be signing a contract because she/he was already deemed safe to manage the power chair. On 12/27/23 at 3:03 PM the power chair was returned to the resident. On 1/8/24 at 3:45 PM Resident 12 said after the incident with Staff 3, they took away her/his power chair and told the resident they needed to, during their investigation, so the resident agreed. Resident 12 said Staff 3 told the nurses she/he was violent and they put a guard on her/him and they treated me like a criminal. Resident 12 said she/he had no history of hurting anyone for the [AGE] years she/he lived at the facility. Resident 12 said she/he did not hit Staff 3 with the chair. The facility took away the power chair on 12/8/23 and did not return it until 12/27/23. The resident said they took the guard (1:1 caregiver) off me for two weeks then put it back on. After Christmas, the resident was back on 1:1, they returned the power chair and took the guard duty off again. Resident 12 stated she/he felt like she/he was being singled out but could not find out what was going on because she/he was stuck in her/his room without the use of her/his chair. Resident 12 went on to say taking her/his power chair away messed with her/him hardcore. The resident stated she/he almost quit going to school a couple of times, she/he used to have 100 percent participation at school but it went down to about 20 percent because she/he was depressed as heck. Resident 12 said without her/his power chair she/he was not able to celebrate Christmas with her/his family and the facility did not offer any assistance to help her/him get to the family home. Staff 12 said the CNAs were taking care of her/him but she/he was worried management were going to force her/him to leave. If there was no issue with Staff 3, the resident wanted to stay at the facility so she/he could finish her/his schooling to be a Counselor. The timeline related to the involuntary seclusion of resident 12 was as follows: -The resident was a quadriplegic and the only means for having independence was the use of a power wheelchair. -The resident was accused of intentionally hitting Staff 3 with her/his power chair on 12/8/23. -The resident was informed the power chair would be removed from her/his room and use while the facility conducted an investigation on 12/8/23. -The facility administration provided the resident with a manual wheelchair on 12/8/23. However, the resident was not physically able to use a manual wheelchair due to quadriplegia. -Staff 3 was suspended starting the evening of 12/8/23, for the duration of the investigation. -Staff 3 returned to work on Monday, 12/11/23, indicating the end of the investigation. The power chair was not returned to Resident 12. -The facility had the resident take a new driver's test which she/he passed 12/12/23. The resident did not get her/his power chair back. -On 12/15/23 the facility told the resident to sign a contract before she/he could get the power chair back. The contract had a confession statement and indicated a determination of breach of the agreement would be at the sole discretion of the facility and the resident would then agree to an immediate voluntary discharge. The resident did not sign the contract. -On 12/19/23 Staff 3 asked the power chair company to turn the wheelchair power down to 1 mph (known as turtle mode) but was advised the resident was cognitively able to make the decision on appropriate speed and any decrease in speed by the company could be viewed as a restraint. -Resident 12 was not able to spend the Christmas holiday with her/his family because she/he did not have her/his power chair on 12/25/23. -The facility returned the resident's power chair on 12/27/23. On 1/22/24 at 1:50 PM Staff 16 (Regional Director) acknowledged the power chair was removed on Friday 12/8/23 and returned on 12/27/23. Staff 16 indicated Staff 3 should have handled the situation differently.

Based on observation, interview and record review it was determined the facility failed provide necesssary treatment and services to prevent pressure ulcers for 1 of 2 sampled residents (#1) reviewed for pressure ulcers. Resident 1 developing a Stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone) pressure ulcer. Findings include: Resident 1 was readmitted to the facility on [DATE] with diagnoses including right leg fracture. A 6/1/23 physician order indicated Resident 1 was to always wear a knee immobilizer to the non-weight bearing right lower extremity. On 6/2/23 Resident 1 was sent to the ER for pain control due to the leg fracture. The hospital History and Physical indicated the resident had a pressure ulcer on the lateral (outside) of the right ankle. On 7/8/23 a Wound and Skin Evaluation created by Staff 14 (LPN-Unit Manager) indicated Resident 1 had a new Stage 4 pressure ulcer to the right lateral malleolus (bony prominence on the side of the ankle). This was over one month after the pressure ulcer was identified in the ER. There was no documentation in the resident's record to indicate the physician was called, an investigation was completed or treatments were put in place. Observations from 7/10/23 through 7/14/23 on day and evening shifts revealed Resident 1 lying in bed with her/his immobilizer on and Resident 1's right leg was on a pillow with her/his right foot laying on the pressure ulcer. On 7/14/23 at 11:06 AM Staff 2 (DNS) stated Staff 14 (LPN-Unit Manager) and Staff 31 (LPN) found the wound but did not notify the physician or complete an investigation. Staff 2 stated staff should have called the physician to clarify if the brace could be removed for showers and skin inspections.

