Every finding on record at Sierra Post Acute

Based on observations, record review and interviews, the facility failed to ensure two (#2 and #3) of five residents reviewed for abuse were kept free from abuse.Specifically, the facility failed to protect Resident #3 and Resident #2 from physical abuse by Resident #1.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was received from the nursing home administrator (NHA) on 7/14/26 at 9:20 a.m. It revealed in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not limited: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors and/or any other individual.II. Incident of physical abuse by Resident #1 towards Resident #3 and Resident #2 on 6/20/26A. Facility investigationOn 6/20/26 a resident reported to the nurse that Resident #3 was on the floor. Resident #3 reported to the nurse she had been involved in a verbal altercation with Resident #1, due to her observing Resident #1 throwing water on Resident #2 (see incident below) which caused Resident #2 to cry. Resident #3 said she told Resident #1 to stop the behavior at which point Resident #1 became upset, cursed at her and pushed her, causing her to fall and land on her buttock.Resident #3 was assessed by facility staff and assisted back to her wheelchair. Resident #3 and Resident #1 were separated for safety.The facility substantiated physical abuse based on witness statements and video surveillance.During the investigation of the incident between Resident #1 and Resident #3 on 6/20/26, it was discovered Resident #1 had also thrown water on Resident #2 (see above). Resident #2 was found to be wet from a liquid being spilled on him by Resident #1. There were no injuries noted. The facility substantiated the allegation based on witness statements and video surveillance. B. Resident #1 (assailant)1. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included Parkinson's disease (progressive neurological disorder), dementia and mild neurocognitive disorder (decrease in mental function).The 7/7/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. He required set up/clean up assistance with walking, eating, and toilet hygiene. He was independent with transfers. The MDS did not indicate that the resident had behaviors.2. Record reviewThe psychosocial care plan, initiated 3/31/26, documented Resident #1 was at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills. The resident had poor impulse control related to dementia. Resident #1 had been involved in physical altercations with peers as the aggressor (initiated 6/24/26). Interventions included administering medications as ordered by the physician, encouraging the resident to voice feelings and frustration, establishing rapport using therapeutic communication, providing emotional support and encouraging visits with friends and family. A nursing progress note, dated 6/20/26 at 11:48 p.m., revealed a resident had notified the nurse of an altercation between Resident #1 and Resident #3. Upon completion of an assessment, it was noted Resident #1 was in the hallway visibly upset. Several residents reported that Resident #1 had engaged in verbal altercation with Resident #3 that then escalated to physical contact. Per witnesses, Resident #1 pushed Resident #3, causing her to fall into a seated position on the floor.A social services progress note, dated 6/20/26 at 10:54 a.m., revealed a follow-up visit with Resident #1 was conducted for an altercation. Resident #1 was unable to recall the incident. Resident #1 reported he was having a great day. Resident #1 was observed interacting with other peers at ease and denied distress or fear. There were no psychosocial concerns noted during the interaction. A physician's progress note, dated 6/22/26 at 7:00 a.m., revealed Resident #1 was seen for follow-up after an altercation with another resident. Resident #1 had no complaints and was unable to recall the altercation. Resident #1 was at baseline. An interdisciplinary team (IDT) progress note, dated 6/22/26 at 4:08 p.m., revealed the plan of care was discussed for Resident #1 as he was the alleged aggressor in a resident-to-resident altercation with Resident #3. Resident #1 was noted to have pushed Resident #3 on the upper body after Resident #3 confronted Resident #1 for throwing water on Resident #2 (see incident above). There were no injuries, bruising, or abrasions and no facial expression of any pain. The residents were immediately separated. All notifications were completed per facility protocol. Both residents involved were placed on frequent checks and educated to seek staff assistance as needed. Resident #1 denied fear and no psychosocial concerns were noted.C. Resident #3 (victim) 1. Resident StatusResident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2026 CPO, diagnoses included bipolar (mental health condition with extreme shifts in mood, energy and activity), vascular dementia, major depressive disorder, type 2 diabetes and hypertensive heart failure (fluid overload on the heart).The 6/3/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of nine out of 15. She required staff supervision/touch assistance with ambulation 10 feet with a wheelchair. She was independent for transfers. The MDS did not indicate that the resident had behaviors.2. Record reviewThe behavior care plan, initiated 6/23/17, documented Resident #3 had episodes of allegedly initiating physical aggression towards other residents due to bipolar disorder and dementia with behavioral disturbance. Resident #3 had been involved in psychical altercations as the victim (revised 6/24/26). Interventions included providing behavior health counseling, identifying triggers, such as a need for soda and peers passing by making comments that may or may not be directed towards the resident and de-escalating the resident via methods of contacting family and redirection. A nursing progress note, dated 6/21/26 at 12:11 a.m., revealed the nurse was alerted by residents that Resident #3 was on the floor. Resident #3 was found on the floor sitting upright. Resident #3 stated she had been involved in a verbal altercation with Resident #1. Resident #3 said Resident #1 had thrown water on Resident #2, causing him to cry. Resident #3 told Resident #1 to stop and then Resident #1 became upset, cursed at her (Resident #3) and pushed her, causing her to fall and land on her back. Resident #3 was assessed and assisted back to her wheelchair with staff assistance. The resident had no visible injuries Resident #3 remained alert and responsive. Neurological assessments were initiated per facility protocol. All parties were notified per facility policy. The residents were placed on 15-minute monitoring. A social services, dated 6/21/26 at 10:58 a.m., revealed Resident #3 shared her perception of the altercations. Resident #3 denied distress and fear and continued with her daily routine. There were no psychosocial concerns at that time. A nurse practitioner note, dated 6/22/26 at 10:38 a.m., revealed staff reported Resident #3 was pushed down on 6/20/26 in the afternoon by another resident. Her neurological assessments had been stable. Resident #3 did complain of mild pain in her buttock and right elbow. Resident #3 had a full range of motion (ROM) of the joints involved. An IDT note, dated 6/22/26 at 11:31 a.m., revealed that on 6/20/26 Resident #3 was allegedly pushed by another resident.3. Resident interviewResident #3 was interviewed on 7/13/26 at 12:55 p.m. Resident #3 said she thought someone had pushed her but she grew up with five brothers so she could defend herself. Resident #3 denied being fearful of anyone or having fear of living in the facility. Resident #3 was unable to recall specific details of the incident with Resident #1 on 6/20/26.D. Resident #2 (victim) 1. Resident statusResident #2, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2026 CPO, diagnoses included congestive heart failure, diabetes and intellectual disability.The 6/4/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of eight out of 15. He required moderate staff assistance with toileting. He was independent with ambulation transfers and bed mobility. 2. Record reviewThe behavior care plan, initiated 4/11/24, revealed Resident #2 exhibited or had the potential for aggressive or violent behaviors (verbal or physical) towards staff, peers or self, placing himself or others at risk for harm or distress related to his intellectual disabilities. Resident #2 had been involved in resident-to-resident allegations as the victim. Inventions included identifying early warning sign triggers, such as his perception of others being treated unkindly, using one-step directions, avoiding rushing and overstimulation of the resident and providing a calm, low stimulation area for redirection when agitated as the resident permitted.A social services note, dated 6/22/26 at 2:47 p.m., revealed Resident #2 denied fear or distress following the event with Resident #1 on 6/20/26. Resident #2 continued with his daily routine with no psychosocial concerns noted. A nursing progress note, dated 6/23/26 at 9:10 a.m., revealed that during an investigation of another event on 6/20/26 (between Resident #1 and Resident #3), it was noted Resident #2 had liquids spilled on him by Resident #1. The resident had no signs of distress and denied pain. An IDT note, dated 6/23/26 at 2:01 p.m., revealed Resident #1 was the alleged aggressor observed to throw water on Resident #2. There were no injuries and no facial indicators of pain. The residents involved were immediately separated for safety. All parties were notified per facility protocol. Resident #2 was educated to seek staff assistance as needed. III. Staff interviewsThe social services director (SSD) and the NHA were interviewed together on 7/13/26 at 2:15 p.m. The SSD said Resident #1 was admitted from home and had cognitive difficulties leading to confusion and wandering into other residents' spaces. The SSD said Resident #1 had recently been in altercations with other residents as the aggressor. However, she said she felt the situation with Resident #3 and Resident #2 on 6/20/26 was an isolated situation, as Resident #1 was normally not aggressive day-to-day. The SSD said he responded well to redirection from staff. The SSD said she had not identified any behaviors from Resident #1 adjusting to living in the facility. The SSD said Resident #1 passively participated in activities in the common area and enjoyed playing cards, drinking coffee and socializing with his peers. The SSD said Resident #2 spent his days at the facility being very social, friendly and watching television while sitting on the couch in the common area. She said he socialized around meal time in the dining room and would return to the couch after meals. The SSD was unsure if Resident #2 had been involved with other resident-to-resident situations. The NHA said Resident #2 had previously been involved in occurrences. The NHA said if Resident #2 felt if a resident was not being included he would get involved. The NHA said Resident #2 likes rules and if he perceives something wrong he will check on the situation. The SSD said Resident #3 had been living in the facility for a long period of time and she got along with staff and peers with ease. The SSD said Resident #3 was willing to involve herself if she knew something was wrong. The SSD said she did not identify any changes in behaviors for Resident #1, Resident #2 or Resident #3 following the incidents on 6/20/26.Licensed practical nurse (LPN) #1 was interviewed on 7/13/26 at 3:22 p.m. LPN #1 said if abuse was suspected, observed or reported, she would notify the supervisor after ensuring residents' safety. LPN #1 said Resident #1 liked to wander the halls, participate in activities and drink coffee. LPN #1 said she had not observed Resident #1 have any concerning aggressive behaviors, as he was easily redirectable if needed.LPN #1 said Resident #2 liked to watch television in the common area and would socialize with his peers. She said she had not noted any behaviors from Resident #2. LPN #1 said Resident #3 could be forgetful but she had not noted any agitation or aggressive behaviors for the resident. The NHA was interviewed again on 7/13/26 at 3:47 p.m. The NHA said abuse was any allegation involving, physical, verbal, mental, or misappropriation of property of a resident.The NHA said if any type of abuse was suspected or observed, the staff should alert the supervisor, or himself, as he was the abuse coordinator. He said once notifications were made, the facility immediately ensured resident safety and began an investigation into the situation. The NHA said the facility wanted to promote the safety and well-being of the residents. The NHA said in the situation of Resident #3 being pushed by Resident #1, Resident #1 was separated and placed on frequent checks to promote safety for all residents. He said while the facility was investigating how Resident #3 was found on the floor, it was discovered that Resident #1 had also thrown water on Resident #2. The NHA said the facility reviewed video surveillance along with obtaining witness statements of other residents and were able to determine that Resident #1 had first thrown water on Resident #2 and then pushed Resident #3 after she intervened. The NHA said after a resident-to-resident incident occurred, social services would do a follow up visit to evaluate how residents were doing and follow up with those concerns if needed, such as latent fear or trauma from the incident. He said the SSD would notify the IDT if additional assessments might be needed, such as nursing assessments or even third party psychosocial evaluations. The NHA said based on the follow-up, it helped determine resident cares moving forward. The director of nursing (DON) was interviewed on 7/13/26 at 4:08 p.m. The DON said staff should first separate the residents involved in a resident-to-resident incident to promote safety of the residents. She said staff should then notify their supervisor and the NHA. The DON said residents should be assessed for injuries. The DON said a resident pushing another resident or throwing water on another resident would be considered abuse.