Based on observation, interview and record review it was determined facility staff failed to ensure professional standards were followed related to pressure ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. Resident 1 developed a Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone) pressure ulcer. Findings include: Resident 1 was admitted to the facility on [DATE] with diagnoses including a fractured leg. A 6/1/23 physician order indicated Resident 1 was to wear a knee immobilizer to the non-weight bearing right lower extremity at all times. On 6/2/23 Resident 1 was sent to the ER for pain control due to a leg fracture. The hospital History and Physical document indicated the resident had a pressure ulcer on the lateral (outside) of the right ankle. The hospital did not order treatment for the pressure ulcer. Resident 1 returned to the facility on [DATE]. There was no documentation in Resident 1's in clinical record related to the pressure ulcer identified at the hospital. On 7/8/23 a Wound and Skin Evaluation created by Staff 14 (LPN-Unit Manager) indicated Resident 1 had a new Stage 4 pressure ulcer to the right lateral malleolus (bony prominence on each side of the ankle). There was no documentation in the resident's clinical record to indicate the physician was called, an investigation was completed or treatments were put in place. Observations from 7/10/23 through 7/14/23 on day and evening shifts revealed Resident 1 lying in bed. Resident 1's right leg was on a pillow, the immobilizer was in place and her/his right foot was turned out with pressure on the wound. On 7/14/23 at 10:15 AM Staff 34 (LPN) stated if she saw an order which indicated knee immobilizer at all times she would clarify with the physician whether the immobilizer could be removed for skin checks and showers. On 7/14/23 at 11:06 AM Staff 2 (DNS) stated Staff 14 (LPN-Unit Manager) and Staff 31 (LPN) found the wound but did not notify the physician or complete an investigation. Staff 2 stated staff should have called the physician to clarify if the brace could be removed for showers and skin inspections. Staff 2 stated if staff monitored the wound after it was identified during the resident's 6/2/23 hospital visit the wound may not have worsened. Refer to F 686

Based on interview and record review it was determined the facility failed to provide care and services for wound care for 2 of 3 sampled residents (#s 2 and 16) reviewed for wound care and 1 of 1 sampled resident (#10) reviewed for bowel care. As a result, Resident 16 developed a wound infection which required hospitalization . Findings include: The facility's wound care policy and procedure dated 10/2019, indicated upon admission staff nurses complete the nursing admission evaluation including a careful evaluation of the skin with thorough and descriptive documentation of any alteration in skin integrity, provide detailed documentation in the progress notes, obtain and enter a treatment order for any identified skin issues and enter into the TAR monitoring each shift for condition and presence of a dressing (if used), daily monitoring for signs of infection or drainage, dressing changes as ordered and initiate care plan for altered skin integrity and include any treatments. 1. Resident 16 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following spinal surgery and muscle weakness. The facility's initial nursing admission form dated 12/9/22 and completed by Staff 4 (LPN) provided documentation for the resident's surgical wound as followed: lumbar incision. Dressing in place. No measurements or observations of the surgical incision were documented in the resident's clinical record upon her/his admission to the facility. Resident 16's care plan, initiated 12/9/22, did not have any care planned interventions for the surgical wound. Physician orders revealed no wound care orders for the resident until a follow up surgeon's appointment was completed on 12/19/22. The 12/2022 TAR did not indicate any assessments, care or treatments were completed for the resident's surgical wound for the duration of her/his stay at the facility. A nursing progress note dated 12/21/22 at 10:53 AM revealed Resident 16 was observed to be pale, confused and unable to focus her/his eyes after being transferred to bed from a chair. The provider was notified. A nursing progress note dated 12/22/22 at 1:24 AM revealed Resident 16's nausea was subsiding and she/he had no further episodes of diarrhea. A nursing progress note dated 12/22/22 at 10:44 AM revealed Resident 16 was assessed by Staff 7 (Nurse Practicioner) and the surgical wound was examined. The wound was found to be open with purulent drainage and the resident was sent to the emergency department. Hospital records dated 12/22/22 at 11:31 AM revealed Resident 16 was admitted to the hospital in septic shock (widespread infection). The surgical wound was found to contain fecal matter and was attributed to the resident's diarrhea at the facility the previous evening. Resident 16 was not interviewed due to discharge from the facility. On 4/6/23 at 9:47 AM, Staff 4 confirmed on the morning of 12/22/22, Resident 16's wound was observed by her and Staff 7, the wound appeared infected and the decision was made to send the resident to the hospital. On 4/10/23 at 10:26 AM, Staff 3 (Unit Manager) confirmed it was an expectation that residents have comprehensive skin and wound assessments upon admission to the facility and there was no documentation Resident 16 received daily wound care during her/his stay at the facility. On 4/12/23 at 2:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were advised of the findings of this investigation and provided no additional information. 22762 2. Resident 2 was admitted to the facility in 2021 with diagnoses including osteomyelitis (bone infection) of the right ankle and foot and diabetes. Resident 2's 7/29/21 hospital discharge orders indicated she/he had a diabetic ulcer of the right midfoot and surgery for amputation of her/his right fourth and fifth toes. The discharge document did not include orders for her/his right foot wound care. A 7/29/21 Skin and Wound Evaluation revealed Resident 2 had a surgical wound with 16 sutures on the right foot. Wound measurements were listed as: 0 cm area, 0 cm length and 0 cm width. There was no evidence of infection and light bloody drainage was noted. The dressing to the wound was described as dry. The 7/2021 TAR included instructions dated 7/30/21, to follow if the right foot dressing became dislodged: Okay to clean with wound cleaner and rinse, pat dry and apply Vaseline gauze dressing then wrap with gauze as needed for 14 days until follow up appointment with doctor. Resident 2's medical record did not include a signed physician's order for the 7/30/21 right foot wound care instructions on the 7/2021 TAR. The resident's record lacked documented evidence of routine monitoring of the right foot wound, including ensuring the dressing was dry and intact, from 7/31/21 through 8/12/21. An 8/24/21 Skin and Wound Evaluation, 26 days after the first evaluation, revealed the resident's surgical wound measurements were listed as 2.7 cm area, 5.2 cm length and 0.8 cm width. There was no evidence of drainage or infection documented. On 4/12/23 at 1:30 PM and 1:41 PM Staff 2 (DNS) acknowledged the initial wound care for Resident 2's right foot were likely discussed during report and passed on during admission and the initial evaluation process. Staff 2 further acknowledged there was a lack of monitoring and evaluation of the right foot wound from 7/29/21 through 8/24/21 and was not best practice. 3. Resident 10 was admitted to the facility in 9/2022 with diagnoses including Parkinson's Disease (brain disorder affecting balance and coordination), traumatic brain injury and generalized anxiety disorder. The facility's Bowel Protocol included the following information: After day three (with) no bowel movement: Step 1 - Give milk of magnesia (saline laxative) 30 ml PO or give 10 mg bisacodyl (stimulant laxative) PO if no bowel movement in 12 hours. Step 2 - Give bisacodyl suppository if no bowel movement in 12 hours (24 hours from Step 1). Step 3 - Evaluate (bowel assessment) and report your evaluation to the provider. Resident 10's bowel monitor revealed the following: From the morning of 9/30/22 through the evening of 10/7/22 (eight days) no BMs (bowel movements) were documented for the resident. A 10/3/22 progress note indicated the resident had no documented BM for 3 days. Has an order for scheduled Miralax (osmotic laxative - draws water into the colon). The 10/2022 MAR revealed Resident 10 received Miralax daily every morning beginning on 10/1/22. There was no documented evidence PRN bowel care medications were administered per the facility's Bowel Protocol after it was identified on 10/3/22 Resident 10 had no BMs for three days. A 10/7/22 progress note indicated no documented BM for 3 days. The progress note further indicated Resident 10's last BM was on 9/29/22 and her/his name was placed on today's laxative list. According to the 10/2022 MAR no PRN bowel care medications were administered to Resident 10 on 10/7/22. On 10/8/22 the bowel monitor revealed Resident 2 had two medium BMs. A 10/9/22 at 7:23 AM progress note indicated no documented BM for 3 days. Constipation continues. A 10/9/22 at 5:47 PM progress note indicated Resident 10 called 911 due to abdominal pain and requested to be taken to the hospital. A 10/10/22 at 7:00 AM progress note revealed Resident 10 reported while at the Emergency Department, she/he had an extra large BM with no other issues. A progress note at 2:30 PM revealed the resident returned to the facility. Resident 10 reported on 10/10/22 she/he called for staff assistance due to abdominal cramping and when there was no response she/he called 911. Resident 10 was sent to the Emergency Department where she/he had explosive diarrhea and then returned to the facility. The resident's 10/2022 MAR indicated no PRN bowel care medications were administered until 10/14/22 when Resident 10 received a dose of milk of magnesia. The facility failed to ensure the Bowel Protocol was followed for Resident 10 when she/he experienced constipation. On 4/5/22 at 3:00 PM Staff 12 (LPN) stated she did not recall Resident 10 having problems with her/his bowels. On 4/12/23 at 11:47 AM Staff 2 (DNS) reviewed the facility Bowel Protocol with this surveyor and acknowledged it was not followed for Resident 10.

Based on interview and record review it was determined the facility failed to ensure residents maintained weight and hydration within acceptable parameters for 2 of 3 sampled resident (#s 2 and 23) reviewed for nutrition and dehydration. Resident 2 experienced severe weight loss and dehydration which resulted in the resident requiring intensive care hospitalization . Findings include: The facility policy and procedures for Weight Monitoring and Documentation revised 6/2017 indicated it was the policy of the facility to monitor nutrition parameters including weights. Procedures included admission weights would be taken within 24 hours of admission and weekly weights would be documented for a minimum of four weeks following admission. 1. Resident 2 was readmitted to the facility on ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The facility weights for Resident 2 from 2/5/20 to 2/27/20 included the following information: 2/5/20 weight 161 pounds 2/16/20 weight 142.2 pounds 2/21/20 weight 136.2 pounds 2/27/20 weight 129 pounds The Vitals Report revealed Resident 2's initial weight was 161 pounds and 22 days later the resident's weight was 129 pounds, which constitutes a severe weight loss. On 2/15/20 a Nutrition Screen indicated Resident 2 had dysphagia and currently received dysphagia (difficulty in swallowing) advanced textured food and nectar thick liquids. Oral intake from 2/8/20 through 2/15/20 ranged from 51-100%. Resident 2's weight on 2/5/20 was 161 pounds which was 101% of her/his ideal body weight of 160 pounds. A care plan dated 12/5/19 and revised 2/27/20 indicated Resident 2 was at nutritional risk related to dysphagia evidenced by a need for texture altered food and thickened liquids. Resident 2 would maintain adequate nutritional status by maintaining weight with no sign or symptoms of malnutrition. Resident 2 required extensive assistance with eating. The care plan did not include interventions to monitor Resident 2's weight loss or gain. On 2/27/20 a History Progress note from the facility's NP (Nurse Practitioner) indicated nursing staff and therapy reported Resident 2 had increased trouble swallowing, was more lethargic and leaning to the left, and may have aspirated on liquids. The NP requested an EKG which showed a fast heart rate, and the NP indicated a probability Resident 2 was experiencing another stroke or heart attack. Resident 2 was sent to the ER. A 2/27/20 ER physician note revealed Resident 2 had altered mental status, increased weakness, and lack of engagement for the past five to seven days. Resident 2 had continued weight loss of approximately 30 pounds in less than a month. Notes indicated seven days ago Resident 2 was at her/his baseline and had decreased cognition since. Resident 2 was put on NG (naso gastric) tube feeding related to severe malnutrition. Resident 2 was admitted to the ICU. On 9/1/21 at 12:53 PM Witness 4 (Complainant) stated Resident 2 was in the facility for three weeks. Witness 4 visited Resident 2 on 2/27/20 and stated Resident 2 looked