Based on observations record review and interviews the facility failed to ensure that the resident environments remained free from accidents hazards as was possible and that each resident had adequate supervision to prevent accidents for for one resident (#10) of three residents reviewed for falls out of sample 34 residents. Resident #10 was admitted on [DATE] for long term care with diagnoses of emphysema (shortness of breath), dementia (impaired memory and thinking), paranoid personality disorder (mental health condition), epilepsy (neurological disorder) and repeated falls. Resident #10 was identified as a high fall risk. Resident #10 sustained eight falls in three months (October 2025 to January 2026).On 10/25/25, Resident #10 sustained a fall where he hit his head. He was sent to the hospital and was diagnosed with a closed head injury. Observations during the survey revealed the facility failed to consistently implement person-centered fall interventions.Specifically, the facility failed to ensure fall precautions were consistently in place for Resident #10. Findings include:I. Facility policy and procedureThe Falls and Fall Risk, Managing Policy, revised December 2007, was received from the Nursing home administrator (NHA) on 1/30/26 at 12:21 p.m. It revealed in pertinent part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.II. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO) diagnoses included emphysema, dementia, paranoid personality disorder ), epilepsy and repeated falls. The 12/5/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview of mental status (BIMS) score of seven out of 15. He required staff supervision for toileting, dressing and ambulation. He needed setup assistance with meals and personal hygiene. He was independent with bed mobility. The MDS indicated resident had sustained falls.B. Record reviewThe 7/12/24 comprehensive care plan documented Resident #10 was at risk for falls with and without injury related to dementia with agitation, cognitive impairment, difficulty in walking, wandering, vision and hearing impairment.Interventions put in place by the facility were:-Call light with in reach (initiated 2/2/25);-Personal items within reach (initiated 2/2/25);-Traction strips and signs posted in the room/bathroom to remind Resident #10 to use call light and wait for assistance (initiated 8/27/25); -Bed in low position (initiated 9/13/25);-Keep the resident's personal belongings with inreach (initiated 9/15/25);-Moving the resident's room closer to nurses' station (initiated 9/25/25);-Hipsters as tolerated (initiated 10/2/25);-Low profile fall mat (initiated 10/13/25); and,-Offer scrum cap when out of bed initiated on 10/15/25.The January 2026 CPO documented the following physician's orders:-Low profile fall mat, ordered on 10/13/25;-Offer scrum cap (protective helmet) when out of bed, ordered on 10/15/25; and,-Apply hipsters in the morning, ordered on 10/2/25.Resident #10's electronic medical record (EMR) revealed the resident sustained falls on:-On 10/1/25 the resident fell while pulling his wheelchair backwards.-On 10/7/25 the resident was found on the floor near his wheelchair.-On 10/11/25 the resident was found on the floor near his bed and wheelchair.-On 10/15/25 the resident had a witnessed fall when he turned too fast, lost his balance and struck his head. -On 10/25/25 the resident had a suspected fall resulting in hematoma to right eye and head.-On 1/12/26 the resident was found on the floor next to the toilet in the bathroom with a call light on in his room.-On 1/17/26 the resident was found on the floor next to his bed.-On 1/19/26 the resident was found on the floor in another resident's room. The 10/11/25 post fall reviews documented the resident was a moderate risk for falls.The 10/25/25 post fall review documented the resident was moderate risk for falls. A progress note on 10/25/25 at 10:45 a.m. documented the resident had a change in condition related to a fall. All parties were notified. The resident was sent to the emergency room for evaluation.A progress note on 10:25/25 at 10:49 a.m. documented Resident #10 was assessed by a registered nurse (RN) at 10:30 a.m. due to a report from a licensed practical nurse (LPN) on the memory care unit. The LPN reported a hematoma (raised bruise) to the resident's lateral upper right eye. Per the LPNs report the resident may have fallen during the previous shift but there was no report or injury on file. Resident #10 endorsed he fell in the dining room or his bedroom. Resident #10 reported he was dizzy when he fell but denied at the time of assessment. The hematoma measured 5 centimeters (cm) by 2.5 cm.A progress note on 10/25/25 at 4:31 p.m. documented the resident returned to the facility. A computed tomography (CT imaging test) scan was performed. The results indicated the resident sustained a periorbital (eye) and left parietal (top rear area of the skull) hematoma.A progress note on 10/27/25 at 4:22 a.m. documented the nurse was told Resident #10 had sustained a fall on her previous shift on 10/25/25. The nurse documented resident remained asleep throughout the night as per his usual pattern, no abnormal sound or activity was noted. The emergency room notes from 10/25/25 documented the resident was seen for a fall with a closed head injury. A resident reported a right sided headache. Imaging showed right periorbital and left parietal scalp hematomas. A physician progress note dated 11/14/25 at 8:18 a.m. documented the physician was requested to see the resident for MRI results of the brain which showed late subacute versus chronic subdural hematoma 11 millimeters (mm). The facility reported that the patient remained neurologically stable without any focal deficits or symptoms. C. Observations and interviewsOn 1/27/26 at 8:40 a.m Resident #10 was lying in bed A (resident was assigned bed B) of the residents room with no fall mat in place. The call light was not in reach of the resident (see care plan interventions and CPOs orders above).On 1/27/26 at 9:27 a.m. the resident's bathroom was observed to have no traction strips on the floor (see care plan interventions above).On 1/27/26 at 4:10 p.m. Resident # 10 was lying in bed A with no fall mat on the floor next to the bed.On 1/28/26 at 8:15 a.m. Resident #10 was rolling around in his bed with no fall mat or callight within reach. III. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 1/28/26 at 1:44 p.m. She said she had only been on the unit a few times but she utilized the computer records for resident care needs. CNA #3 said Resident #10 was not a fall risk and had not had falls. -However, Resident #10 had sustained eight falls in three months (see record review above).CNA #3 said he could wear pads to his hips (hipsters) but she could not find them. CNA #3 said residents with falls sometimes had their bed mid level. CNA #3 said the resident did not need his bed low to the ground. LPN #3 was interviewed on 1/28/26 at 1:57 p.m. LPN #3 said Resident #10 was a high fall risk resident. LPN #3 said the resident should have a fall mat next to his bed, hipsters and scrum cap on as fall interventions. Resident #10's room was observed with LPN #3. Resident #10's fall mat was laying next to bed B in the room. However the resident had been observed sleeping in bed A during the survey.LPN #3 said the mat should be on the side the resident got out of bed on so if he was sleeping in bed A the mat was not in the best position to protect the resident if he were to fall out of bed. LPN #3 said she was unable to locate Resident#10's hipsters or scrum cap in resident's current room. LPN #3 then went to another room, which was Resident #10's old room to look for other interventions ordered for fall prevention. LPN #1 said the resident was moved to his current room over a week ago and maybe his things had not been moved over yet. LPN #3 said she was unsure if the room move was permanent or why his personal belongings were still in his old room. LPN #3 said she located the resident's scrum cap on the dresser and his hipsters in the drawer along with his personal belongings in his old room. -The facility failed to ensure fall interventions were consistently in place. The director of nursing (DON) was interviewed on 1/29/26 at 12:23 p.m. She said the staff could review the resident's care plan or Kardex (staff directive tool) for care needs and interventions needed for keeping residents safe. The DON said if they had any new interventions, there was a binder at each nurses' station to help the staff learn about new interventions put in place for residents. The DON went to the memory care unit and observed Resident #10's current room. She said the resident's room move was permanent and was not sure why his personal belongings were not moved to his new room since it had been over a week since the move. The DON said fall interventions should be used at all times in order to keep residents safe.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in three of three unit nourishment refrigerators/freezers.Specifically the facility failed to:-Ensure food was labeled and dated appropriately in the main kitchen and in the nourishment room refrigerators; and,-Ensure food was disposed of timely. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 2/4/26. It read in pertinent part, The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety. (Chapter 3-25) A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. (Chapter 3-29) B. Facility policy and procedureThe Food Receiving and Storage policy, revised November 2022, was provided by the nursing home administrator (NHA) on 1/30/26 at 12:21 p.m. It read in pertinent part, Foods shall be received and stored in a manner that complies with safe food handling practices. Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). PHF (Potentially Hazardous Food )/TCS (Time/Temperature Control for Safety) foods are stored at or below 41 degrees Fahrenheit (F), unless otherwise specified by law. Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins are not overcrowded. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods to prevent meat juices from dripping onto these foods. All food items to be kept at or below 41degrees F are placed in the refrigerator located at the nurses' station and labeled with a use by date. All foods belonging to residents are labeled with the resident's name, the item and the use by. Beverages are dated when opened and discarded after twenty-four (24) hours. Other opened containers are dated and sealed or covered during storage. Partially eaten food is not kept in the refrigerator.C. Observations and interviewsOn 1/26/26 at 8:15 a.m. the initial tour of the main kitchen was conducted with the dietary manager (DM). Observation in the walk-in freezer revealed an opened box of egg rolls with no labeling or dating, the plastic bag in the box was not closed. The DM said it should be labeled and dated when delivered and then when opened and the plastic bag should not be open to air in the freezer.On 1/27/26 at 8:50 a.m. a follow up tour of the main kitchen was conducted with the dietary director who was the registered dietician (RD) for the facility. Observations in the walk-in refrigerator revealed a roll of ground beef in a plastic wrap dated 1/14/26 and use by date of 1/18/26. The RD said she would throw it away to be safe. The RD said cooked food was good for three days and raw/fruit and vegetables were good for five days. Observations in the walk-in freezer revealed a pan of lemon bars with plastic wrap over and dated 10/16/25. The RD said there should also be an expiration date. The RD said she would toss it. There were four pizza flat breads, wrapped in plastic wrap, with no label or date. The RD said she would throw it away to be safe. An opened box of ice cream bars was in a tub, there was no label or date. The RD said there should be a date of arrival and expiration date. There was a bucket of approximately six random meats, wrapped in plastic wrap with no label or date. The RD said there should be a date of arrival and expiration and also she would want to know what type of meat it was and that should be written on the label. There were four grilled cheese sandwiches in a plastic bag with no label or date. The RD said she would discard all of the unlabeled products because she was not sure how old it was. On 1/28/26 at 3:17 p.m. the nourishment refrigerators/freezers located at the nurses' station were observed with activities assistant (AA) #1. The Legacy nourishment refrigerator/freezer was observed, there were melted chocolate ice cream streaks in the freezer. The Sarvata kitchenette nourishment refrigerator/freezer was observed, there was an opened square metal container of yellow creamy food with a half covered piece of plastic wrap and a serving spoon inside the food. There was no labeling of the food or date. AA #1 removed the container and said she did not know what it was. The Sarvarta nourishment refrigerator/freezer located at the nurses' station was observed, the refrigerator was tightly packed and overcrowded. There was an opened coffee creamer with no date. There was a tupperware with chili with no name or date. There was a half full plastic container of soda with a straw in it, with no name or date. There was an opened container of yogurt with no name or date. In the freezer there were five ice packs. AA #1 said the kitchen staff was responsible for cleaning and throwing out old food from the nourishment freezers and refrigerators. On 1/28/26 at 3:50 p.m. the Prasada nourishment freezer and refrigerator located at the nurses' station was observed with the RD. Three resident snack and beverage items were pulled from the refrigerator, that included an unknown beverage in a plastic cup, an opened sports drink and snack in a plastic bag. These items were not labeled or dated.D. Staff interviewsThe RD was interviewed on 1/27/26 at 9:00 a.m. The RD said food was delivered on Tuesdays and Thursdays. She said that was when she and the DM would go through the freezer and refrigerator to throw out old products and label new products coming in.The RD was interviewed on 1/28/26 at 3:40 p.m. The RD said she and the DM were responsible for maintaining clean nourishment and kitchen freezers and refrigerators. The RD said they were also responsible for cleaning out and discarding outdated food and beverages. The RD said she had no cleaning logs for the four nourishment freezers/refrigerator or the for the main kitchen walk-in freezer or walk-in refrigerator. The RD said it could get confusing without a cleaning log regarding who had completed the cleaning and if it was getting done. The RD said it should be done one time per week. The RD said all the nourishment and kitchen freezers and refrigerators should only have items in it that were labeled and appropriately dated. She said there should not be any ice packs kept in the freezer. The RD said the square metal container of yellow creamy food found at the Sarvata kitchenette nourishment refrigerator may have been left over macaroni and cheese, however it should have been labeled and dated and she would throw it out. The RD said it had been over three months since she had cleaned the Sarvata nourishment freezer and refrigerator located at the nurses' station. The RD said she would be doing education on food labeling that all foods in the kitchen and nourishment freezers/refrigerators should be labeled with name of item, received date, date of opening, pull date for frozen foods, and date of expiration. The RD said the DM was currently going through/cleaning out the walk-in freezer and refrigerator in the main kitchen to bring it up to date and then they would start on the nourishment freezers and refrigerators.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on two out of three units.Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers performed hand hygiene while cleaning resident rooms;-Ensure housekeepers cleaned high touch areas; -Ensure dwell times were followed during resident room cleaning; and,-Ensure hand hygiene was conducted appropriately during wound care. I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 2/2/26 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 2/2/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. According to the Hydrogen Peroxide Cleaner Disinfectants, dated 2026. Retrieved from: https://www.cloroxpro.com/products/clorox-healthcare/hydrogen-peroxide-cleaner-disinfectants/?UTM_Campaign=CHP&UTM_Content=Healthcare-Portfolio&gad_campaignid=12892269504&gad_source=1&gbraid=0AAAAADsLA85AqyjqCvlI5MJB9j4oAflA4&gclid=CjwKCAiAs4HMBhBJEiwACrfNZWJE_AtzZ5uMJ4R7PyKAVuDgbW1rvSf-02wA5WnrSSW7YrOQJWSi8xoCE1IQAvD_BwE&gclsrc=aw.ds&utm_campaign=PPH%7CBranded%7CLT%7CP%7CKW%7CCHP%2BHydrogen%2BPeroxide%7CMulti%7CEnglish%7CENKW-ENBR&utm_content=121962823576&utm_medium=cpc&utm_partner=OMD&utm_source=google&utm_term=clorox%20hydrogen%20peroxide%20wipe on 2/2/26 it was revealed in pertinent part. Wipe the surface until completely wet. To disinfect, keep surface wet for the contact time (1 minute for most bacteria and viruses; 2 minutes for C. auris). According to the Technical Bulletin: Concentrated SPIC and SPAN Disinfecting All-Purpose Spay and Glass Cleaner, updated 7/23/21, was retrevied on 2/2/26 from https://assets.ctfassets.net/xsotn7jngs35/6qI41K6mC3OnnZQcx32AeU/e0c1c6588d8efe3daf05cd1a676226ff/english_37000325352_bulletin.pdf. It revealed in pertinent part, To Sanitize/Disinfect: For visibly soiled areas, a precleaning is required. Spray hard, non-porous surfaces until thoroughly wet. To Sanitize: Treated surfaces must remain visibly wet for 15 seconds before wiping. To Disinfect: Treated surfaces must remain visibly wet for the time indicated for each organism listed under the efficacy section. A rinse is required for surfaces in direct contact with food. According to the Comet Disinfecting-Sanitizing Bathroom Cleaner, updated 9/13/18, was retrieved on 2/2/26 from http://assets.ctfassets.net/xsotn7jngs35/5xJmZUMq9KOiw27ZTOf5rl/3e9635a410c1491ab8da7d19612c390/cometbathroomcleaner-37000225706-bulletin.pdf. It revealed in pertinent part, TOILET BOWLS AND URINALS: Empty water from the toilet bowl or urinal. Hold 6-8 from the surface. Spray exposed surfaces. Brush thoroughly. Let stand for 5 minutes, then flush. B. Facility policy and procedure The Cleaning and Disinfecting Resident Rooms policy, revised August 2013, was received from the nursing home administrator (NHA) on 1/30/26 at 12:21 p.m. It revealed in pertinent part, The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, when these surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (daily, three times per week) and when surfaces are visibly soiled. The environmental services director and administrator, in conjunction with the infection preventionist, will select appropriate facility disinfectants. Steps in the Procedure for Resident Room Cleaning: 1. Gather supplies as needed. 2. Prepare disinfectant according to manufacturer's commendations. 3. Discard disinfectant/detergent solutions that become soiled or clouded with dirt and grime and prepare fresh solutions. 4. Change mop solution water at least every three (3) rooms, or as necessary. 5. Change cleaning cloth when they become soiled. Wash cleaning cloth daily and allow cloth to dry before reuse. 6. Clean horizontal surfaces (e.g., bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters. 7. Clean personal use items e.g., lights, phones, call bells, bedrails, etc.) with disinfectant solution at least twice weekly. The Handwashing/hand Hygiene policy, revised October 2023, was received from the NHA on 1/30/26 at 12:21 p.m. It revealed in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections.All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Environmental measures are taken to reduce contamination associated with sinks and sink drainage, including:the use of disinfectants that are EPA-registered for biofilm removal to clean sinks and faucets daily. Indications for Hand Hygiene:. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. II. Observations On 1/28/26 at 9:16 a.m. housekeeper (HK) #1 was cleaning room [ROOM NUMBER], a double occupancy room on the Prasada unit. She [NAME] by sweeping the A side of the room then collected a Spic N Span all purpose disinfectant and a glass spray entered the residents' bathroom and sprayed the toilet down with the Spic N Span. HK #1 returned to her cleaning cart at the entrance of the door, collected two Clorox Hydrogen Peroxide wipes, went to A side of the room, wiped down the night stand then went to bed B side of room and wiped down the bed side table wiping around the resident personal items. She then wiped the legs of the table down to the floor. -HK #1 failed to use a different wipe for each side of the room. The surfaces wiped with the Clorox wipes did not remain wet for the one minute dwell time (see professional reference above). HK #1 then collected the trash from the trash can near the sink and replaced it with a new bag. She collected the toilet bowl brush and one red rag for the housekeeping cart. She then entered the bathroom, scrubbed the toilet bowl with the brush. She then took the red rag, wiping the toilet bowl rim, then seat and then lid. -HK # failed to clean the toilet from the cleanest area to dirtiest areas. HK #1 returned to her cart, collected a dry mop pad, dunked it into the mop bucket, rang it out then went into the restroom and mopped the bathroom. HK #1 went back to her cart, removed the mop pad and repeated the process of dunking the new mop pad in the mop bucket, then mopped the room from the B side to the A side then to the doorway. HK #1 then removed the mop pad, replaced it with a dry mop pad and mopped the floor with a dry pad to dry the floor. -HK #failed to change her gloves and complete hand hygiene after cleaning the toilet. She then reached into the mop bucket where she contaminated the cleaning solution with soiled gloves twice, while wetting each mop pad. At 9:26 a.m. HK #1 said she was done cleaning room [ROOM NUMBER]. She removed her gloves and moved to the next room. -HK #1 failed to clean high touch areas in the resident room and bathroom like call lights, light switches, bed controls. HK #1 failed to clean the resident sink area. HK#1 moved her cart to room eight, a triple resident room at 9:28 a.m. She applied clean gloves, knocked on the door and announced herself. -HK #1 failed to perform hand hygiene between rooms and prior to applying clean gloves. HK #1 collected the Spic n Span disinfectant and went to the bathroom sprayed the toilet. She collected the trash by the sink and side A and took it to the cart. She replaced the trash bags in trash cans and collected two Clorox hydrogen peroxide wipes. She wiped the bedside table, the night stand on the B side. She then went to the C bed night stand and wiped it down. The surface dried in 30 seconds. -HK #1 did not wipe bed A's night stand or bed side table. H K#1 also used the same Clorox wipe for both B and C beds. HK #1 failed to ensure the surface remained wet for the dwell time for the Clorox (see professional references above) HK #1 collected Spic n Span disinfectant all purpose spray and glass cleaner. She sprayed the sink then the mirror. She wiped the mirror then the sink handles then, then the sink bowl, she then wiped the counter top with the same rag. -HK #1 failed to clean the sink area from cleanest to dirtiest. HK #1 returned to her cart, collected the toilet bowl brush, brought it into the bathroom, scrubbed the toilet bowl then took it back, re entered the room, touched the light switch at the sink then returned to cart collected a roll of toilet paper and placed it into the bathroom. -HK #1 touched areas in the room, items on the cleaning cart with soiled gloves used to clean the toilet bowl. HK #1 collected a new rag from the cart, re entered the bathroom, wiped the toilet and returned to her cart. HK #1 changed gloves. -HK #1 changed her gloves but failed to perform hand hygiene between changes. HK #1 then took a new mop pad, dunked it into the mop water, rang it out then mopped the bat II. Failure to perform hand hygiene per professional standards of practice A. Observation On 1/28/26 at 2:15 p.m. the IP was preparing to provide catheter care to Resident #54. She performed hand hygiene. She left the room to get a Foley catheter bag. She washed her hands and donned (put on) personal protective equipment (PPE). She undid the secure tabs of his adult disposable brief. She took off the old drain sponge, grabbed a clean washcloth and placed it in the warm, soapy water. She washed the supra pubic area. She then grabbed a second clean washcloth and cleaned the area a second time. She grabbed a clean washcloth, placed it in the warm water, and rinsed the area. She grabbed a clean washcloth and dried the area. She placed a new drain sponge on the supra pubic catheter site. She reattached the secure tabs of his adult disposable brief. She took off her PPE and disposed of it. She washed her hands, and she put on gloves, and grabbed the garbage bag from the resident's waste basket, along with PPE and an old Foley catheter bag, to take to the garbage disposal area. -The IP failed to change her gloves and perform hand hygiene after removing the soiled drain sponge. And failed to place the old Foley catheter bag in a red bag for bodily fluids. C. Staff interviews The IP was interviewed on 1/28/26 at 2:30 p.m. The IP said she did not normally perform supra pubic catheter care. She said the nurse assigned to the resident was having an issue with the catheter care and asked her to complete the care. She said gloves should be changed after removing the dirty dressing. The DON was interviewed on 1/28/26 at 2:50 p.m. The DON said the nurse should remove the old dressing, remove gloves, wash hands and place clean gloves on to complete the Foley catheter care. She said the nurse should place the dirty Foley catheter bag into a red biohazard bag to discard it.