like she/he had another stroke. Witness 4 stated there was a care conference meeting and the facility stated they were not aware the resident had a significant weight loss. Witness 4 stated when visiting Resident 2 staff left meal trays in front of Resident 2 even though she/he was not able to feed herself/himself. Witness 4 stated Resident 2 was sent to the ER and admitted to the ICU for severe malnutrition and aspiration pneumonia. On 9/16/21 at 12:50 PM Staff 21 (Social Service) stated Witness 4 told her how concerned she/he was that the CNAs did not attend to the resident timely. Staff 21 stated Witness 4 was not happy with the care Resident 2 was receiving. Staff 21 stated the look on Witness 4's face was heartbreaking when the facility had a care conference and Resident 2 was brought in and looked horrible. Staff 21 stated Resident 2 lost a lot of weight since the last time Witness 4 saw her/him. Witness 4 thought Resident 2 had another stroke. Staff 21 stated nobody from the facility called to let Witness 4 know about the weight loss. Staff 21 stated the facility was so short staffed they could not take fluids to the residents. On 9/16/21 at 1:34 PM Staff 31 (LPN) stated she was not aware Resident 2 had a significant weight loss. Staff 31 stated another manager entered the the Nutrition at Risk assessment on 3/10/20 which was for 2/2020 but she was late completing the assessment. Staff 31 stated staff received a red flag warning in the electronic medical record for a significant weight loss. Staff 31 stated she did not remember seeing a red flag warning in the electronic medical records related to the significant weight loss. Staff 31 stated her expectation of staff for residents with severe weight loss or any weight loss was to notify nurses, the dietician, and management. Staff 31 stated, it was a system failure, and someone should have noticed. No documentation was found in progress notes related to severe weight loss. No further documentation was provided by the facility regarding Resident 2's severe weight loss. b. Resident 2 admitted to the facility in 2/2020 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A 2/19/20 Nutritional CAA indicated Resident 2 adequate fluid intake and was working with a Speech Therapist for safe oral intake. A care plan dated 12/5/19 and revised on 2/27/20 indicated Resident 2 received thicken liquids, with a goal she/he would show no signs or symptoms of dehydration and staff were to offer fluids at the bedside and every meal to maintain hydration. Resident 2 needed one on one staff assistance to eat and drink. A 2/5/20 Nutrition Screen indicated Resident 2 had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 currently received nectar thick liquids. Intake in the past week for fluid was [PHONE NUMBER] cc from meals daily. Resident 2 required a minimum of 1633 cc of fluid daily. According to the Mayo Clinic (https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/water/art- 256), the average adult required 2700-3667 cc of fluid per day to maintain adequate hydration. A Fluid Monitor document dated 2/5/20 through 2/26/20 revealed: -2/5/20 100 cc for all shifts -2/6/20 1660 cc for all shifts. -2/7/20 1160 cc for all shifts. -2/8/20 1120 cc for all shifts. -2/9/20 800 cc for all shifts. -2/10/20 720 cc for all shifts. -2/11/20 980 cc for all shifts. -2/12/20 1560 cc for all shifts. -2/13/20 1360 cc for all shifts. -2/14/20 1540 cc for all shifts. -2/15/20 1260 cc for all shifts. -3/16/20 800 cc for all shifts. -2/17/20 720 cc for all shifts. -2/18/20 1320 cc for all shifts. -2/19/20 990 cc for all shifts. -2/20/20 960 cc for all shifts. -2/21/20 1640 cc for all shifts. -2/22/20 1160 cc for all shifts. -2/23/20 720 cc for all shifts. -2/24/20 280 cc for all shifts. -2/25/20 1080 cc for all shifts. -2/26/20 500 cc for all shifts. A progress noted dated 2/6/20 through 2/25/20 revealed documentation Resident 2 was encouraged to drink more fluids. No documentation was found the NP (Nurse Practitioner) or physician was notified regarding Resident 2's low intake and refusals of fluids. No further documentation was provided by the facility regarding Resident 2's low intake of fluids. A 2/27/20 NP (Nurse Practitioner) note indicated Resident 2 was lethargic, [CONDITION(S)] (fast heart rate), an EKG was performed, and the NP strongly suspected Resident 2 was having another stroke or a heart attack. The NP stated to send Resident 2 to the hospital due to likely aspiration pneumonia and probable dehydration. IV fluids were ordered but staff were unable to administer IV fluids due to Resident 2's dehydration. Nursing reported the resident may be dehydrated as her/his urine was darker, and she/he was unable to drink thin liquids. No documentation was found the NP was notified the resident was not drinking and had dark urine. No further documentation was provided by the facility. A 2/27/20 ER physician note revealed Resident 2 was seen in the ER due to altered mental status and fever. Resident 2 had significant [CONDITION(S)] (high sodium levels) secondary to dehydration. Resident 2 did show improvement in mentation with hydration. Resident 2 was admitted to the ICU. On 9/16/21 at 11:32 AM Staff 35 (LPN) stated Resident 2 was not taking in fluids as much as she/he should and was not urinating much. Staff 35 acknowledged the physician was not notified. On 9/17/21 at 10:05 AM Staff 73 (CNA) stated the resident was not drinking much in the last week or urinating. Staff 73 stated the nurse was not notified. On 9/16/21 at 1:34 PM Staff 31 (LPN) stated she was not aware Resident 2 was not drinking fluids and had dark urine. Staff 31 stated if staff wrote in progress notes Resident 2 was not drinking and had dark urine the physician should have been notified. Staff 31 stated her expectation was for staff to notify nursing right away if a resident was not drinking or urinating. Staff 31 reviewed fluid documentation for the resident and acknowledged Resident 2 was not consuming adequate amounts of fluids. 