Based on observation and interviews, the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls could be made without being overheard on two of three units.Specifically, the facility failed to have a private area for residents to make and receive telephone calls and inform the resident of these areas on the Prasada and Legacy units. Findings include:I. Facility policy and procedureThe Resident Right to Privacy in Communication policy, undated, was provided by the nursing home administrator (NHA) on 1/30/26 at 12:21 p.m. It read in pertinent part, It is the policy of this facility to support and facilitate a resident's right to privacy in communications with individuals and entities within and external to the facility. Reasonable access means that telephones, computers and other communication devices are easily accessible to residents and are adapted to accommodate resident's needs and abilities, such as hearing or vision loss. Policy Explanation and Compliance Guidelines: Have reasonable access to private telephone conversations. The facility will provide residents with reasonable access to the use of a telephone, including TTY (Teletype) and TDD (telecommunications device for the deaf) services, where calls can be made without being overheard. Reasonable access should include: Placing telephones at a height accessible to residents who use wheelchairs; Adapting telephones for use by residents with impaired hearing; Prior to or upon admission, the social service designee, or another designated staff member, will inform the resident of provisions the facility has made for access to the use of a telephone and privacy in communications.II. ObservationsThe facility had three units.The secured behavioral health unit (Prasada) downstairs had one public landline telephone placed at the nurses' station/dining area with no private area for a phone call.The secured memory care unit (Legacy) on the main level had one public landline phone at the nurses' station with no private area for a phone call.III. Resident observations and interviewsOn 1/26/26 at 12:05 p.m. an unidentified resident was in the dining room of the secured behavioral health unit (Prasada) and was standing at the nurse's station making a personal phone call to his mother. It was during lunchtime and the resident's conversation was overheard by all the residents sitting in the dining room.Resident #21 was interviewed on 1/26/26 at 1:30 p.m. Resident #21 said he wanted to call his family member and ask her to get him some more things. Resident #21 said he made his phone calls at the Prasada nursing station/dining room area, which was the only public phone for the residents to use since there was no portable phone. Resident #21 said having a phone call with privacy would be great but presently that was not an option. Resident #56 was interviewed on 1/26/26 at 2:39 p.m. Resident #56 said today was his birthday and he had talked to his grandma on the phone at the Prasada nurses' station. Resident #56 said he would have liked it better to talk to his grandma more privately and it had been a long time since he had his own phone. Resident #56 said he did not know if it was an option to have a private phone conversation. On 1/28/26 at 2:26 p.m. Resident #5 was at the nurses' station in the secured memory care unit (Legacy). Resident #5 was having a personal phone call to a family member. There were three residents standing around and one unidentified certified nurse (CNA) at the nurses' station sitting across from Resident #5, all were able to hear the residents' conversation and the phone call was on speaker. IV. Group meeting interviewThree residents (#67, #70 and #75) were interviewed on 1/28/26 at 12:37 p.m. Resident #67 and Resident #70 attended the resident council meetings regularly and Resident #75 did not attend the meetings regularly. The residents were identified as alert and oriented by the facility and assessment. Resident #67 said he received and made phone calls on the Legacy unit. Resident #67 said the phone was located at the nurses' station and there was not a room or phone available for private calls. Resident #67 said he did not have a personal phone due to the expense. Resident #75 said he did not need to make a phone call on the Prasada unit. Resident #75 said there was a phone located in the dining room by the nurses' station. Resident #75 said it was the only phone available to the residents and they did not have a private location for a call.Resident #70 said he made phone calls on the Sarvata unit in the computer room that could be used to make private calls. Resident #70 said he did not have a personal phone. V. Staff interviewsThe activities director (AD) was interviewed on 1/27/26 at 4:25 p.m. The AD said the residents used the phone sitting at the nurses' station/dining room area and it was easily accessible because they could walk right up to it on the Prasada unit.CNA #5 was interviewed on 1/27/26 at 4:30 p.m. CNA #5 said the residents used the telephone at the nurses' station/dining room area and there was not a private phone for the residents to use on the Prasada unit.CNA #6 was interviewed on 1/27/26 at 4:35 p.m. CNA #6 said the residents used the phone at the nurses' station/dining room area. CNA #6 said that families could call in to talk to a resident and the staff would go get the resident to talk at the nurses' station. CNA #6 said there was no private phone for the residents to use on the Prasada unit.CNA #7 was interviewed on 1/27/26 at 4:45 p.m. CNA #7 said the residents used the phone at the nurses' station and there was not a private phone on that unit for the residents to use on the Legacy unit. Licensed practical nurse (LPN) #5 was interviewed on 1/27/26 at 4:50 p.m. LPN #5 said the residents used the phone at the nurses' station and the unit did not have a private phone on the Legacy unit.The social services director (SSD) was interviewed on 1/28/26 at 9:40 a.m. The SSD said there was a room on the Sarvata unit where residents could make a private phone call. The SSD said on the other two units (Legacy and Prasada) there was a landline phone the residents could use at the nurses' station with unlimited access. The SSD said there should be a place on each unit where phone calls could be made without being overhead. The SSD said privacy of communication was important because it was just one of those needs and a resident right. The SSD said she was not aware that some residents did not know that having a private phone conversation was an option. The SSD said she would provide education on that at the next resident council meeting. The SSD said there may be space to make private phone calls happen and she understood the residents perspective. The SSD said she would get together with the NHA and the environmental services director and see what the facility could do.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication carts. Specifically, the facility failed to ensure there were no loose pills in the medication cart. Findings include:I. Facility policy and procedureThe Storage of Medication policy, 2001, and revised on 11/2020, was received from the nursing home administrator on 1/30/26 at 12:21 p.m It revealed in pertinent part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.II. ObservationsOn 1/27/26 at 1:15 p.m., medication cart B was observed with licensed practical nurse (LPN) #1. There were three loose pills in the drawers. LPN #1 said one of the pills was Advil. On 1/27/26 at 1:30 p.m., medication cart A was observed with RN #1. There were twenty loose pills in the drawers. RN #1 was unable to identify any loose pills. III. Staff interviewsLPN # 1 was interviewed on 1/27/26 at 1:25 p.m. She said the night nurses were responsible for cleaning the medication carts, but all nurses were responsible for ensuring the cart was clean.RN #1 was interviewed on 1/27/26 at 1:45 p.m. RN #1 said all nurses were responsible for ensuring the medication carts were clean.The director of nursing (DON) was interviewed on 1/28/26 at 1:50 p.m. She said that the unit manager nurse was overseeing the task of cleaning the medication cart. The DON said the medication carts were assigned to be cleaned once a week by the nurse manager. The DON said nurses should be cleaning the medication cart on their shift as well. The DON said, The task was not getting done. The risk is that a resident could find a loose pill and take it.

Based on observations, record review and interviews, the facility failed to ensure two (#21 and #32) of five residents reviewed were kept free from abuse out of 34 sample residentsSpecifically, the facility failed to protect Resident #21 from physical abuse by Resident #32. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, was provided by the nursing home administrator (NHA) on 1/26/26 at 2:10 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.II. Incident of physical abuse by Resident #32 towards Resident #21 on 1/5/26A. Facility investigation The facility investigation was provided by the NHA on 1/27/26 at 3:44 p.m. The investigation documented on 1/5/26, two residents (Resident #21 and Resident #32) experienced an unwitnessed altercation inside their room. According to the investigation at approximately 1:45 p.m., Resident #32 exited his room and reported to a certified nurse assistant (CNA) that he hit his roommate (Resident #21) in the head because he was told to by voices. The investigation documented the CNA was able to separate the two residents to prevent further escalation and an additional CNA notified the nurse on duty. The investigation documented Resident #21 sustained no injuries after the altercation on 1/5/26. The investigation documented interventions to prevent additional occurrences included placing the residents on frequent checks, social services following up with the residents and a room change. The investigation documented Resident #21 was interviewed on 1/5/26 at 3:02 p.m. and said Resident #32 went crazy. It documented Resident #21 denied feeling fearful or distressed. The investigation documented Resident #32 was interviewed on 1/5/26 at 2:54 p.m. It documented Resident #32 stated the voices were in his head. It documented Resident #32 was provided with and declined the crisis line phone number. It documented no psychosocial concerns. The facility interviewed additional residents who could not identify what happened between Resident #21 and Resident #32 on 1/5/26, and no other residents expressed concern about their safety. According to the investigation, the altercation was substantiated as both residents confirmed the incident took place. According to the investigation, the incident did not cause injury or psychosocial stress to either resident, and interventions were successful in preventing additional incidents. III. Resident #32 (assailant)A. Resident statusResident #32, age less than 65, was readmitted on [DATE]. According to the January 2026 computerized physician orders (CPO), the diagnoses included unspecified schizoaffective disorder, unspecified affective mood disorder, type 2 diabetes mellitus, generalized muscle weakness and nicotine dependence. The 1/17/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. The MDS assessment indicated the resident had hallucinations and exhibited behavioral symptoms. The resident was independent with bed mobility, transfer, and locomotion. The resident was taking antipsychotic and anticonvulsant medication. B. Resident interviewResident #32 was interviewed on 1/26/26 at 12:34 p.m. Resident #32 said he was involved in a resident-to-resident altercation with his roommate. Resident #32 said he suddenly started flipping out and punched his roommate in the face while he was lying in bed. Resident #32 said he felt safe and was happy with his room change. C. Record reviewThe behavior care plan, revised 1/6/26, documented Resident #32 exhibited, or had potential for verbally/physically aggressive or violent behaviors towards staff, peers, or self that placed himself and others at risk for harm or distress related to his schizoaffective disorder. Interventions included administering medications as ordered (initiated 11/7/25), applying de-escalation protocols (initiated 11/7/25), moving the resident into a private room on 1/14/26 and providing a calming area for redirection when agitated as the resident permits (initiated 11/7/25). The schizoaffective disorder care plan, revised 8/4/25, documented Resident #32 had schizoaffective disorders and targeted behavior symptoms, including: internal stimuli, auditory hallucinations, delusions, and physical/verbal aggression. Interventions included obtaining authorization for sitter services as needed (initiated 6/13/25), providing mental health services (initiated 8/4/25), encouraging the resident to express his feelings appropriately (revised 8/7/24), and providing a program of activities of interest to the resident (revised 8/7/24).-Review of the schizoaffective disorder care plan revealed documentation the resident was recently involved in two separate resident to resident altercations.A nurse note, dated 1/5/26 at 2:20 p.m. documented at approximately 1:45 p.m., the resident left his room and reported to a CNA he hit his roommate, Resident #21, in the head approximately two to three times because he heard voices tell him to. It documented that the CNA separated the residents, and another CNA reported the incident to the nurse. It documented Resident #32 was placed on frequent checks and sat in a different area away from Resident #21. It documented Resident #32's provider and mental health case worker were notified. A facility provider note, dated 1/6/26 at 5:36 p.m., documented Resident #32 was evaluated after an altercation with his roommate. It documented Resident #32 punched Resident #21 in the face three times. It documented Resident #32 stated he was angry when asked why he did it, and the resident refused to elaborate due to embarrassment. It documented the treatment plan included management by outpatient psychiatric and mental health services, repeat lab work and medication review and adjustment.III. Resident #21 (victim)A. Resident statusResident #21, age over 65, was admitted on [DATE], and readmitted [DATE]. According to the January 2026 CPO diagnoses included intracranial injury, dementia, post-traumatic stress disorder, and major depressive disorder.The 12/17/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. He required supervision/touch assistance with toileting hygiene, oral hygiene, bathing/showering and personal hygiene. He required set up/clean up assistance with eating, upper and lower body dressing and rolling right and left. He was independent with walking and sitting to stand transfers.The MDS assessment indicated the resident did not display behavioral symptoms or rejection of care. B. Resident interviewResident #21 was interviewed on 1/26/26 at 1:00 p.m. Resident #21 said that his old roommate had hit him in the head while he was sleeping. Resident #21 said he moved to another room and had a different roommate now. Resident #21 said he was okay after he was hit and was not hurt or afraid. Resident #21 said his old roommate just hit him and he did not know why. Resident #21 said he was not concerned about the incident or hurt about it and was happy with his new room.C. Record reviewThe trauma-informed care plan, revised 6/25/25, revealed the resident was at-risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing related to transportation accident. Interventions included allowing him time to make choices in care and encourage active decision making, approaching the resident in a calm, reassuring manner, encouraging the resident to verbalize his feelings, encouraging the resident to participate in activities of choice, monitoring for signs/symptoms of decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and report abnormal findings to physician. A nurses note, dated 1/5/25 at 2:37 p.m., documented the nurse was notified by a CNA that Resident #32 admitted to hitting Resident #21 two to three times in the head while he was sleeping in bed. The CNAs separated the residents and put them on frequent checks. When the nurse assessed Resident #21 he denied any pain or loss of consciousness. Resident #21 was asked if he was in fear and he stated no and said his roommate just went crazy. The doctor was notified of the incident and Resident #21's guardian attempted to be notified but his voicemail was full and was unable to leave a message at the time. IV. Staff interviewsCNA #9 was interviewed on 1/28/26 at approximately 10:05 a.m. CNA #9 said Resident #32 was easily agitated. CNA #9 said Resident #32 was involved in a resident-to-resident altercation two to three weeks ago, when he punched his roommate. CNA #9 said the altercation was not observed. She said Resident #32 reported it himself. CNA #9 said Resident #21 was moved into a different room after the 1/5/26 altercation occurred. CNA #9 said Resident #32 was moved into a different room approximately one week prior, however he was unsure why. Registered nurse (RN) #2 was interviewed on 1/28/26 at 2:01 p.m. RN #2 said Resident #32 was initially placed on one-to-one observations after the altercation occurred. RN #2 said the resident was recently moved into a separate room as an intervention for the altercation. RN #2 said she was unsure why there was a delay in the room change occurring. RN #2 said Resident #32's triggers included hearing voices related to his medical condition. RN #2 said facility management would come onto the unit and alert staff of any changed care plan interventions. RN #2 said care interventions could be found in the resident's care plan or on the 24 hour nurse report sheets. RN #2 said updating the resident's care plan timely was important for resident safety and continuity of care. The social services director (SSD) was interviewed on 1/29/26 at 1:49 p.m. The SSD said Resident #32 stated he hit Resident #21 due to uncontrollable anger that came up. The SSD said Resident #32 did have a history of resident-to-resident altercations. She said in the past, the reported root cause was his auditory hallucinations. The SSD said moving Resident #32 to a different room was delayed due to a different resident occupying it, and the facility needed to provide a five day room change notification. The SSD said the social services team was responsible for managing the resident's behavior care plans. The NHA was interviewed on 1/29/26 at 3:09 p.m. The NHA said Resident #32 participated in facility activities and received frequent visits from social services. The NHA said he was unable to state what interventions were put in place to manage Resident #32's anger related outbursts after the resident-to-resident altercation on 1/5/26.