3. Resident 23 was admitted to the facility in 12/2020 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A weight summary report indicated Resident 23's weights were as follows: -12/1/20 147 lbs. -1/30/21 134.5 lbs. (an eight percent weight loss from 12/1/20) -2/2/21 129.4 lbs. (a 12 percent weight loss from 12/1/21) A 2/2021 Documentation Survey Report revealed Resident 23 refused to be weighed 10 instances in the month of 2/2021. A 3/3/21 Nutritional Screen revealed Resident 23 had an unintended weight loss over the past seven days of four to five pounds or more. Resident 23's intake at meals was less than 50 percent and she/he often refused meals. Resident 23 had a weight loss noted of 10.98 percent in last two months which was clinically severe, Resident 23 would be started on nutritonal supplement three times a day between meals. A recomendation was made to discuss Resident 23 at NAR (Nutrition at Risk) meetings per policy and obtaining weekly weights. Resident 23 was in the category of malnourished. No documentation was found in clinical records Resident 23 was discussed at NAR meetings. A 3/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9:00 PM administration was documented NA from 3/15/21 through 3/31/21. No documentation of was included on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] No records were found in clinical records why the third administration of Boost was not administered to Resident 23. A 3/14/21 revised care plan indicated Resident 23 was at risk for nutritional problem with goals including no significant weight loss of five percent in 30 days or 10 percent in 180 days and maintaining a BMI between 25 and 27 with no signs or symptoms of malnutrition. Interventions included administer medications as ordered, proved oral nutrition supplement, a registered dietitian to continue to monitor resident. A 4/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Nutritional supplement three times a day between meals with a start date of 3/14/21. The 9:00 PM administration was documented NA from 4/1/21 through 4/30/21. No documentation was found what NA indicated. -Nutritonal supplement with high protien give one can by mouth three times a day for supplement with a start date of 4/3/21. The 9:00 PM administration was documented as medication scheduled outside of service time 22 instances out of 28 opportunities. A weight summary report indicated Resident 23's weight was obtained on 3/12/21 with a weight of 133. No documentation was found in clinical records Resident 23's weight was obtained from 3/12/21 through 5/8/21. On 5/8/21 Resident 23's weight was 123. On 9/15/21 at 10:24 AM Staff 25 (CNA) stated Resident 23 always needed assistance with eating. Some staff would put the food tray in front of her/him and not assist Resident 23. On 9/30/21 at 10:43 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 64 (Regional Nurse Consultant) stated when a resident had a 12 percent weight loss it was expected to complete weekly weights unless otherwise specified by the physician. Staff confirmed if recommended to complete weekly weights and NAR it should be completed. Resident 23 was care planned to have registered dietitian monitor the resident which would be expected to be completed monthly. Staff confirmed staff should obtain clarification for nutritional supplement instead of documenting outside of service time on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review it was determined the facility failed to prevent and correct abuse for 4 of 4 residents (#s 1, 2, 3 and 4) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Policy and Guidelines for Implementation: Freedom Form Abuse, Neglect and Exploitation: dated 11/2017 included the following elements: -For allegations of abuse, the facility will: Immediately implements safeguards to prevent further potential abuse. -Resident to resident abuse: Cognitive impairment or mental disorder does not preclude a resident from being abusive. -In determining abuse, willful (deliberate) action (not inadvertent or accidental) will be considered regardless of whether the individual intended to inflict injury or harm. -Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk of abusive, aggressive interactions (e.g. physical, sexual or verbal aggression; taking, touching or wandering into another's room/space. 1. Resident 1 admitted to the facility in 11/2019 with [DIAGNOSES REDACTED]. The Quarterly MDS dated ,[DATE] indicated Resident 1 had a BIMS score of 15 which indicated Resident 1 was cognitively intact. The care plan dated 11/1/19 indicated Resident 1 had limited physical mobility. Required monitoring and assistance with meals and eats in room or in F wing dinning. Resident 1 appears concerned during meals. On 2/4/20 at approximately 8:15: AM Resident 1 reported an allegation of resident to resident abuse to Staff 13 (CNA). A witness statement by Staff 13 (CNA) dated 2/4/20 at 8:15 AM indicated Resident 1 wheeled her/his self out of the F wing dining room and stated Resident 2 walked into the F wing dining room stood next to her/him and proceeded to touch her/him inappropriately. A witness statement by Staff 11 (LPN/Unit Manager) dated 2/4/20 at 8:20 AM indicated she asked Resident 1 if she/he felt uncomfortable around Resident 2 and she/he replied I have always felt uncomfortable around her/him because she/he looks at me strange and she/he is always lost. I just want her/him to stay away from me. A FRI received by the State Survey Agency on 2/4/20 at 9:26 AM indicated an un-witnessed allegation of resident to resident sexual abuse. The report indicated Resident 2 had been involved in a similar allegation. On 3/12/20 at 9:30 AM Resident 1 stated on 2/4/20 she/he was alone in the F wing dining room when Resident 2 walked up to her/him and proceeded to touch her/his chest, neck and face. Resident 1 told Resident 2 to stop three times before Resident 2 walked away. Resident 1 stated she/he was able to self-propel her/himself out of the F wing dining room to report the incident to staff. Resident 1 confirmed she/he did not give Resident 2 consent to touch her/him. On 3/13/20 at 4:45 PM Staff 2 (DNS) acknowledged Resident 2 had a history of [REDACTED]. Staff 2 further stated she did not consider Resident 2's actions willful due to her/his cognitive impairment and stated the event was unavoidable. On 3/13/20 at 4:46 PM Staff 10 (RN Consultant) acknowledged the facility failed to prevent resident to resident abuse. 2. Resident 2 was admitted to the facility in 1/2008 with [DIAGNOSES REDACTED]. The Quarterly MDS dated ,[DATE] indicated Resident 2 had a BIMS score of 7 which indicated mild cognitive impairment. The Annual MDS dated [DATE] indicated Resident 2 had long standing mental health issues, [MEDICAL CONDITION] and behavioral symptoms directed towards others including abusing others sexually. Resident 2's care plan last revised on 10/23/17 indicated inappropriate behavior towards others including grabbing and self-exposure. Resident 2's care plan last revised on 4/12/19 indicated: socially inappropriate behavior as evident by attempting to grab female's breast and history of exposing self in public areas. On 11/24/19 and 11/26/19 Resident 2 sexually exposed her/himself in front of females. Resident 2's care plan last revised on 4/21/19 indicated redirect from female residents in the F wing dining room. No meals in the F wing dining room. A FRI received by the State Survey Agency on 2/4/20 at 9:26 AM indicated an un-witnessed allegation of