Based on observations, record review, and interviews, the facility failed to ensure that two residents (#1 and #23) of the three residents reviewed for oxygen received proper respiratory care and services in accordance with professional standards of practice, the residents' care plan, and the residents' choice out of 34 sample residents. Specifically, the facility failed to:-Ensure Resident #1 was provided with continuous oxygen supplementation per the physician's orders; and, -Ensure Resident #23's nebulizer was cleaned appropriately. Findings include: I. Facility policy and procedure The Oxygen Administration policy, revision date October 2010, was received from the nursing home administrator (NHA) on 1/28/26 at 4:55 p.m. It revealed in pertinent part, Review the physician's orders or facility protocol for oxygen administration. Assemble the equipment and supplies as needed. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included bipolar disorder (severe mood swings from extreme high to extreme lows), vascular dementia (cognitive decline caused by reduced blood flow to the brain), chronic obstructive pulmonary disease (COPD), type 2 diabetes (chronic condition that the body does not produce enough insulin), congestive heart failure (chronic condition where the heart cannot pump enough blood to meet the bodies needs), kidney disease stage 3 (kidneys have moderate damage and are less able to filter waste), muscle weakness and wheelchair dependence. The 12/10/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident required supervision or touching assistance with activities of daily living (ADL). The MDS assessment revealed that the resident required continuous oxygen at 2 liters per minute (LPM) via a nasal cannula. B. Observations and resident interview On 1/26/26 at 11:30 a.m. Resident #1 was in her room with oxygen flowing at 2 LPM via nasal cannula. She said she was getting ready to go to the dining room for lunch. She said she did not have a portable oxygen tank. She said she only needed to have oxygen in her room. Resident #1's room did not have a portable oxygen tank for the resident to use. On 1/27/26 at 8:20 a.m. Resident #1 was in the dining room eating breakfast without a portable oxygen tank or nasal cannula. On 1/27/26 at 11:35 a.m. Resident #1 was in the dining room without a portable oxygen tank and nasal cannula. On 1/28/26 at 8:45 a.m. Resident #1 was in the dining room, coloring with markers in her marker book with no portable oxygen tank. On 1/28/26 at 10:45 a.m. Resident #1 was in the dining room, coloring with markers in her book with no portable oxygen tank. C. Record review Review of Resident #1's January 2026 CPO revealed the following physician's order: Oxygen at 2 LPM via nasal cannula continuously, ordered 1/6/24. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 1/28/26 at 10:40 a.m. LPN #1 said Resident #1 had a physician's order for oxygen at 2L nasal cannula continuously. LPN #2 was interviewed on 1/28/26 at 10:45 a.m. LPN #2 said Resident #1 had the right to refuse a portable oxygen tank. LPN #2 said she asked Resident #1 if she wanted to have a portable oxygen tank and Resident #1 said yes. LPN #2 said she went and got a newly sanitized portable oxygen, filled the tank and got her a nasal cannula. LPN #2 said she turned on the oxygen to 2 LPM and placed the nasal cannula on the resident. The DON was interviewed on 1/28/26 at 1:50 p.m. The DON said Resident #1 was on 2 LPM of oxygen via a nasal cannula continuously. The DON said each resident should be issued a portable tank and a regulator for their room when an oxygen order was written for the resident. The DON said it was important to follow the physician's orders because the resident could have low oxygen saturation. III. Resident #23 A. Manufacturer's instructions The [NAME] Compressor Nebulizer System instructions for use, undated, was provided by the nursing home administrator (NHA) on 1/28/26 at 4:14 p.m. It read in pertinent part, Converts liquid medicine into a mist by using compressed air technology, suitable for all ages for the treatment of the upper and lower respiratory tract. Cleaning: Following the cleaning instructions after each use will prevent any remaining medication in the bottle from drying, resulting in the device not nebulizing effectively, and will help prevent infections. Wash the nebulizer parts after each use. Dry the parts immediately after washing. Remove the inhalation accessory (mask or mouthpiece) from the nebulizer kit. Disconnect the air tubing from the nebulizer. Gently twist the inhalation top counterclockwise and lift to separate the nebulizer into two sections. Remove the baffle. Discard remaining medication. Rinse all the parts of the accessories (nebulizer kit, the mouthpiece and mask) in warm water and a mild detergent. Rinse thoroughly with warm water. Hand dry or air dry in a clean environment using a soft, clean lint-free cloth. Cleaning the device and the tube's outer surface: Use a cloth dampened with antibacterial detergent (non-abrasive and free of solvents of any kind). Assemble the nebulizer and store the nebulizer kit appropriately. Caution: The nebulizer kit should be replaced every six months. Disinfecting: You can disinfect daily by soaking the parts in medical disinfectant which is commercially available in some pharmacies. If your physician or respiratory therapist specifies a different cleaning procedure, follow their instructions. Effective disinfection is only possible if the nebulizer has been cleaned. Disinfect accessories (nebulizer kit, mask, mouthpiece) after the last treatment of the day. Disconnect all parts according to the above 1-5 steps. Fill a container, suitable to contain all the individual components to be disinfected, with a solution of drinking water and disinfectant, while respecting the proportions indicated on the packaging of the disinfectant itself. Completely immerse each individual component in the solution, taking care to avoid the formation of air bubbles in contact with the components. Leave the components immersed for the period of lime indicated on the packaging of the disinfectant, and associated with the concentration chosen to prepare the solution. Remove the components now disinfected and rinse thoroughly with lukewarm drinking water. Hand dry or air dry in a clean environment using a soft, clean lint-free cloth. Assemble the nebulizer and store the accessories in a dry, sealed bag. B. Resident status Resident #23, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses include vascular dementia, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, sleep apnea, dependence on supplemental oxygen and long term (current) use of inhaled steroids. The 11/17/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. She was dependent on one person for oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing and personal hygiene. She required supervision or touching assistance for rolling right and left, lying to sitting transfers and wheeling wheelchair. She required partial/moderate assistance for sit to stand transfers, chair to bed transfers, toilet transfers and shower transfers. The assessment indicated the resident received oxygen treatment. B. Observations On 1/26/26 at 1:24 p.m. Resident #23 had a nebulizer unit sitting on the television (TV) stand with the mask and tubing connected and sitting on the table. There was no storage bag. Resident #23 was lying in bed with her oxygen on via nasal cannula. On 1/27/26 at 9:31 a.m. Resident #23 was in the dining room area using a portable oxygen tank connected to her wheelchair. The nebulizer unit was on the TV stand and leaning against the TV. The face mask used for the nebulizer treatments was turned upside down and sitting on the TV stand. The tubing and mask was hooked up and connected to the nebulizer unit. C. Resident interview Resident #23 was interviewed on 1/28/26 at 12:35 p.m. Resident #23 said after a nebulizer treatment, which occurred four times a day, the nurse just left everything on the TV stand table. Resident #23 said she had never seen the nurses clean it. D. Record review Review of Resident #23's oxygen therapy care plan, initiated 1/30/25, revealed the resident required the use of oxygen continuously due to COPD. Interventions included to administer oxygen at 4 LPM via nasal cannula, dietary referral as indicated, completing labs as ordered and to report abnormal findings to physician, maintaining the head of bed elevated to level of comfort to promote oxygenation, monitoring and reporting signs of hypoxia (deficiency in the amount of oxygen reaching the tissues) to physician and observing oxygen precautions. -The care plan failed to include cleaning frequency for the nebulizer unit/accessories or cleaning instructions. Review of Resident #23's respiratory care plan, initiated 1/31/25, revealed the resident experienced shortness of breath (SOB) and trouble breathing with exertion and when lying flat due to COPD, obesity and obstructive sleep apnea (OSA). Interventions included in pertinent part, to administer medications as ordered and monitor for side effects/adverse reactions and effectiveness, monitor for shortness of breath, irregular respiration, wheezing, crackles, rhonchi, excessive secretions, coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, tightness of neck or chest muscles, malaise or fatigue and inform physician promptly, monitor vital signs, skin color, oxygen saturation, airway functioning and report abnormal findings to physician, position with head of bed elevated to prevent episodes of shortness of breath while lying flat. -The care plan failed to include cleaning frequency for the nebulizer unit/accessories or cleaning instructions. Review of Resident #23's additional respiratory care plan, initiated 1/31/25, revealed the resident was at risk for complications with the respiratory system due to COPD, OSA, obesity, oxygen dependence, and nicotine dependence. Interventions included in pertinent part, completing labs/chest Xray as ordered and reporting abnormal results to physician, monitor for shortness of breath and inform physician promptly, monitoring vital signs, skin color, oxygen saturation, and airway function, and providing oxygen therapy as ordered. -The care plan failed to include cleaning frequency for the nebulizer unit/accessories or cleaning instructions. Review of Resident #23's January 2026 CPO did not reveal physician orders indicating instructions on how to clean the nebulizer unit. Review of Resident #23's January 2026 medication administration record/treatment administration record (MAR/TAR) did not reveal documentation that cleaning was being completed. III. Staff interviews Unit manager #1 was interviewed on 1/28/26 at 12:40 p.m. Unit manager #1 said she was the unit manager of the secured behavioral health unit (Prasada). Unit manager #1 said she did not administer the treatments in her current role. She said she was aware of the treatments and had been trained on nebulizer treatments. Unit manager #1 said after a nebulizer treatment the nurse would rinse the accessories with water and let air dry on a cloth at the sink. Unit manager #1 said it was important to clean the nebulizer unit and accessories to rinse off particles, germs and leftover medication. Certified nurse aide (CNA) #8 was interviewed on 1/28/26 at 1:09 p.m. CNA #8 said she wiped equipment down on the unit such as blood pressure machines, tables in the dining room and walkers, but she did not clean the nebulizer units. Registered nurse (RN) #2 was interviewed on 1/28/26 at 1:50 p.m. RN #2 said she administered the treatments. RN #2 said she knew the nebulizer unit was working properly because when she pushed the green button the unit came on and she could hear it and see it puff during treatment. RN #2 said after administering the nebulizer treatment to Resident #23, she hung the mask on the hook of the machine which was sitting on the TV stand. RN #2 said she thought the night shift washed out the nebulizer/accessories and put on a towel to air dry. RN #2 said she had not seen an order for the night nurse to clean the unit. RN #2 said it was important to clean the nebulizer/accessories after each treatment to prevent an infection. The director of nursing (DON) was interviewed on 1/28/26 at 1:49 p.m. The DON said the nebulizer treatment process was to get medication from the cart as ordered, put the medication vial in the nebulizer unit, put the mask on the resident, and push start. The DON said after the nebulizer treatment, the nurses were responsible for cleaning the mask with running water, but not the tubes. She said then the nurse put it on the bedside table to air dry on a wash cloth. The DON said she thought the way to sanitize the unit was to use sani-wipes. -However, according to the manufacturer's recommendations the nebulizer machine should have been cleaned after each use by rinsing all the parts of the accessories (nebulizer kit, the mouthpiece and mask) in warm water and a mild detergent. Rinse thoroughly with warm water, hand dry or air dry. Disinfect daily by soaking the parts in medical disinfectant which is commercially available in some pharmacies, after the last treatment of the day (see manufacturer's recommendations above). The DON said it was important to clean the mask to prevent infections. The DON reviewed Resident #23's electronic medical record (EMR) and said she did not see any guidance or physician's orders on cleaning the nebulizer unit/accessories and there was nothing in Resident #23's care plan either. The DON said she would want physician's orders and a care plan to be there to prevent infections. The DON said she would do nurse education today to clean after every use and she would also add that to the care plan and get physician orders.

Based on record review and interviews, the facility failed to implement policies and procedures related to influenza immunizations for one (#5) of five residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to provide the influenza 2025/2026 vaccine to Resident #5. Findings include:I. Professional referenceAccording to the Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2025-26 Influenza Season, dated [DATE]. Retrieved on [DATE] from https://www.cdc.gov/mmwr/volumes/74/we/mm7432a2.htm?s_cid=OS_mm7432a2_w. It revealed in pertinent part, For most persons who require only one dose of influenza vaccine for the season, vaccination should ideally be offered during September or October. However, vaccination should continue after October and throughout the influenza season as long as influenza viruses are circulating and an unexpired vaccine is available.II. Facility policy and procedureThe Influenza Vaccination policy, undated, was received from the nursing home administrator (NHA) on [DATE] at 12:21 p.m. It revealed in pertinent part, The policy of this facility to minimize the risk of acquiring, transmitting or experiencing complicationsfrom influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Influenza vaccinations will be routinely offered annually from [DATE]st through [DATE]st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. Additionally, influenza vaccinations will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area. Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record or the staff's medical file.III. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO) diagnoses included dementia (decline in memory), hypertension ( high blood pressure), atrial fibrillation (abnormal heart function) and epilepsy (abnormal electrical impulses resulting in seizures).The [DATE] minimum data set (MDS) related the resident was severely cognitive impaired with a brief interview of mental status (BIMS) score of three out of 15. The MDS indicated the resident had received the influenza vaccine outside the facility. -However, review of Resident #5's electronic medical record (EMR) did not reveal the resident was administered the influenza vaccine (see record review below).B. Record reviewReview of Resident #5's vaccine records failed to indicate residents had received the 2025/2026 influenza vaccine. Review of Resident #5 EMR revealed a consent form that indicated the resident requested to receive the influenza vaccine upon admission ([DATE]). Review of the [DATE], [DATE] and [DATE] CPO did not reveal the resident had a physician's order for the influenza vaccine to be administered. The [DATE] CPO failed to have the influenza vaccine order until [DATE] (during the survey) when Resident #5 was administered the influenza vaccine by the facility. IV. Staff interviewsThe infection preventionist (IP) and the director of nursing (DON) were interviewed on [DATE] at 11:00 a.m. The IP said vaccines were looked up in the state immunization portal and tracked in the residents' medical records. The IP said all residents were asked annually and upon admission if they would like the Influenza vaccine. The IP said the facility held a flu vaccine clinic on [DATE]. The IP said after review Resident #5's vaccine records there was an error. The IP said it appeared he had received the vaccine from an outside provider but after further review (during the survey) it was found he had not received the vaccine. The DON said Resident #5 had received his influenza vaccine on [DATE] (during the survey).

Based on record review and interviews, the facility failed to ensure the resident was treated with respect and dignity and care was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life and recognized the resident for one of three units for dignity.Specifically, the facility failed to treat the resident with dignity during meals. Findings include:I. Facility policy and procedureThe Dignity policy, dated February 2021, was received from the nursing home administrator (NHA) on 1/30/26 at 12:21 p.m. It revealed in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights. For example, residents are: provided with a dignified dining experience.The Assistance With Meals/Mealtime policy, undated, was received from the NHA on 1/30/26 at 12:21 p.m. It revealed in pertinent part, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals.II. ObservationsDuring a continuous observation of the lunch meal on the memory care unit (MCU) on 1/26/26, beginning at 11:45 a.m. and ending at approximately 12:30 p.m. the following was observed: At 11:58 a.m. certified nurse aide (CNA) #4 was assisting Resident #26. CNA #4 was standing between Resident #26 and Resident #5 as she assisted Resident #26 with eating by spooning food into his mouth. Resident #5 told CNA #4 to sit down, CNA #4 responded that there were no chairs to sit on.Observations in the dining room revealed there was one open chair at another table.At 12:27 p.m., licensed practical nurse (LPN ) #4 was passing out meal trays in the MCU and then assisted Resident #40. LPN #4 stood next to Resident #40 despite there being a chair not in use at the table.On 1/27/26 at 11:32 a.m. continuous observation of the MCU lunch was observed. CNA #3 was standing next to Resident #5. After he attempted to stand from his wheelchair she began assisting him to eat with his spoon while she stood over him. At 11:49 a.m. CNA #3 was assisting Resident #40 with eating while standing over him. CNA #3 then went to assist Resident #42 and remained standing while assisting him to eat.III. Staff interviewsCNA #3 was interviewed on 1/28/26 at 1:44 p.m. She said she had only worked at the facility for about a month and part of her job was to assist residents in the dining room with eating. CNA #3 said when assisting residents to eat she should be seated in order to see their mouth to ensure food reached their mouth. CNA #3 said she did not realize she had stood over residents while assisting them. LPN #3 was interviewed on 1/28/26 at 1:57 p.m. She said there were about three to four residents on the MCU who required meal assistance. LPN #3 said staff should assist residents with eating while sitting to ensure they were at eye level and be able to interact with them. The director of nursing (DON) was interviewed on 1/29/26 at 12:38 p.m. She said the CNAs and the nurses on the floor were to provide meal assistance to residents. The DON said staff should be sitting at eye level when assisting residents to eat and communicating with them as well.