resident to resident sexual abuse. The report indicated Resident 2 had been involved in a similar allegation. On 3/12/20 at 3:00 PM Staff 4 (Agency CNA) stated she was aware of Residents 2's inappropriate behaviors and stated she/he only targets one gender. Staff 4 further stated she/he witnessed Resident 2 expose her/himself in front of other residents. Resident 2 requires redirection from other residents and requires supervision in common areas. On 3/12/20 at 3:05 PM Staff 5 (Agency CNA) stated she was aware of Resident 2 inappropriate behavior and she/he only seeks one gender. Resident 2 is care planned for one on one caregivers, but this does not always happen. On 3/12/20 at 3:10 PM Staff 3 (RN/Unit Manager) stated Resident 2 has had inappropriate behavior for the past couple of years and is care planned for one on one male caregivers. On 3/12/20 at 3:30 PM Staff 6 (CMA) indicated she was aware of Resident 2's inappropriate behavior towards other residents and she/he seeks only one gender. Staff 6 further stated Resident 2 had a history of [REDACTED]. On 3/13/20 at 1:15 PM Staff 13 (CMA) stated staff are very aware of Resident 2's behaviors. Resident 2 is usually very quiet but has a temper and is easily over stimulated by loud noise and can become angry towards other residents and staff. Staff 13 stated Resident 2's inappropriate behavior has been occurring over the past few years. Resident 2 is care planned to have male caregivers, but this does not always happen. Review of progress notes dated from 11/24/19 through 2/19/20 indicated Resident 2 had multiple inappropriate sexual behaviors with other residents. On 3/13/20 at 4:45 PM Staff 2 (DNS) acknowledged Resident 2's history of inappropriate behavior. Staff 2 denied the allegation of abuse and stated, Resident 2's actions were not willful, and the event was unavoidable. On 3/13/20 at 4:46 PM Staff 10 (RN Consultant) acknowledged the facility failed to prevent resident to resident abuse. 3. Resident 3 was admitted to the facility in 10/2019 with [DIAGNOSES REDACTED]. Resident 3's care plan date initiated 2/19/19 indicated resident prefers to sleep with over head light on. Resident 3's care plan last revised on 10/29/19 indicated limited physical ability and required extensive two-person assists with positioning in bed. A witness statement by Staff 8 (CNA) dated 2/24/20 indicated she walked into Resident 3's room to answer her/his call light and noticed all the lights were turned off even though the resident preferred to have overhead light on. Staff 8 stated Resident 3 reported her/his roommate, Resident 4 had walked over to her/his bed and hit her/him a few times, turned off her/his overhead light and returned to bed. A witness statement by Staff 11 (LPN/Unit Manager) dated 2/24/20 indicated Resident 3 reported Resident 4 walked over to her/his bed and hit her/him multiple times turned off her/his overhead light and walked away. Staff 11 asked Resident 3 if it hurt and Resident 3's eyes opened wide and she/he said, yes it hurt. Staff 11 asked Resident 3 if she/he was upset and she/he stated yes, I couldn't move. A FRI received by the State Survey Agency on 2/24/20 at 6:39 PM indicated an un-witnessed allegation of resident to resident physical abuse. The facility ruled out abuse indicating this was an isolated incident stating Resident 4 had no prior history of violence towards roommates and her/his actions were not willful or predictable. The report indicated Resident 4 had been involved in a similar allegation. Review of the facility Incident Investigation Report dated 2/24/20 indicated around 12:30 AM Resident 3 turned her/his call light on. Resident 3 was upset and told staff that someone just hit her/him a couple of times and turned her/his overhead light off. Resident 3's roommate, Resident 4 was awake sitting on the edge of her/his bed. Staff asked Resident 4 if she/he hit Resident 3 but she/he denied the allegation. On 3/12/20 at 2:30 PM Resident 3 was not able to recall specific details including times and dates of the allegation due to cogitative impairment. Resident 3 was able to recall being hit by that person. On 3/13/20 at 4:50 PM Staff 2 (DNS) confirmed Resident 4 had a history of [REDACTED]. Staff 2 stated Resident 4's actions were not willful or avoidable. Staff 2 further stated if someone was to walk up to me and punch me in the face but did not leave a mark or cause an injury, I would not consider that abuse. On 3/13/20 at 4:51 PM Staff 10 (RN Consultant) acknowledged the facility failed to prevent and correct resident to resident physical abuse. 4. Resident 4 was admitted to the facility in 5/2008 with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] indicated Resident 4 had verbal behaviors directed towards other residents and staff. Resident 4's care plan last revised on 1/19/19 indicated resident initiated physical aggression in the hallway with roommate. Resident 4's care plan last revised on 4/2/19 indicated history of physical and verbal aggression towards other residents and staff. Resident 4's care plan last revised on 4/2/19 indicated limit napping during the day to avoid disturbing residents at night. A FRI received by the State Survey Agency on 2/24/20 at 6:39 PM indicated an un-witnessed allegation of resident to resident physical abuse. The facility ruled out abuse indicating this was an isolated incident stating Resident 4 had no prior history of violence towards roommates and her/his actions were not willful or predictable. The report indicated Resident 4 had been involved in a similar allegation. Review of the facility Incident Investigation Report dated 2/24/20 indicated Resident 4 had displayed impulsive behavior and has a history of verbal and physical behaviors with residents. On 1/9/19 Resident 4 had physical contact with another resident. Resident 4 denied the 2/24/20 allegation with her/his roommate. When asked if her/his roommate sleeps with the light on and does this make it difficult to sleep Resident 4 appeared annoyed and stated yes. The facility indicated Resident 4 had a new bruise on her/his right posterior middle finger and anterior fingers. Resident 4 was asked when she/he injured her/his hand she/he replied, I don't recall. The facility indicated Resident 4's actions were impulsive, and her/his actions were not willful. On 3/13/20 at 4:50 PM Staff 2 (DNS) confirmed Resident 4 had a history of [REDACTED]. Staff 2 stated Resident 4's action were not willful or avoidable. Staff 2 further stated if someone was to walk up to me and punch me in the face but did not leave a mark or cause an injury, I would not consider that abuse. On 3/13/20 at 4:51 PM Staff 10 (RN Consultant) acknowledged the facility failed to prevent and correct resident to resident abuse.