Based on observations, record review and interviews, the facility failed to ensure two (#3 and #1) of five residents were kept free from physical abuse out of five sample residents.Resident #3, was admitted on [DATE] with diagnoses of malignant neoplasm of left lung, heart failure, closed nondisplaced intertrochanteric fracture of left femur, unspecified dementia, pulmonary emphysema and post-traumatic stress disorder (PTSD). Resident #4, was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia with psychotic disturbance, cognitive communication deficit, hypertensive chronic kidney disease, and obstructive pulmonary disease.On [DATE] Resident #3 wandered into Resident #4's room. Resident #4 reacted and pushed Resident #3, which caused Resident #3 to fall. Resident #3 sustained a left femur fracture. Specifically, the facility failed to:-Protect Resident #3 from physical abuse by Resident #4; and, -Protect Resident #1 from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 10:39 a.m. It revealed in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors; and/or any other individual. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents, neglect of residents; and/or theft, exploitation or misappropriation of resident property. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. Protect residents from any further harm during investigations. II. Incident of physical abuse by Resident #4 towards Resident #3 on [DATE] A. Facility investigation The facility investigation, dated [DATE], documented Resident #3 wandered into Resident #4's bedroom. Resident #4 pushed Resident #3, causing him to fall. The investigation documented Resident #3 sustained a fracture of the intertrochanteric femur from the fall. The investigation documented Resident #4 was interviewed on [DATE]. Resident #4 said Resident #3 was walking and not in a wheelchair. The investigation documented both residents were placed on 15-minute checks. The staff reported the incident to the police, the physician and hospice. The staff also completed skin assessments, placed a stop sign on Resident #4's door and changed Resident 3's transfer status. A medication review was completed for Resident #3 and his care plan was updated. The investigation documented Resident #3 was not transferred to the hospital. B. Resident #3 (victim) 1. Resident status Resident #3, age [AGE], was admitted on [DATE] and expired on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included malignant neoplasm of left lung, heart failure, closed nondisplaced intertrochanteric fracture of left femur, unspecified dementia, pulmonary emphysema and post-traumatic stress disorder (PTSD). The [DATE] minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. He required assistance with transfers, personal care and bathing from one person. 2. Resident #3's representative interview Resident #3's representative was interviewed on [DATE] at 1:40 p.m. The representative said after Resident #3's fall (on [DATE]), the hospice nurse mentioned that even if the resident received treatment, his chances of a complete recovery were very low. She said the hospice nurse said it was time to reduce the pain and keep him comfortable. 3. Record review The [DATE] progress note, documented at 5:55 a.m., revealed a staff member heard a scream coming from Resident #4's bedroom. Two staff members went to check on the resident and observed Resident #3 on the floor on his left hip. The staff members asked Resident #4 what happened to Resident #3. Resident #4 admitted he pushed Resident #3 after he (Resident #3) opened his (Resident #4) door and came into his bedroom, causing Resident #3 to fall. The nurse performed a full-body assessment and 72-hour neurological checks and risk management were started. The staff notified the on-call nurse, the NHA, the resident's representative and hospice of the incident. Resident #3 had pain in his hip and sustained a fracture of the left femur. The comprehensive care plan, revised [DATE], documented Resident #3 required a wheelchair and one-person assistance for mobility. C. Resident #4 (assailant) 1. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included Alzheimer's disease, dementia with psychotic disturbance, cognitive communication deficit, hypertensive chronic kidney disease and obstructive pulmonary disease. The [DATE] MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. He required assistance with transfers, bathing and personal care from one person. 2. Observations On [DATE] at 10:50 a.m. Resident #4 was in his room and there was a stop sign on his door. At 3:20 p.m. Resident #4 was in his room and there was a stop sign on his door. 3. Record review The behavior care plan, revised [DATE], revealed Resident #4 was at risk for behavioral symptoms (striking out, grabbing others, combative, verbally, or physically abusive and violent behavior) due to his dementia with moderate psychotic disturbance. The care plan documented he preferred his personal space and kept his door closed because he did not like others coming into his room to invade his privacy. Interventions included documenting/recording behavioral episodes, encouraging the resident to verbalize feelings, investigating and reporting all allegations, managing environmental factors to optimize comfort, notifying the physician and the family of episodes of aggression and abusive behaviors, and social services visits and monitoring/documenting physical aggression (hitting, kicking, pushing, grabbing, biting, spitting or throwing objects). The [DATE] progress note, documented at 6:49 a.m., revealed a nurse heard a scream coming from Resident #4's room. On arrival, the nurse noted another resident on the floor. Resident #4 was standing in the entryway of his bathroom. Resident #4 stated that Resident #3 pushed the door to come in, then Resident #4 pushed Resident #3 which caused him to fall. Fifteen-minute checks were started. D. Staff interviews Certified nurse aide (CNA) #2 was interviewed on [DATE] at 3:54 p.m. CNA #2 said Resident #4 rarely left his bedroom and got very upset when somebody entered his room without knocking on the door. CNA #2 said before the incident with Resident #3, the staff tried to prevent other residents from going to Resident #4's bedroom. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 4:19 p.m. LPN #1 said the staff placed a stop sign on Resident #4's door after the incident on [DATE] with Resident #3. LPN #1 said the staff tried to be vigilant with other residents and redirect them when they went close to his room. LPN #1 said Resident #4 liked his personal space. LPN #1 said before the incident on [DATE], the staff had similar interventions implemented and Resident #4 did not have any previous incidents with other residents. LPN #1 said Resident #4's biggest behavioral trigger was when people walked into his bedroom. LPN #1 said after the incident, the staff posted a stop sign on the resident's door and that prevented other residents from entering his room. LPN #1 said Resident #3 was on hospice services when the incident occurred. The director of nursing (DON) was interviewed on [DATE] at 12:06 p.m. The DON said before the incident between Resident #3 and Resident #4, the staff designated a private room at the end of the hall for Resident #4. The DON said before this incident, there were no issues with other residents. The DON said the incident was unwitnessed. The NHA was interviewed on [DATE] at 12:15 p.m. The NHA said before the incident, there was a knock on the door sign posted on Resident #4's door. The NHA said Resident #4 admitted he pushed Resident #3 with the intention to make him leave his room, which caused Resident #3 to lose his balance and fall. III. Incident of physical abuse by Resident #2 towards Resident #1 on [DATE] A. Facility investigation The NHA provided the [DATE] facility investigation on [DATE] at 4:23 p.m. it revealed the altercation occurred on [DATE]. The investigation documented Resident #1 was interviewed on [DATE] by the social services assistant. Resident #1 reported he was just sitting on the couch and Resident #2 he hit him on his right eye. Resident #1 denied being fearful saying he was not scared of anything. The investigation documented Resident #2 was interviewed on [DATE] by the social services assistant. Resident #2 reported he did not know what happened, he just saw him (Resident #1) and hit him. The investigation revealed Resident #5 was the resident who went and notified the staff of the altercation. Resident #5 was interviewed on [DATE]. Resident #5 reported he had seen Resident #2 hit Resident #1. Resident #5 said Resident #1 did not hit back and just walked away. Resident #5 said Resident #1 was just sitting on the couch at the time of the altercation. The investigation documented the facility substantiated the altercation. B. Resident #1 (victim) 1. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included schizoaffective disorder (mood disorder), chronic obstructive pulmonary disorder (ineffective oxygen exchange), hypothyroidism (imbalance of thyroid hormones) and hyperlipidemia (elevated lipids levels in blood). The [DATE] MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. He required supervision assistance with toileting. He required setup assistance with dressing, personal hygiene and eating. He was independent with bed mobility, transfers and ambulation. 2. Observations During a continuous observation on [DATE], beginning at 12:45 p.m. and ending at 1:53 p.m. the following was observed: At 12:45 p.m. Resident #1 was sitting on the couch in the dining room. Resident #1 was making hand movements in circular motion. Resident #1 then went to the patio door, collected an apron and sat outside on a bench waiting for smoking time. Several other residents began to join him on the patio. At 1:18 p.m. Resident #1 returned from his smoking break and sat in a chair in the dining room. At 1:31 p.m. Resident #1 began pacing in the dining room with his hands on his hips or swinging back and forth while pacing. 3. Record review A progress note, dated [DATE] at 9:24 p.m., revealed an unidentified resident went a to nurse and said Resident #2 hit Resident #1. The progress note documented the facility reviewed the video footage and it revealed that Resident #1 was sitting on the dining room couch when Resident #2 approached him and swung at his head. Resident #1 and Resident #2 were separated and went to their rooms. Resident #1 reported that he was hit in the right eye but denied pain and verbalized he was okay. Resident #1 reported he was not afraid of Resident #2. A progress note, dated [DATE] at 12:54 a.m., documented Resident #1 complained of pain to the right side of his face. Resident #1 was administered pain medication. There was no bruising or raised area to the resident's face noted. A physician's note, dated [DATE] at 2:49 p.m., revealed Resident #1 was the victim in an altercation with another resident (Resident #2) who smacked him in the face, causing a small ecchymosis (bruising or discoloration) in their periorbital area/blackeye. The facility reported that Resident #1 was at baseline since the altercation and his black eye was improving/resolving. C. Resident #2 (assailant) 1. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included schizoaffective disorder, type 2 diabetes (abnormal glucose levels) and gastroesophageal reflux disease (stomach acid flows backward into the esophagus). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required setup assistance with eating, toileting, dressing and personal hygiene. He was independent with bed mobility transfers and ambulation. The assessment indicated the resident had hallucinations. 2. Observations During a continuous observation on [DATE], beginning at approximately 12:45 p.m. and ending at 1:53 p.m., the following was observed: At approximately 12:45 p.m. Resident #2 came out of his room and sat on the couch in the dining room in between two unidentified residents. A few minutes later, an unidentified staff member approached Resident #2 and asked if they could chat. The unidentified staff member offered a more private location to talk, however Resident #2 refused. The resident reported feeling fine and he was then specifically asked by the staff member about his anxiety and his sleeping patterns. After the visit, Resident #2 had water and returned to his room. Resident #2 was in and out of his room several times during the observation to collect water from the water dispenser in the dining area. At 1:41 p.m. Resident #2 came out of his room and was heard yelling down the hall at an unidentified staff member. Resident #2 threw away a pizza box then went down the hall to talk with staff. 3. Resident #2's interview Resident # 2 was interviewed on [DATE] at 9:53 a.m. Resident #2 reported he felt safe in the facility and he had no issues with other residents who resided in the facility. Resident #2 said he did not want to talk about the altercation between him and Resident #1. 4. Record review The psychosocial behavior care plan, revised on [DATE], revealed Resident #2 was at risk for behavioral symptoms, such as striking out, grabbing others, combativeness, verbally/physically abusive due to delusions, auditory commanding hallucinations and schizoaffective disorder. The care plan documented the goal was for the resident to accept supportive strategies and demonstrate adequate control of his emotions, which would not result in injury to himself or others. Pertinent interventions included providing diversional activities, administering medications, monitoring for side effects of medications, encouraging the resident to verbalize his feelings and observing the resident for potential triggers. A progress note, dated [DATE], revealed an unidentified resident reported to staff that Resident #2 had hit Resident #1. Resident #2 reported he did not know why he hit Resident #1, but he just got really mad. Resident #2 was placed on 15-minute checks and was in his room. A nurse progress note, dated [DATE], documented stat (immediate) labs were ordered for Resident #2. A physician's progress note, dated [DATE] at 2:52 p.m., revealed the visit was for a post-altercation with another resident. Resident #2 did not provide details of the altercation. The note documented, per the facility, Resident #2 slapped another resident (Resident #1) for an unknown reason. Resident #2 denied auditory/visual hallucinations at the time of the visit. E. Staff interviews CNA #1 was interviewed on [DATE] at 2:02 p.m. CNA #1 said she received information about each resident's behaviors during the report at shift change. She said she also got to know the residents to learn about their behaviors. CNA #1 said Resident #2 talked to himself, laughed, wrote down notes and could have outbursts at times. CNA #1 said his aggression was random and hard to know when it would happen. CNA#1 said early signs of Resident #2 having an outburst included if Resident #2 reported he was hearing voices, when he was not focused on any activities or when he was distracted. CNA #1 said staff were to check in with Resident #2 when this occurred and provide a safe space for Resident #2, which was usually his room. CNA #1 said she was aware of Resident #2 having several altercations with other residents. She said the altercations were always with a different resident. CNA #1 said Resident #1 stayed to himself and was not very social with others. CNA #1 said Resident #1 was always noted to be moving his hands/arms and would talk to himself. CNA #1 said Resident #1 enjoyed being outside as it seemed that it comforted him. CNA #1 said Resident #1 did not bother other residents. CNA #1 said the altercation between Resident #1 and Resident #2 came out of nowhere. She said she was not on the unit at the time of the altercation but was told about it on her next shift on the unit. CNA #1 said she did not see any changes to their behaviors post-incident but the staff kept a close eye on them. Registered nurse (RN) #1 was interviewed on [DATE] at 9:47 a.m. RN #1 said Resident #1 kept to himself and did not bother other residents. RN #1 said Resident #2 was often conversing with other residents. RN #1 said Resident #2's triggers for behavioral outbursts occurred when Resident #2 was pacing and when he was responding/talking to himself. RN #1 said Resident #2 had internal stimuli that he responded to. RN #1 said if Resident #2 was aware of hearing the voices he would go into his room where he felt the safest. She said the staff would check on him to help him recognize what was real and what was not. RN #1 said she was aware that Resident #2 had been in several resident-to-resident altercations. RN #1 said the altercation between Resident #1 and Resident #2 happened fast. She said Resident #1 was sitting on the couch when Resident #2 came out of his room, hit him (Resident #1) and then went back to his room. RN #1 said Resident #2 was not remorseful at the time of the altercation but later reported his internal stimuli told him to do it. The social services director (SSD) and social services assistant #1 were interviewed together on [DATE] at 11:54 a.m. Social services assistant #1 said Resident #1 kept to himself. The SSD said Resident #2 would talk with other residents and partake in smoke breaks. Social services assistant #1 said Resident #2 would become quiet with everyone prior to an event. The SSD said Resident #2 had been receiving mental health services for his physical aggression. The SSD said after every altercation Resident #2 was involved in, the facility would review the altercation and had not found any similarities. The SSD said Resident #2 did not really have triggers that they had been able to identify due to his diagnoses with command hallucination. The SSD said Resident #2 did not always notify the staff that he was having hallucinations. The SSD said if he did notify the staff or the staff noticed the resident was off, the staff were to talk to him to de-escalate him. The SSD said the altercation on [DATE] happened so quickly. The DON was interviewed on [DATE] at 12:06 p.m. The DON said Resident #1 kept to himself and he had a lot of hand movements. The DON said Resident #2 had hallucinations. The DON said Resident #2 was pretty quiet upon admission, but he had opened up more and told staff when he was having hallucinations. The DON said after any altercations, the facility completed a clinical review consisting of a medication review by the consulting pharmacy, physician follow-up, blood work and psychological follow-up and monitoring. The DON said Resident#2 had been in several resident-to- resident altercations since [DATE] and the facility had not been able to identify any patterns. The DON said the facility had all staff complete a crisis prevention intervention training (CPI) to aid interventions. The NHA was interviewed on [DATE] at 12:22 p.m. He said the residents on the Prasada unit were a younger population. The NHA said Resident #2 usually kept to himself, but would interact with staff and other residents. The NHA said the staff had been trying to navigate Resident #2's impulses since his last altercation. The NHA said Resident #2 was receiving mental health services and he had opened up.The NHA said he had begun to be more active in activities. The NHA said Resident #2 did not realize what occurred in the moment when the altercation between Resident #1 and Resident #2 occurred, however, later he recognized something happened and he (Resident #2) was in the wrong.

Based on record review and interviews, the facility failed to ensure one (#3) of three residents received adequate supervision to prevent accidents out of eight sample residents. The facility failed to develop and implement a person-centered care plan upon Resident #3's admission to the facility that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury. Resident #3 fell on [DATE] (10 days after his admission to the facility) and sustained a T12 to L1 fracture, which required surgical intervention. The facility failed to ensure Resident #3 was assessed by a qualified person, a registered nurse (RN), prior to Resident #3 being moved off the floor. Findings include: I. Facility policy and procedure The Fall Prevention Program policy and procedure, implemented March 2020, was provided by the nursing home administrator (NHA) on 2/26/25 at 12:08 p.m. It revealed in pertinent part, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground, or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. The nurse will refer to the facility's high risk or low/moderate risk protocols when determining interventions. High risk protocols: the resident will be placed on the facility's fall prevention program: indicate fall risk on care plan, place fall prevention indicator on the name plate to the resident's room and place fall prevention indicator on resident's wheelchair; implement interventions from Low/Moderate Risk Protocols, provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status or recent changes in functional status; provide additional interventions as directed by the resident's assessment, including but not limited to: assistive devices, increased frequency of rounds, sitter if indicated, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education and therapy services referral. Low/Moderate risk protocols: implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: a clear pathway to the bathroom and bedroom doors, bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed, call light and frequently used items are within reach, adequate lighting and wheelchair and assistive device are in good repair; implement routine rounding schedule; monitor for changes in resident's condition, gait, ability to rise/sit and balance; encourage residents to wear shoes or slippers with non-slip soles when ambulating; ensure eye glasses are clean and the resident wears them when ambulating; monitor vital signs in accordance with facility policy; and complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. When any resident experiences a fall, the facility will: assess the resident, complete a post fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions and obtain witness statements in the case of injury. II. Resident #3 A. Resident status Resident #3, age 81, was admitted on [DATE] and discharged to the hospital on 12/23/24. According to the December 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with agitation and a history of falling. The 12/5/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. He was dependent on staff for toileting and transfers and substantial to maximal assistance with showering, dressing and bed mobility. It indicated he used a manual wheelchair and a walker for mobility. B. Resident #3's representative interview The resident's representative was interviewed on 2/25/25 at 4:49 p.m. The representative said Resident #3 fell out of bed on 12/23/24 at 4:00 a.m., but the facility did not contact her until 7:15 a.m. She said she asked why she was not contacted when the fall happened, but the facility staff did not have an answer. She said she was informed Resident #3 had rolled out of bed. She said Resident #3 was transported to the hospital later that night and MRI (diagnostic imaging) and CT (diagnostic imaging) scans were completed. She said the results showed Resident #3 had fractured his lower back. She said the physician at the hospital said when a resident fell out of bed without a mat, the injury could be significant. The representative said while Resident #3 was at the facility, his bed was never low to the ground. She said she was 5 feet, 3 inches tall and the bed was consistently waist high. She said she went to visit him at the facility every day. She said there was never a fall mat in place next to the bed. She said she asked the facility to consider putting side rails on the bed because Resident #3 said he kept feeling like he was going to fall out of bed. She said the therapist said he would benefit from small side rails at the top of the bed, however the facility never installed them. C. Record review 1. Resident's history The 11/17/24 hospital progress notes documented Resident #3 presented at the hospital with a functional decline at home including multiple falls with the caregiver unable to keep the resident safe. It indicated the resident's responsible party said he had experienced multiple falls at home. The 12/13/24 admission nursing summary progress note documented Resident #3 was admitted for hospitalization for COVID-19 and sepsis (infection of the blood). The resident required a wheelchair and a front wheeled walker for mobility. The 12/13/24 admission evaluation/assessment documented Resident #3 was alert with short-term and long-term memory impairments and was oriented to self and place. The resident was non-ambulatory and required assistance with transfers, dressing, bathing, grooming/hygiene, toileting and bed mobility. There were no bed rails attached to the bed. The 12/16/24 physician admission history and physical documented the resident was admitted following a urinary tract infection with sepsis, stage four chronic kidney disease, hypertension (high blood pressure) and paroxysmal atrial fibrillation (type of heart rhythm disorder characterized by short, irregular episodes of rapid heart rate that originate in the upper chambers of the heart. The physician documented the resident had functional impairments and cognitive deficits with potential high risk for frequent falls The 12/13/24 fall risk assessment documented Resident #3 sustained three or more falls in the past 90 days, had moderately impaired vision, ambulated with problems and with devices, the resident displayed the following behaviors: easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varied over the course of the day; and had three of more circulatory/heart conditions. This assessment concluded the resident was considered a high risk for falls, scoring 32 out of 42. The 12/13/24 rehabilitation screening form documented Resident #3 was a new admission with observable functional and cognitive deficits. The resident leaned to the right and was unable to hold up his bilateral lower extremities when seated. The resident reported back pain with transfers and required physical, occupational and speech therapy. The 12/16/24 bed rail and entrapment assessment documented that bed rails were being considered for use for the left and right upper portion of the bed. The resident had significant difficulty engaging in bed mobility and required significant assistance. It indicated the bed rails would reduce back pain with self-repositioning and assist with bed mobility and transfers. The assessment recommended to install bedrails on Resident #3's bed, however the rails were never installed as indicated (see resident representative interview above and staff interviews below). The activities of daily living (ADL) care plan, initiated on 12/14/24, documented Resident #3 was at risk for ADL/mobility decline and required assistance related to chronic disease progression, cognitive impairment and a recent hospitalization . Resident #3 required assistance of one staff member with bed mobility and assistance of two staff members with transfers. The fall risk care plan, initiated on 12/14/24 and revised on 12/16/24, documented Resident #3 was at risk for falls with or without injury related to altered balance while standing and/or walking, altered mental status, hearing impairment, hypoglycemia (low blood sugar), unsteady gait, type 2 diabetes, pain, recent illness and protein caloric malnutrition. The interventions, initiated on 12/14/24, included anticipating and meeting the resident's needs, educating and reminding the resident to call for assistance with all transfers; encouraging the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; keeping the call light within reach and obtaining a physical and occupational therapy consult as indicated. -The facility failed to develop the comprehensive care plan to include person-centered interventions and address the residents' history of falls and recent ADL decline. 2. Fall incident on 12/23/24 The 12/23/24 nursing progress note, documented at 4:08 a.m. by licensed practical nurse (LPN) #1, revealed Resident #3 was alert and able to make his needs known. Resident #3 was found on the floor by the certified nurse aide (CNA). The note documented the resident said he said he tried to stop himself, but he could not and fell off the bed. He said the bed was too small. LPN #1 documented Resident #3 did not hit his head (however, this could not be verified since the fall was unwitnessed), had no bruising, was able to move all extremities and denied pain. His neurological checks were within normal limits. A review of Resident #3's electronic medical record (EMR) did not reveal documentation of Resident #3 being assessed by a RN prior to being moved off the floor (see staff interviews below), nor vital signs taken. -At 2:33 p.m. Resident #3 experienced an episode of hypotension (low blood pressure) of 86/58 milliliters of mercury (mmHg). The nurse left a message for the physician. -At 3:31 p.m. Resident #3 was still experiencing hypotension when the physician called back. The physician ordered the resident to be sent to the hospital. The 12/23/24 hospital notes documented Resident #3 presented to the emergency room following a fall with a sustained vertebral fracture. The CT scan of the thoracic spine demonstrated an acute distraction fracture through the T12 to L1 intervertebral disc space with 1.5 centimeters (cm) diastases across the injury. The 12/24/24 interdisciplinary team documented that on 12/23/24 at approximately 4:00 a.m., Resident #3 was found down on the floor at the side of the bed. The resident said he was trying to turn in bed and rolled out. The interventions included placing a fall mat at the side of the bed and providing the resident with a bariatric bed. The 12/24/24 rehabilitation post-fall screen documented Resident #3 rolled out of bed when he attempted to turn and reposition himself. It indicated Resident #3 would benefit from a fall mat and a bariatric bed to reduce the risk of falls out of bed. The 12/24/24 neurologist hospital progress notes documented Resident #3 presented with an unwitnessed fall and sustained an unstable fracture with hypotension. The resident was found to be possibly septic and imaging revealed a three column injury, a traumatic fracture with distraction/extension at the T12 to L1. The resident wished to proceed with surgical stabilization. The 12/27/24 operative note documented the surgeon performed an open reduction and stabilization of the T12 and L1 vertebral body fracture. The surgeon documented in pertinent part, Resident #3 was an [AGE] year old male found to have a T12 to L1 fracture III. Staff interviews The director of nursing (DON) was interviewed on 2/26/25 at 10:48 a.m. The DON said Resident #3 sustained a fall on 12/23/24 at approximately 4:00 a.m. She said Resident #3 rolled out of the bed on his right side. She said the resident was not on a low bed at the time of the fall. She said she thought a fall mat was present, however, she was unable to find documentation that it was in place. The DON said immediately following a fall and prior to a resident being moved from the ground, the resident must be assessed by a RN. She said the RN assessment was important in determining if an injury occurred. She said a LPN was unable to conduct an assessment because it was outside their scope of practice. She said Resident #3 was not assessed by a RN immediately following the fall. The DON said there was a RN in the facility at the time of Resident #3's fall, but the LPN chose not to get the RN to perform an assessment. She said, at approximately 8:00 a.m., when she arrived to the facility, she performed an assessment of Resident #3, however she said she did not document that assessment in the resident's EMR. The DON said she was aware Resident #3 sustained a fracture to the back once he was evaluated at the hospital. She said Resident #3 had complained of back pain throughout his stay at the facility, however she did not know what it was attributed to. The DON said Resident #3 fell at 4:00 a.m. and the resident's responsible party was not contacted until 8:04 a.m. She said she did not have a good reason as to why the facility waited four hours to contact the resident's family. The DON confirmed an assessment was conducted to determine if bed rails were appropriate and safe for Resident #3, based on his responsible party's request. She said it was determined that partial upper side rails would be both safe and effective for Resident #3, however, she said they were never installed on the bed. She said Resident #3 was over six feet tall and they decided to order the resident a bigger bed before installing the partial side rails. -However, the DON was unable to provide documentation to show the facility had ordered a bigger bed for Resident #3. The DON said the fall interventions documented on the resident's comprehensive care plan were not person-centered. She said the facility was waiting on the therapy department to implement person-centered interventions. She acknowledged Resident #3 had been in the facility for 10 days at the time of the fall. She said the facility staff did not think to put the intervention of a low bed in place for Resident #3. The primary care physician (PCP) was interviewed on 2/26/25 at 1:32 p.m. The PCP said Resident #3 was admitted with a history of frequent falls. He said Resident #3 was a little non-cooperative with care when he was first admitted , however after a couple of days, he was compliant with care. He said he did not feel the bed was unusually high, however, he said he would have liked to have seen the facility implement a fall mat. The PCP said a distraction fracture typically was caused from a motor vehicle accident and was known as a seatbelt fracture. He said it was possible the fracture was caused from the fall if he rolled in a weird way out of the bed, but unlikely. However, he said he did not have any other explanation for how Resident #3 sustained an acute fracture of the T12 to L1 intervertebral disc space for Resident #3 other than the fall.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting one (#1) out of three residents reviewed for accident hazards of three sample residents. The facility failed to provide adequate supervision during a smoking break to a resident, who required the use of oxygen. On 8/21/24 Resident #1 exited the behavioral health secured unit door and entered the smoking patio with his oxygen tank and nasal cannula on his face. Certified nurse aide (CNA) CNA #1 and CNA #2 were present to supervise the resident smoking session. CNA #1 was handing out the cigarettes to the residents and CNA #2 was lighting the cigarette for the residents. Resident #1 reached over other residents for his cigarette and CNA #1 handed him a cigarette. Resident #1 proceed to the line to get his cigarette lit. CNA #2 lit his cigarette but did not observe that the resident's oxygen was in place. Resident #1 proceeded to a chair in the corner of the smoking patio and began smoking his cigarette. CNA #1 and CNA #2 saw another resident running towards Resident #1 and patting his hair which was on fire. Both CNAs ran to Resident #1 and the fire had already been extinguished. CNA #2 immediately removed the resident's nasal cannula and oxygen tank. CNA #2 turned the oxygen off and both CNAs escorted the resident to the nurse's station. The nurse immediately called 911 and sent Resident #1 to the hospital related to the burns on his face. Due to the facilities failure to ensure adequate supervision while residents were smoking, Resident #1 sustained burns to his forehead, tip of his nose, both nostrils, upper and lower lip and his cheeks. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/4/24 to 9/5/24, resulting in the deficiency being cited as past noncompliance with a correction date of 8/21/24. I. Accident investigation The 8/20/24 accident investigation was provided by the NHA on 9/4/24 at 10:30 a.m. The investigation documented the nurse was alerted by CNA #1 and CNA #2 that Resident #1 had been burned when his oxygen ignited while he was smoking on 8/20/24 at approximately 4:00 p.m. The nurse completed first aide to Resident #1 while waiting for emergency medical services (EMS) to arrive. The paramedics took over the resident's care of the visible burns and were attempting to keep his airway clear. The resident was sent to the emergency department. The hospital notes revealed that soot (ashes from the fire) was present in the posterior oropharynx (the back wall of the throat). The physician, the police, the nursing home administrator (NHA), the director of nursing (DON), the ombudsman and the resident's guardian were notified of the incident. The staff members that were involved were provided education on the smoking policy and suspended pending an investigation. Resident #1 was interviewed by the nurse and the DON immediately following the incident. Resident #1 said he was sorry that he had forgotten to take his oxygen off before entering the smoking patio. He said he was afraid he had ruined the smoking session for everyone. He said his face hurt. When Resident #1 returned from the hospital, the nurses progress note on 8/22/24, stated he said the staff had saved his life and that he was so happy to be home. II. Facility corrective action A. Immediate action The NHA, the police department, the DON, the ombudsman and the resident's legal guardian were notified of the incident. Resident #1 was immediately transferred to the hospital for evaluation and treatment of his burns. The two employees that were involved were immediately educated on the smoking policy and suspended pending an investigation. All staff working in the facility at the time of the incident were provided reeducation on the smoking policy. The following day (8/21/24) the remainder of facility staff were reeducated on the smoking policy with return demonstration. B. Interventions put into place The facility reviewed their current policy 8/20/24, to ensure appropriate procedures were in place to prevent harm /potential harm. The policy met all the criteria of what was needed and all of the staff were reeducated on the smoking policy. The incident was in violation of the policy and procedure, so all of the residents who smoked and all of the staff present at the time of the incident were educated on the policy immediately that day (8/20/24). In addition, all staff that were not present were educated the following day (8/21/24). The NHA would ensure that all newly hired staff would receive education on safe smoking and the facility policy. The education given included the following information: Smoking while using oxygen can be extremely dangerous and can lead to serious consequences. Oxygen is a medical gas that can increase the risk of fire when used in the presence of smoking. While oxygen itself isn't flammable, an oxygen-rich environment can cause materials to ignite more easily and burn faster. This includes flammable substances like cigarettes, which can burn hotter and faster in an oxygen rich environment. Oxygen molecules can also cling to clothing, hair, skin and ignite if they come into contact with the flame. Smoking while using oxygen can lead to catastrophic consequences, including severe injuries, property damage, and loss of life. Some people have been left with serious facial or upper body burns after smoking while on oxygen. It is our responsibility to ensure that we are protecting our residents from harm. It is our job to ensure that residents who smoke have appropriate personal protective equipment (PPE) if needed and do not have oxygen on. If a known oxygen user is also a smoker, staff is to ensure that the oxygen tank is turned off and left inside the building prior to handing out any cigarettes. Residents smoking times is not a time for staff to be on the phone, texting, or playing games. When supervising a resident smoke break, staff need to be actively supervising the residents. Newly admitted residents would be assessed for history or current smoking upon admission. The facility initiated daily random audits of all three units on 8/21/24 to monitor residents who required supervision for smoking. The monitoring included oxygen use, assistive devices, burn holes in clothing/chair cushions, supervision, that staff had all smoking equipment in their possession and any resident concerns. The DON or designated supervisor was to continue the audits for three months. III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the September 2024 computerized physician orders (CPO), the diagnoses included Schizophrenia (mental disorder that causes abnormal behaviors), other psychoactive substance abuse, chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen and nicotine dependence. The 8/12/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He had no behaviors and did not reject care. He was independent with all of his activities of daily living (ADL). He received oxygen therapy. -The MDS assessment did not indicate the resident smoked. B. Record review The smoking care plan, initiated on 6/19/23 and revised on 8/23/24, revealed Resident #1 currently smoked with direct supervision from a staff member during designated smoking times per facility protocol. Resident #1 was forgetful at times and would ambulate into the smoking designated area with his oxygen present. The interventions included: evaluating the residents ability to smoke safely upon admission, reevaluated quarterly, upon significant change and as determined by qualified staff, instructing and informing Resident #1 about the facility policy on smoking, locations, times, safety concerns and any changes,monitoring for unsafe smoking practices notifying the charge nurse immediately if it was suspected resident had violated the facility smoking policy,providing Resident #1 the required supervision while smoking, storing Resident #1's smoking supplies in the nurse's station, and assisting Resident #1 in removing his oxygen prior to going out into any designated smoking areas. The smoking care plan also documented that the facility could impose smoking restrictions on a resident at any time if it was determined that the resident could not smoke safely with the available levels of support and supervision; and, that the facility maintained the right to confiscate smoking items found in violation of facility smoking policies. A physician's order, dated 5/21/24, revealed the resident was receiving continuous oxygen at three liters per minute (LPM) via a nasal cannula. A readmission progress note dated 8/22/24 at 4:46 p.m. revealed Resident #1 was readmitted to the facility from the hospital post smoking/burn incident. It documented Resident #1 had extensive reddened/burned areas to his nose, cheeks, lips and chin. As well as various small blisters and open/seeping blisters to his face with edema (swelling) throughout. III. Staff interviews CNA #1 was interviewed on 9/4/24 at 1:15 p.m. CNA #1 said she was one of the CNAs supervising the smoking session at the time of the incident on 8/20/24. She said she had worked at the facility for nine years, but usually worked in the memory care unit. She said she received education on the smoking policy and the needed equipment. such as a smoking apron. She said she was educated to ensure residents were smoking safely. She said that prior to the incident Resident #1 rounded the corner of the dining room without his walker and was carrying his oxygen tank. She said Resident #1 returned to his room to retrieve his walker while she attended to another resident. She said Resident #1 usually had his oxygen tank attached to his walker, left the walker at the door and removed his oxygen from his face. CNA #1 said after she attended to a resident, it was time to take the residents out for their smoking session. She said all of the residents that smoked, lined up to receive their cigarettes. She said she was passing the cigarettes one by one to each resident. She said Resident #1 was eager to smoke and reached over the other residents to retrieve his cigarette. She said she did not see his face and did not know he was still wearing his oxygen. She said Resident #1 had long hair which was in his face and he always left his oxygen tank attached to the walker at the door. CNA #1 said CNA #2 was lighting the cigarettes in a separate line. She said Resident #1 sat down to smoke his cigarette as the staff continued to pass and light cigarettes for the other residents in line. She said she saw another resident run up to Resident #1 and pat his hair to put the fire out. She said she yelled to CNA #2 that Resident #1 was on fire while running to the resident. She said by the time she arrived to Resident #1, the fire was already out. She said CNA #2 immediately grabbed the oxygen tank and turned it off. She said the nasal cannula had burned away. She said her and CNA #2 then escorted Resident #1 inside the nurses station for treatment. She said the nurse called 911 and treated the resident's burns while awaiting EMS. She said the resident was then sent to the hospital. She said the DON immediately reeducated her on the smoking policy and she was suspended pending the investigation. CNA #2 was interviewed on 9/5/24 at 9:51 a.m. CNA #2 said it was the normal smoke session and CNA #1 had heard out to the smoking patio while he ran to do something quickly in the office. He said he hurried outside to assist CNA #1. He said CNA #1 had already begun passing cigarettes out. He said he had his lighter and to make the process faster he started to light the cigarettes. He said he lit Resident #1's cigarette but did not notice he was still wearing his oxygen. He said he was not paying attention as well as he should have been. He said Resident #1 walked over to a chair and sat down to smoke his cigarette while he continued to light other resident's cigarettes. CNA #2 said he then heard another resident yelling that his hair was on fire, He said he looked up and saw a resident patting at Resident #1's hair. He said he ran over to the residents and removed the oxygen tank and turned it off. He said the nasal cannula had burned away. He said he and CNA #1 helped the resident back into the building to the nurse's station. He said Resident #1 usually was good about taking his oxygen off and leaving it at the door on his walker. He said everything moved so quickly he did not pay attention to Resident #1's face and nose area. He said the staff had to constantly keep their eye on everyone. He said he still [NAME] guilty for not observing Resident #1's oxygen and lighting his cigarette. He said he was immediately reeducated on the smoking policy and suspended pending an investigation. The NHA was interviewed on 9/5/24 at 10:43 a.m. The NHA said when the incident occurred two CNAs were present. He said Resident #1 required supervision with supervised smoking and was the only resident receiving oxygen therapy in the behavior health unit that smoked. He said the smoking material was kept at the nurse's station for safety and the residents had scheduled smoking times. The NHA said each resident had been assessed for safe smoking practices. He said if a resident was assessed as safe to light their own cigarette, they were allowed to light it themselves. He said if they were assessed as not safe to light their own cigarette, staff would light it for them. He said on the day of the incident the staff should have been aware of whether the resident was wearing his oxygen or not. He said oxygen should always be removed before smoking. He said both CNA #1 and CNA #2 were reeducated on the smoking policy and procedure and were suspended pending an investigation. He said both of the CNAs returned to working the floor after the suspension and a written performance review was completed. He said the facility immediately reeducated all staff on the smoking policy. He said every resident was reassessed for smoking safety and the smoking policy was revamped to include that the supervised monitor was responsible for removing the oxygen and oxygen tubing at the nurses station before the smoking session. The NHA said in addition to the measures they put in place to prevent the incident from happening again, the facility requested the local fire marshal to assess the smoking area at the facility.

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Take the appropriate measures to mitigate mice populations in the facility including failing to eliminate or minimize food sources; and, -Attempt to eliminate mice from entering the facility through door gaps and holes. Findings include: I. Professional reference According to the Center for Disease Control (CDC), revised July 2019, Guidelines for Environmental Infection Control in Health-Care Facilities, retrieved on 3/25/24 from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, Mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: -Eliminating food sources, indoor habitats, and other conditions that attract pests; -Excluding pests from entering the indoor environments; and -Applying pesticides as needed. Rodents can transmit viruses such as Lymphocytic choriomeningitis, bacteria such as Campylobacteriosis, Leptospirosis, Plague, Salmonellosis, Tularemia, Yersiniosis, and fungi such as Dermatophytosis. II. Facility policy and procedure The facility's policy on pest control was requested from the nursing home administrator (NHA) on 3/20/24 at 11:45 a.m. -A policy on bed bug prevention was provided by the NHA on 3/20/24 at 11:58 a.m., however, the policy did not have broader guidelines on pest prevention and control in regards to mice. III. Observations A. Sarvata unit On 3/20/24 at 10:00 a.m., the Sarvata unit was observed. Observations revealed the following: -Mouse traps were observed in several locations in the Sarvata unit. -Debris and food crumbs were scattered throughout the hallways, along baseboards, and under the radiators. B. Kitchen On 3/20/24 at 10:10 a.m., the kitchen was observed. Observations revealed the following: -There were dried spills and crumbs on the floor throughout the kitchen. -There was a glue-type mouse trap under the rack used to store clean dishes with mouse feces surrounding it. -There was a gap around the window air conditioning (AC) unit with visible daylight. -A mouse trap was found under a desk in the dry storage room. C. Activities office and storage room On 3/20/24 at 10:29 a.m., the activities office and storage room were observed. Observations revealed the following: -A large cart with several open bins of chips and snacks was in the activities storage room. -Several chip bags in the activities storage room had holes in the bags where they had been chewed through. -Mouse droppings were in the corners of the room along with two mouse traps. -Gaps were identified around the window AC unit with daylight showing. -At 10:32 a.m. a mouse ran out of a cabinet and under a desk in the activities office. D. Main dining room On 3/20/24 at 10:34 a.m., the main dining room was observed. Observations revealed the following: -There were mouse traps in the corners of the dining room, one of which had mouse urine and visible dirt surrounding it. -Food crumbs were swept under the radiators along the entirety of the dining room. -Large gaps were identified under the doors to the main entrance, allowing daylight to be visible. E. Legacy unit On 3/20/24 at 10:41 a.m., the Legacy unit was observed. Observations revealed the following: -There were mouse droppings in the corners of the dining room of the Legacy unit and in their kitchenette. -Debris and food crumbs were scattered throughout the hallways, along baseboards, and under the radiators. -Daylight was visible under the door leading outside from this unit. -Mouse droppings were found behind the television (TV) in the activities room. -At 10:51 a.m., the window AC unit in the nurses' station had a gap approximately two to three inches wide around it. A blanket was stuffed into the gap in order to fill the space. -At 10:59 a.m. there was a mouse trap in one of the residents' rooms. -Food was on the floor in room [ROOM NUMBER]. F. Conference room On 3/20/24 at 11:07 a.m., the conference room was observed. Observations revealed the following: -There was daylight visible around the window AC unit in the conference room. IV. Record review Pest control service invoices were provided for the following dates: 12/13/23, 1/2/24, 1/8/24 and 2/12/24. -No details about the services that were provided were revealed in the invoices from the company. Resident council notes from 1/24/24 at 10:10a.m. revealed residents complained about mice running around the facility. V. Staff interviews The dietary director (DD) was interviewed on 3/20/24 at 10:20 a.m. The DD said the facility had always struggled with mice. The DD said the facility was having issues with mice eating food in the activities room since the activities department was always getting snacks for the residents. The DD said he found a mouse in one of the traps approximately one to two weeks prior. The DD said the rain and snow drove mice into the facility but he did not know how they were getting into the facility. The activity director (AD) was interviewed on 3/20/24 at 10:26 a.m. The AD said she had recently come back from a leave of absence but she had not seen any snacks that were chewed through since she came back. The activities assistant (AA) was overheard talking to the AD on 3/20/24 at 10:31 a.m. The AA said the reason the snack bins did not have lids was because they did not have enough in the budget to purchase lids for the bins. CNA #1 was interviewed on 3/20/24 at 10:45 a.m. CNA #1 said there were mouse traps in the dining room of the Legacy unit because the facility had a problem with mice in a different area, and the facility did not want the problem to move to the Legacy unit. CNA #1 said she had not seen any mouse activity since she started at the facility in June 2023. The NHA, maintenance supervisor (MS), and operations manager (OM) were interviewed on 3/20/24 at 11:14 a.m. The MS said the facility had issues with mice coming into the building for the past year. The MS said the pest control company was coming every two weeks in January and the mice issue was under control at that time. The pest control company had been coming every month since that point. The MS said a resident found a mouse in their room the day prior (3/19/24), so the MS called the pest control company to expedite their next visit. The MS said the facility had not identified where the mice were coming in but he thought it was due to people leaving the doors open during deliveries. The MS said he had not seen any gaps in the doors nor around the AC units. The NHA said the facility was using one pest control company but had switched to another company in January 2024.