Based on interview and record review it was determined the facility failed to report allegations of abuse within a two hour period for 2 of 4 residents (#s 3 and 4) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Policy and Guidelines for Implementation: Freedom Form Abuse, Neglect and Exploitation: dated 11/2017 included the following elements: For allegations of abuse, the facility will: Immediately report the allegation to appropriate authorities. 1. Resident 3 was admitted to the facility in 10/2019 with [DIAGNOSES REDACTED]. On 2/24/20 at approximately 12:30 AM Resident 3 reported an allegation of abuse to Staff 8 (CNA). On 2/24/20 at approximately 12:45 AM Staff 8 reported an allegation of abuse to Staff 11 (LPN). On 2/24/20 at approximately 8:00 AM Staff 11 informed Staff 2 (DNS) of the allegation of abuse. On 2/24/20 at 6:39 PM Staff 2 submitted a report to the State Survey Agency, a period of over 18 hours from the time facility staff were made aware of the allegation of abuse. On 3/13/20 at 4:50 PM Staff 2 (DNS) stated she did not feel Resident 4's actions constituted abuse and did not meet the 2-hour reporting requirement. Staff 2 further stated if someone was to walk up to me and punch me in the face but did not leave a mark or cause an injury, I would not consider that abuse. On 3/13/20 at 4:50 PM Staff 10 (RN Consultant) confirmed the facility failed to report the allegation of abuse within the required mandatory reporting time frame of two hours. 2. Resident 4 was admitted to the facility in 5/2008 with [DIAGNOSES REDACTED]. On 2/24/20 at approximately 12:45 AM Staff 8 (CNA) reported an allegation of abuse to Staff 11 (LPN). On 2/24/20 at approximately 8:00 AM Staff 11 informed Staff 2 (DNS) of the allegation of abuse. On 2/24/20 at 6:39 PM Staff 2 submitted a report to the State Survey Agency, a period of over 18 hours from the time facility staff were made aware of the allegation of abuse. On 3/13/20 at 4:50 PM Staff 2 stated she did not feel Resident 4's actions constituted abuse and did not meet the 2-hour reporting requirement. Staff 2 further stated if someone was to walk up to me and punch me in the face but did not leave a mark or cause an injury, I would not consider that abuse. On 3/13/20 at 4:50 PM Staff 10 (RN Consultant) confirmed the facility failed to report the allegation of abuse within the required mandatory reporting time frame of two hours.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 2 of 4 residents (#s 1 and 3) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Policy and Guidelines for Implementation: Freedom Form Abuse, Neglect and Exploitation: dated 11/2017 included the following elements: - For allegations of abuse, the facility will: Immediately implements safeguards to prevent further potential abuse. -Resident to resident abuse: Cognitive impairment or mental disorder does not preclude a resident from being abusive. -In determining abuse, willful (deliberate) action (not inadvertent or accidental) will be considered regardless of whether the individual intended to inflict injury or harm. -Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk of abusive, aggressive interactions (e.g. physical, sexual or verbal aggression; taking, touching or wandering into another's room/space. 1. Resident 1 admitted to the facility in 11/2019 with [DIAGNOSES REDACTED]. The Quarterly MDS dated ,[DATE] indicated Resident 1 had a BIMS score of 15 which indicated Resident 1 was cognitively intact. The care plan dated 11/1/19 indicated Resident 1 had limited physical mobility. Required monitoring and assistance with meals and eats in her/his room or in F wing dinning. Resident 1 appears concerned during meals. Review of the facility Incident Investigation Report dated 2/4/20 indicated Resident 1 was unsupervised in the F wing dining room when Resident 2 walked up to her/him and touched her/his chest. Resident 1 told Resident 2 to stop. Resident 2 stopped and then touched Resident 1's neck. Resident 1 told Resident 2 to stop. Resident 2 stopped and then touched Resident 1's face; at this time a CNA entered the dining room and re-directed Resident 2 to her/his room. A witness statement by Resident 1 dated 2/4/20 indicated at approximately at 8:15 AM Resident 2 walked into the F wing dining room and stood on her/his left side and stared at her/him. Resident 2 then touched my chest through my shirt, and I told her/him no. She/he then took her/his hand off my chest and then she/he touched my neck and face. I told her/him no again and she/he stopped. I wheeled myself out of the F wing dining room to tell staff. A witness statement by Staff 13 (CNA) dated 2/4/20 at 8:15 AM indicated Resident 1 wheeled her/himself out of the F wing dining room and stated Resident 2 walked into the F wing dining room stood next to her/him and proceeded to touch her/him inappropriately. A witness statement by Staff 11 (LPN/Unit Manager) dated 2/4/20 at 8:20 AM indicated she asked Resident 1 if she/he felt uncomfortable around Resident 2 and Resident 1 replied I have always felt uncomfortable around her/him because she/he looks at me strange and she/he is always lost. I just want her/him to stay away from me. A FRI received by the State Survey Agency on 2/4/20 at 9:26 AM indicated an un-witnessed allegation of resident to resident sexual abuse. The report indicated Resident 2 had been involved in a similar allegation. On 3/12/20 at 9:30 AM Resident 1 stated on 2/4/20 she/he was alone in the F wing dining room when Resident 2 walked up to her/him and proceeded to touch her/his chest, neck and face. Resident 1 told Resident 2 to stop three times before Resident 2 walked away. Resident 1 stated she/he was able to self-propel her/himself out of the F wing dining room to report the incident to staff. Resident 1 confirmed she/he did not give Resident 2 consent to touch her/him. On 3/12/20 at 3:00 PM Staff 4 (Agency CNA) stated she was aware of Residents 2's inappropriate behaviors and stated she/he only targets one gender. Staff 4 further stated she witnessed Residents 2 expose her/himself in front of other residents. On 3/12/20 at 3:05 PM Staff 5 (Agency CNA) stated she was aware of Resident 2 having inappropriate behavior and she/he seeks out only one gender. On 3/12/20 at 3:30 PM Staff 6 (CMA) indicated she was aware of Resident 2's inappropriate behavior towards one gender. Staff 6 further stated Resident 2 had a history of [REDACTED]. On 3/12/20 at 3:10 PM Staff 3 (RN/Unit Manager) stated Resident 2 has had inappropriate behavior for the past couple of years. Staff 3 further stated Resident 2 required supervision and was care planned to be redirected from other residents in the F wing dining room. On 3/12/20 at 3:15 PM Staff 7 (LPN/Unit Manager) stated Resident 2 had a history of [REDACTED]. Staff 7 further stated Resident 2 requires redirection and supervision around other residents. On 3/13/20 at 1:15 PM Staff 13 (CNA) stated Resident 2's inappropriate behavior has been occurring over the past few years. Resident 2 is care planned to have a male caregiver, but this does not always happen. On 3/13/20 at 4:30 PM Staff 2 (DNS) acknowledged Resident 2 had a history of [REDACTED]. Staff 2 further stated she did not consider Resident 2's actions willful due to her/his cognitive impairment and stated the event was unavoidable. On 3/13/20 at 4:31 PM Staff 10 (RN Consultant) confirmed the facility failed to ensure residents were free from abuse. 2. Resident 3 admitted to the facility in 10/2019 with [DIAGNOSES REDACTED]. The Quarterly MDS dated ,[DATE] indicated Resident 3 had a BIMS score range of 0-7 indicated severe cognitively impairment. Resident 3's care plan last revised on 10/29/19 indicated limited physical ability and required extensive two-person assists with positioning in bed. Review of the facility Incident Investigation Report dated 2/24/20 indicated around 12:30 AM Resident 3 turned her/his call light on. Resident 3 was upset and told staff that someone just hit her/him a couple of times and turned off her/his overhead light. Resident 3's roommate, Resident 4 was awake, and staff asked her/him if she/he hit Resident 3 but she/he denied the allegation. Resident 3 did not know who hit her/him. On 2/24/20 at approximately 12:30 AM Staff 8 (CNA) reported an allegation of resident to resident physical abuse. A FRI received by the State Survey Agency on 2/24/20 at 6:39 PM indicated an un-witnessed allegation of resident to resident physical abuse. The facility ruled out abuse indicating this was an isolated incident stating Resident 4 had no prior history of violence towards roommates and her/his actions were not willful or predictable. The report indicated Resident 4 had been involved in a similar allegation. A witness statement by Staff 8 (CNA) dated 2/24/20 indicated when she walked into Resident 3's room to answer her/his call light all the lights were turned off. Staff 8 stated Resident 3 preferred to have her/his overhead light on at night. Staff 8 stated Resident 3 reported that Resident 4 had just walked over and hit her/him a few times, turned off her/his overhead light and returned to bed. Staff 8 stated Resident 4 was sitting on the edge of her/his bed and she asked Resident 4 if she/he hit Resident 3 but she/he denied the allegation. A witness statement by Staff 11 (LPN/Unit Manager) dated 2/24/20 indicated Resident 3 reported Resident 4 walked over to her/his bed and hit her/him multiple times turned her/his overhead light and walked away. Staff 11 asked Resident 3 if it hurt and Resident 3's eyes opened wide and she/he said, yes it hurt. Staff 11 asked Resident 3 if she/he was upset and she/he stated yes, I couldn't move. Resident 3 had no signs of injury. Resident 3 stated she/he did not want to move rooms. On 3/12/20 at 2:30 PM Resident 3 was not able to recall specific details including times and dates of the allegation due to cogitative impairment. Resident 3 was able to recall being hit by that person. On 3/12/20 at 2:35 PM Resident 4 was unable to answer interview questions due to cogitative impairment. On 3/13/20 at 4:45 PM Staff 2 (DNS) confirmed Resident 4 had a history of [REDACTED]. Staff 2 stated she did not consider Resident 4's actions willful and did not consider this abuse due to Resident 4's cogitative impairment. Staff 2 further stated if someone was to walk up to me and punch me in the face but did not leave a mark or cause an injury, I would not consider that abuse. On 3/13/20 at 4:46 PM Staff 10 (RN Consultant) confirmed the facility failed to ensure residents were free from abuse.