Based on observations and interviews, the facility failed to ensure residents resided in a sanitary and comfortable environment for three of three units observed for cleanliness. Specifically the facility failed to: -Ensure resident rooms, dining rooms, hallways, kitchen floors and furniture were free from debris, food, and mice droppings (cross reference F925 pest control); and, -Mitigate unpleasant odors on the Legacy unit. Findings include: I. Facility policy and procedures The Homelike Environment policy, revised February 2021, was received from the nursing home administrator (NHA) via email on 3/20/24 at 11:58 a.m. It read in pertinent part, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: clean, sanitary and orderly environment; pleasant, neutral scents II. Observations A. Sarvata unit On 3/20/24 at 10:00 a.m., the Sarvata unit was observed. Observations revealed the following: -There was significant discoloration and staining on the two couches in the main area of the Sarvata unit. An unidentified resident was sitting on the stained couch. -Debris and food crumbs were scattered throughout the hallways, along baseboards and under the radiators. B. Kitchen On 3/20/24 at 10:10 a.m., the kitchen was observed. Observations revealed the following: -There were dried liquid spills and crumbs on the floor throughout the kitchen. -There was a glue-type mouse trap under the rack used to store clean dishes with mouse feces surrounding it. -There was a gap around the window air conditioning (AC) unit with visible daylight. A mouse trap was under a desk in the dry storage room. C. Activities office and storage room On 3/20/24 at 10:29 a.m., the activities office and storage room were observed. Observations revealed the following: -There were several chip bags in the activities storage room. The bags had holes where they had been chewed through. -Mouse droppings were in the corners of the room, along with two mouse traps. -Gaps were identified around the window AC unit with daylight showing. -At 10:32 a.m., a mouse ran out of a cabinet and under a desk in the activities office. D. Main dining room On 3/20/24 at 10:34 a.m., the main dining room was observed. Observations revealed the following: -There were mouse traps in the corners of the dining room, one of which had mouse urine and visible dirt surrounding it. -Food crumbs were swept under the radiators along the entirety of the dining room. -Large gaps were identified under the doors to the main entrance, allowing daylight to be visible. E. Legacy unit On 3/20/24 at 10:41 a.m., the Legacy unit was observed. Observations revealed the following: -There were mouse droppings in the corners of the dining room of the Legacy unit and in their kitchenette. -Floors in the dining room were visibly soiled with a dark substance. -Debris and food crumbs were scattered throughout the hallways, along baseboards, and under the radiators. -Daylight was visible under the door leading outside from the unit. -A vinyl chair in the activity room was heavily worn, with areas of the black fabric beneath the vinyl exposed in large multi-inch sections. -Tread strips in the room were heavily worn and peeling up, leaving a dark, sticky residue on the floor. -Mouse droppings were found behind the television (TV) in the activities room. -At 10:51 a.m., the window AC unit in the nurses' station had a gap approximately two to three inches wide around it. A blanket was stuffed into the gap in order to fill the space. -Loose medication capsules, dirt and debris were on the floor behind the crash cart on the unit. -At 10:55 a.m., there was a strong odor of urine throughout the hallways of the unit. An odor eliminator bag was stuffed behind one of the handrails. -At 10:59 a.m., there was a mouse trap in one of the residents' rooms and one of the floor tiles was lifted enough to be a potential tripping hazard. -Food was on the floor in room [ROOM NUMBER]. F. Conference room On 3/20/24 at 11:07 a.m., the conference room was observed. Observations revealed the following: -There was daylight visible around the window AC unit in the conference room. III. Record review Cleaning checklists were provided by the NHA at 11:45 a.m. The checklists included tasks such as cleaning and mopping the floor behind all furniture and cleaning all corners. The tasks were on both the deep cleaning and day-to-day checklists which were to be performed by the housekeeping staff. IV. Staff interviews The NHA, maintenance supervisor (MS), and operations manager (OM) were interviewed on 3/20/24 at 11:14 a.m. The MS said the facility had issues with mice coming into the building for the past year. The NHA said they were using one pest control company but switched to another in January 2024. The MS said the pest control company was coming every two weeks in January 2024 and the mice issue was under control at that time. The pest control company had been coming every month since that point. The MS said they had not identified where the mice were coming in but he thought it was due to people leaving the doors open during deliveries. The MS said he had not seen any gaps in the doors nor around the AC units. The MS said he was not sure how the recliners and couches were cleaned. The NHA said the furniture items were on the list to be replaced. She said she was aware that some of the floor tiles were peeling up. The NHA said she had checklists to ensure deep cleaning was ongoing throughout the facility and ensure housekeeping was doing regular cleaning in residents' rooms. The NHA said there were new housekeeping staff members hired in order to keep up with the increase in cleaning. The NHA said she and the OM were cleaning rooms when there was not sufficient housekeeping staff. The NHA said she was not aware of any odor eliminating bags being used. Regarding odors in the facility, the NHA said she was replacing all of the mattresses in the facility, starting with those that belonged to residents that were more resistant to receiving care for activities of daily living. The NHA said she was increasing the frequency of toileting checks for those residents.

Based on observations, record review and interviews, the facility failed to ensure one (#15) of one resident reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 41 sample residents. Resident #15 was admitted to the facility on [DATE]. His admission weight on 9/30/19 was188.4 pounds (lbs). The resident maintained a weight between 180 lbs to 200 lbs between January 2022 and June 2023. The resident was hospitalized in July 2023. When he returned to the facility, the facility failed to weigh the resident until August 2023. The facility did not attempt to weigh the resident after he refused one weight. The registered dietitian (RD) recommended weekly weights in July 2023 and no weights were obtained. Per staff interviews, the resident was not eating, refusing meals and often skipped breakfast and no preventative measures were implemented to address his eating patterns to ensure his intake was adequate. Due to the facility's failure to implement nutritional interventions, Resident #15 sustained a severe weight loss of 32.8 pound weight loss or a 17.09 percent weight loss in 60 days. Findings include: I. Facility policy The Food and Nutrition Services policy, revised October 2017, was provided by the corporate nurse consultant (CNC) #1 on 10/25/23 at 11:05 a.m. It read in pertinent part: Each resident is provided with a nourishing, palatable, well balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each diet. The multidisciplinary staff will assess each resident's nutritional needs, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment. II. Resident #15 A. Resident status Resident #15, age [AGE] years old, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia, schizophrenia, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, psychotic disturbance, psychosis, hypertension, hypertensive chronic kidney disease and osteoarthritis. The 7/19/23 minimum data set (MDS) assessment documented that the resident was unable to complete the brief interview for mental status (BIMS). The staff assessment for mental status was completed. It documented the resident had a memory problem and was moderately impaired, made poor decisions and supervision or cues was required. The resident required supervision with bed mobility and transfers. He required one person assistance with toileting, grooming and personal hygiene. The assessment documented the resident required set up assistance with eating and the resident had not experienced any weight loss. His height was 5 foot 8 inches. B. Record review Resident #15's medical record revealed he experienced a significant unplanned weight loss of 23 pounds; 11.93 percent in six months, from April 2023 to 10/17/23. The resident was discharged on [DATE] and was readmitted on [DATE]. Prior to the discharge, the resident was in the secured memory unit. When the resident returned, the resident was moved to the secured behavioral unit. The facility attempted to weigh the resident one time at readmission but the resident refused and the staff did not reattempt a weight despite the resident being known to be at risk for weight loss. According to the hospital documentation on 7/12/23, the resident weight was 195 lbs. 1. Resident #15 nutritional status The unintended weight changed care plan, initiated on 9/30/19 and revised 8/4/23, documented the resident had potential for unplanned weight loss related to dementia, psychotropic medication, variable meal intakes, declining health status secondary to numerous comorbidities. Interventions included a health supplement shake due to the resident skipping breakfast; monitor weight weekly; and monitor for significant changes. The cognitive care plan, initiated on 11/16/19 and revised on 10/8/21, documented the resident had impaired cognitive function/dementia or impaired thought processes related to disease process. The activities of daily living (ADL) care plan, initiated on 10/3/19 and revised on 3/8/23, documented the resident had a self-care performance. It documented the resident did not require supervision and he was independent with eating. 2. Resident #15 weight loss history revealed significant weight loss as follows: -On 4/19/23, the resident weighed 195.3 pounds -On 5/3/23, the resident weighed 195.4 pounds -On 6/2/23, the resident weighed 195.4 pounds -The facility failed to obtain a weight for July 2023 -On 8/1/23, the resident weighed 162.6 pounds, a 32.8 pound weight loss or a 17.09 percent weight loss in 60 days -On 8/4/23, the resident weighed 165.8 pounds -On 8/18/23, the resident weighed 168.4 pounds -On 8/22/23, the resident weighed 172.8 pounds -On 9/1/23, the resident weighed 168.8 pounds -On 9/5/23, the resident weighed 175.2 pounds -On 9/12/23, the resident weighed 176.6 pounds -On 9/16/23, the resident weighed 173 pounds -On 9/19/23, the resident weighed 176.4 pounds -On 9/26/23, the resident weighed 171.8 pounds -On 10/3/23, the resident weighed 175.2 pounds -On 10/14/23, the resident weighed 168.6 pounds -On 10/17/23, the resident weighted 172 pounds -On 10/21/23, the resident weighed 168.2 pounds -On 10/24/23, the resident weighed 168.6 pounds The 7/14/23 readmission nutritional assessment, completed by a registered dietitian (RD), documented Resident #15 was on a regular diet with a regular texture and a thin liquid diet. It indicated the resident weighed 195.4 pounds on 6/2/23. The RD documentd the resident's intake was erratic at meals with refusals and skipped breakfast due to sleeping. The RD recommended monitoring intake and to obtain weekly weights. -However, the RD did not add any measures for his meal refusals and skipping breakfast. In addition, the RD was aware the resident was not eating prior to hospitalization in July 2023 and losing weight and no preventative measures were put in place to address his nutritional risk. In addition, the resident was not weighed weekly as the RD recommended to help monitor his nutritional status. The 8/4/23 interdisciplinary team weight variance assessment revealed that the resident had a 15.1 percent weight loss in eight weeks. A new intervention was to add mighty shakes in the morning. It revealed that potential medical factors were a recent illness within 30 days, recent significant changes in medication and psychotropic medications. The summary revealed that a nurse on the secure memory unit said the resident stopped eating prior to his hospitalization due to increased behaviors and aggression. -A supplement was added after the resident sustained a 32.8 pound weight loss with no preventative measures in place. The August 2023 CPO documented the following physician order for mighty shake one time a day for weight loss. Provide once the resident wakes up. The start date was 8/5/23. The September 2023 CPO documented the mighty shake was discontinued on 9/8/23. The 10/14/23 interdisciplinary team weight variance assessment revealed that the resident had a 13.7 percent weight loss in six months. The summary revealed the resident intake improved and mostly consumes 76-100 percent of meals. It documented with the weight trending down, mighty shakes were added. The October 2023 CPO documented the following physician order for mighty shake one time a day. The start date was 10/17/23. The October 2023 meal intake records documented the resident consumed the following from 9/20/23 to 10/19/23 the records revealed the resident ate 76-100 percent on 49 occasions; 51-75 percent on two occasions; 26-50 percent on four occasions; and, refused meals on six occasions (10/1/23, 10/3/23, 10/4/23, 10/5/23, 10/8/23 and 10/10/23). Additionally, the resident had less than three meals in a day recorded for several days between 9/20/23 to 10/19/23. The record revealed the resident ate only two meals on three days (9/23/23, 10/15/23 and 10/16//23); and only one meal on two days (9/26/23 and 9/30/23). III. Observations On 10/23/23 from 12:05 p.m. to 12:35 p.m., Resident #15's lunch meal was observed. Registered nurse (RN #1)and an unidentified certified nurse assistant (CNA) delivered the lunch meal tray and beverages to residents who ate meals in their room. The nurse went into Resident #15's room at 12:05 p.m., to deliver his lunch, the resident was lying on his bed and looked asleep. She asked him if he was hungry and he said no; she told him she would come back. The nurse went back at 12:15 p.m. to set up his meal. The nurse cut up the resident's chicken and left the food for him. The resident was lying on his bed and still looked asleep. At 12:35 p.m., Resident #15 did not start to eat his food. Resident #15 was interviewed on 10/23/23 at 1:35 p.m. The resident was unable to communicate why he did not eat his meal or even if he received a lunch time meal. The scales in all units were observed on 10/24/23 between 1:00 p.m. and 1:30 p.m. The secured memory unit had a commercial scale that a resident could stand on, in their television room. The non secured unit had a commercial scale in a locked scale room. It was a scale for residents who could not stand independently. The secured behavioral unit scale had a regular scale. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 10/24/23 at 12:51 p.m. LPN #2 said the resident lost weight because he liked to sleep in instead of getting up for breakfast. LPN #2 showed the scale that was used to weigh residents on the unit. It was a home weight scale and was not a medical weight scale. The RD was interviewed on 10/24/23 at 10:05 a.m. She was familiar with Resident #15. She said the resident stopped eating completely prior to the resident's hospitalization and lost a lot of weight. Upon the resident's return and throughout August 2023, the resident lost a significant amount of weight. The physician ordered a mighty shake nutritional supplement then by September 2023 the resident started to gain some weight and the mighty shakes were discontinued so the resident did not gain too much weight. The resident was prescribed mighty shakes again in October 2023. The RD said the scale in the secured behavioral unit was not as accurate as the scale in the secured memory unit. She weighed herself in both units and said the difference was approximately five pounds and found that the scale in the secured memory care unit was more accurate. The RD said she would add interventions if a resident lost five percent in three months and 10 percent in six months. -However, nutritional interventions should be proactively added and not when the resident sustains a significant weight loss. The intervention would depend upon the resident individualized needs. She said if a resident was not weighed on the day of readmission, then the facility should weigh the resident within three days. She said it was important to have an accurate weight so she could complete an accurate nutritional assessment. She said all residents should be weighed monthly to ensure the resident was not losing weight and to provide a complete nutritional picture of the residents nutritional needs. Resident #15 who had a significant weight loss should have been weighed weekly. The director of nursing (DON) was interviewed on 10/24/23 at 2:00 p.m. She was familiar with Resident #15. The DON said Resident #15's dementia was progressing in addition to his mental illness which both contributed to his weight loss. Additionally, Resident #15 was a picky eater and did not have a hunger drive. The DON said Resident #15 refused to be weighed in July 2023 when he returned from the hospital. The DON said when a resident refused to be weighed the nursing staff should attempt to weigh the resident within three days and document the results. The DON said residents should be weighed weekly for the first weeks after admission and then monthly thereafter. She said there would be times the resident would not be weighed monthly based on the RD's recommendation. She said it was important to weigh resident's monthly because it was indicative of other things that happened to the resident. Monthly weight history helped with the whole picture of the resident health and could trigger concern for other care areas like medication review. The DON said the CNAs weighed the resident and reported to the nurse who would record and report any weight concerns. The DON said the facility offered Resident #15 meal alternatives, like a supplement shake to help with the resident's weight loss; and would recommend adding additional interventions if the resident lost five percent of his weight in three months and 10 percent in six months. The DON said that a two month gap of no weights for a resident would be too long. If the resident refused to be weighed, she would follow up with the interdisciplinary team to develop other interventions. The DON said she placed an order for a medical weight scale to be placed in the resident's unit to reduce weight discrepancies.

Based on observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to implement a method for pest control to control the rodent population throughout the facility that was effective and sanitary. Cross-reference F584 failure to maintain a clean and sanitary homelike environment. I. Professional references According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (1/1/19) page 186, retrieved on 10/25/23, from https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: Routinely inspecting the premises for evidence of pests; -Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and, -Eliminating harborage conditions. According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, (July 2019), pp. 95-96, retrieved on 10/25/23, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf From a public health and hygiene perspective, arthropods (insects) and vertebrate pests (rodents) should be eradicated from all indoor environments, including health-care facilities. II. Facility policy The Pest Control policy, revised May 2008, was provided by the corporate nurse consultant (CNC) #1 on 10/24/23 at 9:35 a.m. It revealed in pertinent part, Facility shall maintain an effective pest control program. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Garbage and trash are not permitted to accumulate and are removed from the facility daily. III. Observations The outdoor patio on the Legacy unit was observed on 10/15/23 at 11:38 a.m. The patio had a large amount of tree leaves and debris in the patio area piled up close to the building. The skilled unit was observed on 10/18/23 at 11:30 a.m. A large mouse was observed running along the edge of the hallway near resident room [ROOM NUMBER]. The mouse ran into room [ROOM NUMBER] and into a crack in the wall at the back corner of the room. The behavioral health unit was observed on 10/23/23 at 3:26 p.m. A live small juvenile mouse was inside the unit running back and forth by the door that led to the unit patio. The mouse went into a cracked section of the baseboard and then to underneath the heating unit. IV. Resident/resident representative interviews A. Resident group interview A group of five alert and oriented residents (#8, #38, #39, #49 and #85) who usually attended the resident council meetings in the facility were interviewed on 10/24/23 at 10:30 a.m. The residents all said they had problems with mice in their rooms. The residents said there were a lot of mice running around the facility and they felt it was a big problem. The rodent infestation had been a problem for the last year. The resident group said they believed the cause of the mice problem was related to residents eating meals and snacks in their rooms and poor housekeeping. The resident group said they had brought the mouse problem to the facility leadership but the problem has not been resolved. Resident #39 and Resident #8 said a woman down the hall ate all meals and snacks in her room and there was a constant pile of crumbs and other food spills on the floor by her bed and under the bed. The residents said the housekeeping staff were not cleaning well under the beds. Both residents said they had observed mice running around under that resident's bed. Those mice would leave that room and travel down the hall stopping in a number of other resident rooms along a path towards the nurses station. Resident #38 said she had a similar problem in her room. Resident #38 said her roommate had a lot of items under her bed and she had seen mice under that bed. Resident #38's representative who was also in attendance at the meeting said Resident #38 had mice in her room and she had reported these sightings to the nursing staff but Resident #38 continued to have mice in her room. B. Resident individual interviews Resident #7 and Resident #44 were interviewed on 10/18/23 at 11:30 a.m. Resident #7 said there was a mouse problem in the facility. She said they were in her room because her roommate kept food in their room. Resident #44 said she sometimes saw mice in her room. Resident #44 did not have containers for her food stash. Resident #8 was interviewed on 10/18/23 at 2:26 p.m. Resident #8 said he had mice in his room. On one occasion Resident #8 said he was woken up by the sound of rustling and when he opened his eyes he saw a large mouse sitting on the seat of his wheelchair staring back at him. Resident #8 said the mouse left excrement on his wheelchair seat; staff just brushed it off but no staff cleaned or sanitized his wheelchair cushion. Resident #8 said he was concerned that a mouse could crawl up into his bed so if staff did not get him up for meals he usually did not eat out of concern that crumbs in his bed would attract the mice. Resident #31 was interviewed on 10/19/23 at 1:30 p.m. Resident #31 said the facility had placed silver box closed mouse traps in his and several other resident rooms. In the last week, the trap in his room caught six mice. Last week I saw a mouse crawling on my dresser. The mouse left feces dropping behind. Resident #31 said he believed the problem was made worse by residents eating in their rooms with the crumbs and food debris not being cleaned up. Resident #39 was interviewed on 10/19/23 at 1:45 p.m. Resident #39 said she saw mice in her room and running down the hall on a number of occasions. Resident #31 was interviewed on 10/24/23 at 3:30 p.m. Resident #31 said Resident #28's family removed her from the facility the day prior (10/23/23) because a mouse got on her bed while she was in bed watching television (see resident representative interview below). Resident #31 said this was upsetting because he also had a mouse in his room that morning. He got up to open his blinds when he heard rustling. He said he observed a mouse crawling down the blinds. Resident #31 said he did not want to get bit so he watched the mouse crawl down the blinds and then behind the heating unit. The mouse disappeared under the heating unit. C. Resident representative interview Resident #28's representative was interviewed on 10/25/23 at 11:24 a.m. The resident representative said the resident's caretaker removed the resident from the facility after the resident called her to say that a mouse had crawled up on her bed while she was watching television. The resident's representative said he was very concerned about the resident's welfare. V. Record review The 8/17/23 resident council minutes were reviewed. The minutes revealed two residents reported they saw mice in their rooms. The staff reported the reason for the mice was that residents left food in their rooms. The 9/21/23 resident council minutes were reviewed. The minutes revealed the old business was reviewed, positive response, resolved. -There was no specific information on what the old business was or how the old business was resolved. The 10/19/23 resident council minutes were reviewed. The minutes revealed residents said the maintenance staff needed to work on the mice problem and place more traps throughout the facility and in resident rooms. The most recent pest control service report was provided by the regional corporate consultant (RCC) #2 on 10/24/23 at 9:28 a.m. The record revealed that the pest control company's last service date for the facility was on 10/11/23. The report revealed that the service provider did not observe pest activity and no staff reported pest activity at the time of service. The service representative documented the replacement of five glue boards for mice control mainly in the employee break room and advised ongoing monitoring, as needed. The service report documented the facility was serviced for mice/rodent control on 6/15/23. During that visit, the services provided recommended that the facility clear debris and piles of mulch and dirt for the alley behind the facility to help control the rodent population. VI. Staff interview Licensed practical nurse (LPN) #1 was interviewed on 10/23/23 at 4:41 p.m. LPN #1 said she saw mice in the behavioral secure unit. She could not remember how long it had been going on but said it had been a while. She said there were mice traps in the unit but she was unable to locate them. She said she mostly saw mice near the heating units and baseboard that was located near the wall to the unit's patio. She did not see pest control come because of the shift she worked. She saw mice more when the weather was colder because mice would try to find warm areas. LPN #2 was interviewed on 10/24/23 at 12:51 p.m. LPN #2 said he saw mice a couple of months ago. He could not remember how long the mice had been in the building but said it had been a while. He said there were mice traps in the unit but he was unable to locate them. He saw mice in the resident's room and told the maintenance staff verbally and through their work order software system about the mouse sightings. He recently saw the pest control company on the unit. The maintenance director (MTD), RCC #2 and operations manager (OM) were interviewed on 10/24/23 at 9:05 a.m. The MTD said the pest control program included having the pest control company scheduled to come monthly. The OM said sometimes the pest control vendor came more than once a month. He said in September 2023, the vendor serviced the facility two times. All three staff members reported they had not seen any mice in the facility. The MTD said the staff and residents reported mice in the dining area and in the resident's room. The OM and the MTD said they believed the cause of mice being in the resident's room was because the resident's rooms were cluttered and there were crumbs and food littering the floor spaces. The OM said the resident's rooms were cleaned every day.

Based on record review and interview, the facility failed to ensure all grievances were followed up on and resolved timely and appropriately. Specifically, the facility failed to investigate and provide feedback for grievances made by residents and their family members. Findings include: I. Facility policy and procedures The Grievance policy, updated 12/17/06, was received from the corporate nurse consultant (CNC) on 10/25/23 at 11:30 a.m. It read in pertinent part: Accordingly, a formal system known as the Resident and Family Concern/Grievance Program is in place to review and act upon concerns or grievances expressed. Any resident has the right to voice grievances without discrimination or reprisal. The Resident Concern/ Grievance Program is intended to reflect the facility policy which acknowledges the right of residents to voice concerns and the expectation of prompt effects by the facility to resolve them. This program is supported by the Resident Council. Any resident, family member or staff member may generate a Resident Concern/ Grievance Report in response to a concern or grievance identified as a result of an individual concern or grievance from a resident, family member and/or staff member. Procedure: The Social Service Director (SSD) is designated for collecting, reviewing, and communicating concerns or grievances to the Administrator. These shall be completed within one business day. Responses and results will be completed within five business days. It is the policy of the facility to handle any complaints or grievances relating to abuse immediately and according to the facility Abuse Prohibition and Control Manual. -Concerns or grievances shall be communicated in writing. The SSD may be called upon to assist in writing these and to complete any necessary forms. -The SSD will complete an investigation and confer with the Administrator. The Administrator may or may not be involved in the actual investigation. Responses will be communicated within 72 hours of completion of the investigation. -The SSD will complete a follow-up interview within 7-10 days to ensure that the approach taken by the facility has resolved the concern. If the concern remains unresolved the SSD will confer with the Administrator and Department Director to develop a revised approach, which is to be implemented immediately upon development (no more than 72 hours following identification that the initial resolution was not satisfactory). The SSD will complete an additional follow-up interview within 7-10 days to ensure that the corrective action taken by the facility has resolved the concern. -The SSD will bring all Resident Concern Reports to the Quality Assurance Committee meeting to review with the team to assess the need for possible further action. II. Resident interviews Resident #28 was interviewed on 10/17/23 at 1:33 p.m. Resident #28 said he voiced concerns to the facility staff but nothing ever changed. He was most concerned about his therapy services and the quality of the service. Since nothing was resolved he just stopped accepting services. Resident #28 said he knew that was not the best idea to not participate in his therapy services; however, he wanted changes in the quality of the services before he resumed services and was waiting for the facility to do something about his concerns. Resident #49 was interviewed on 10/17/23 at 1:50 p.m. Redisnet #49 said it was useless to file a grievance because the facility did not fix anything. Resident #49 said he had complained about the lack of hot water for the past couple of weeks and the facility still had not corrected the problem and he was not always able to take showers because to the problem. Cross-reference F908 essential equipment, safe operating condition. Resident #8 was interviewed on 10/18/23 at 3:27 p.m. Resident #8 said he was not satisfied with the facility's response to grievances. There had been no follow-up to himself or his peers who had filed grievances and there was no resolution to the grievances. Resident #8 said he and his peer had several discussions about their dissatisfaction regarding the way the facility was operating with both the past and new administration and neither was resolving the resident grievance or changing the way the facility was being managed. Resident #8 said these private discussions with his peers were carried over to resident council meetings and voiced to facility leadership. The leadership did not maintain grievance records and did not report back to the resident council group on how the resident grievance/concerns would be fully addressed and resolved. Resident #8 said he encouraged his peers to keep copies of grievance forms they filed as records because the facility never had any documentation of filed grievances to present at the resident council group meetings. Resident #31 was interviewed on 10/19/23 at 1:33 p.m. Resident #31 said he had been complaining of the same things over and over again for months and there had been no resolution. Resident #31 said even if he wrote the complaint on a grievance form the complaint was not addressed. Resident #31 and Resident #39 were interviewed on 10/19/23 at 1:55 p.m. The residents said they had filed a grievance about loud noises on the overnight shift. Some resident played their televisions loudly late at night and some staff talked loudly in the hallway which was interfering with their sleep. The residents said this had been a topic of concern at several resident council meetings but it still had not been resolved. III. Resident group interview Five alert and oriented residents (#8, #38, #39, #49 and #85) who usually attended the resident council and one resident representative were interviewed on 10/24/23 at 10:15 a.m. The resident group said a the start of each resident council meeting they always opened with past business and the invited staff did take that opportunity to go over each concern present at the prior resident council meeting and they were no able to have a discussion about past grievances and hear the facility's response to grievance and the resolution. Past grievances seemed to have been forgotten. Resident #8 said he used to be the resident council president but he resigned because the facility did not take the grievance procedure seriously. Facility staff did not write up grievance forms at the resident council meetings and then did not document or present back on resolution. The resident group said they felt that resident grievances were ignored. The group said the facility did not fix past grievances and the resident council members and other residents had the same concerts over and over again. The resident representative said she and her friend had filed several grievances with facility staff and had received some verbal response at the moment of filing the grievance but had not received a written response on any of the filed grievances and none of the grievances raised had been resolved. IV. Record review A review of resident council minutes for July 2023 through October 2023 revealed the resident in attendance voiced several grievances; however, the minutes field to document the facility's response to the resident grievance and the resident response. All resident council minutes document All grievances can be received and or written by any staff member. All grievances were returned to the department head to ensure grievances are followed up on and resolved. The 7/20/23 resident council minutes revealed the residents voiced grievances included: -Loud noise levels: Ongoing complaints about residents and staff not following quiet hours. These complaints have been a topic of discussion since 4/20/23. Concerns included loud television volumes, and nighttime staff having loud conversations while residents were trying to sleep. -Request for less agency nursing staff. Good nursing care was dependent upon the staff on duty. -Other individualized personal grievances were voiced as well. The 8/17/23 resident council minutes revealed the resident voiced grievances included: -Loud noise levels were better but not resolved. -Requests for less agency nursing staff. -Requests for staff to wear their nametag so it is visible to residents and to have a larger font so the staff names are more readable. -Presence of mice in the facility (cross-reference F925 pest control). -Request for the facility to provide more consistent therapy and restorative nursing services. -Request for maintenance to repair outside landscaping and sidewalks. Residents were concerned about outside walkways being uneven, cracked and hazardous to residents traveling on on the sidewalks to local community areas (cross-reference F584 safe, clean home-like environment). -Laundry delays. -Request for hot meals to be served at dinner instead of sandwiches and other cold foods. -Request for activities programming to resume and for the facility to provide activities based on resident preferences (Cross-reference F679 activities). -Request for the grievance procedure to be followed including completion of grievance forms. Observation during the survey from 10/17/23 to 10/24/23 between the hours of 8:30 a.m. and 2:30 p.m. revealed several staff members were not wearing name tags and many name tags were not placed in a visible location on the staff's person. The 9/21/23 resident council minutes revealed the resident voiced grievances included: -Request for more regular and consistent nursing staff (less agency staff). -Request for the activities program to resume shopping trips and provide more consistent activities programming. -Request for hot meals to be served at dinner instead of sandwiches and other cold foods. -Request for the grievance procedure to be followed including completion of grievance forms. -General maintenance grievance (no specific details documented). -Other individualized personal grievances were voiced as well. The 10/19/23 resident council minutes revealed the resident voiced grievances included: -There were still too many agency nursing staff. -The new therapy staff is off to a slow start. -Mice were still being seen in resident rooms. -Request for an update on the lack of consistent hot water for resident showering (Cross-reference F908). -Request for hot meals to be served at dinner instead of sandwiches and other cold foods. -Request for the activities program to resume shopping trips and provide more consistent activities programming. -However, the resident council minutes failed to document a full discussion on the voiced grievance of the resident council; the facility's attempts to resolve the resident grievances; or the resident's response to the facility's actions to address resident grievances/concerns. -Additionally, the 10/19/23 resident council minutes documented the name of the facility's grievance official as the previous social services director. The form was not updated and many of the entries on the document were not consistently completed. A request was made to the director of nursing/nursing home administrator (DON/NHA) for documentation on individual resident grievances and resident council grievances for the past three months. The DON/NHA provided one individual grievance form. -The DON/NHA was unable to locate any other grievance forms for the grievance voiced during resident council meetings for either the group concerns or the individual personal resident concerns voiced during resident council meetings (see interviews below). V. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on 10/24/23 at 1:00 p.m. LPN #5 said some of the residents knew how to file a grievance and if they did not know how to or could not complete a grievance form, their complaint could not be resolved at the time of complaint and staff should help then fill out a grievance form. Completed grievance forms were sent to the manager on duty so they could be addressed timely. The LPN said the social services department was responsible for monitoring the grievance procedure and for discussing the results of the grievances with the residents. The activities director (AD) was interviewed on 10/24/23 at 3:03 p.m. The AD said the first resident council meeting she attended in her new role was 10/19/23, she learned the residents were not happy, particularly about activities programming. The AD said she was not told she needed to complete grievance forms for the resident's voiced concerns. The AD said she would offer to assist residents in filling out grievance forms after the meeting if they wanted help but no resident asked for her assistance with a grievance form. The AD said most of the department directors attended the resident council meetings so they were aware of the resident council members' grievances and they were responsible for coming up with a resolution to the grievance voiced during the resident council meeting. That same department director was responsible for reporting back to the resident council on any action taken to resolve the group's grievance. The AD said the grievances and resolutions should be documented in the resident council minutes. The social services director (SSD) was interviewed on 10/24/23 at 3:47 p.m. The SSD said the was the new SSD and was in the role of grievance official. The SSD said in starting her position she noticed there was a lack of documentation on resident council grievances and grievance resolution and had identified it as a system oversight. The SSD said moving forward she will start a grievance log to record all resident grievances and monitor complaints to resolution. The SSD said the grievance procedure was for a resident to complete a grievance form or for staff to assist a resident in completing a grievance form for all unresolved grievances/complaints. Each grievance was submitted to the applicable department director for investigation and follow-up this occurred within 72 hours of the grievance being received. Once the department director investigated and addressed the resident's grievance the SSD said she was responsible for conducting a follow-up interview with the resident. The SSD said she let the AD know to bring several blank grievance forms to the resident council meetings and to fill them out for each resident(s) grievance voiced during the meeting. The SSD said she and the AD would make sure that each voiced grievance would be present at the following resident council meeting and determined as resolved or if it needed to be held over as still outstanding additional follow-up. The grievance would be held open until the resident council was satisfied with the facility's actions. The CNC was interviewed on 10/24/23 at 4:10 p.m. The CNC said the facility did not have any documentation of a resident grievance form either individual grievances or from the resident council other than the one individual resident grievance for September 2023 that was already provided. The CNC was not sure why the facility had not documented grievances. The CNC said going forward the facility would provide the staff including the AD and SSD on the facility's grievance policy and the expectations for documenting and addressing all resident grievances. 42193

Based on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis. Specifically, the facility named the DON to also function in the role of the facility ' s nurse home administrator (NHA) and the infection preventionist (IP); delegating all three responsibilities to one individual employee in a facility with an average census of 92 residents. Findings include: I. Facility policy The Director of Nursing Services policy, revised August 2022, was provided by the corporate nurse consultant (CNC) on 10/25/23 at 11:30 a.m. It read in pertinent part: The nursing services department is managed by the director of nursing services (DNS). The director is a registered nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing. The director is employed full-time (40 hours per week). II. Staff interviews A frequent visitor to the building was interviewed on 10/17/23 at 2:30 p.m. The frequent visitor said the facility was struggling to provide good care to residents and residents were observed to be cared for under poor conditions. The frequent visitor said both the staff and the residents reported poor care and poor ability to provide competent care due to a lack of proper leadership. The frequent visitor said that staff reported running out of supplies, poor coordination with lab services and having to sometimes work with agency staff who were less than motivated or knowledgeable enough to provide competent care. The operations manager (OM) was interviewed on 7/19/23 at 4:21 p.m. The OM said he recently earned a bachelor's degree in financial planning and previous to this position he managed a local chain restaurant. He did not attend the facility quality assurance quality improvement (QAPI) meeting but did provide data for the DON to present. The OM said in the role of OM he was responsible for troubleshooting resident satisfaction. In this role, he talked with residents and staff to make sure everything was in place and things were operating and functioning properly. The OM said when he learned of facility concerns whether it be a clinical or physical environment issue he would investigate and bring the information to the DON who was also acting as the full-time NHA and the DON would make the decision on how to handle the concern/problem. The OM said he did not make any managerial or operational decisions; he was in his role to assist the DON in day-to-day activities as directed. The OM said his other duties include running shift change meetings and making sure staff were answering call lights timely. The OM said the facility had been looking for a full-time permanent NHA since the previous NHA resigned from the position. The building has had a number of temporary NHAs in the position but (at the time of the survey from 10/17/23 to 10/24/23) the DON was performing both the role of DON and NHA and was fully responsible for fulfilling both roles since 9/25/23. The OM said the roles of assistant director of nursing (ADON) and infection preventionist were vacant but they had offered the position and expected the ADON candidate to start on 11/2/23. Corporate leadership provided support by phone and in person once a week when possible. The DON/NHA was interviewed on 10/18/23 at 9:30 a.m. The DON said she was hired as the facility ' s full-time DON on 9/25/23. When the facility was unable to find and hire an NHA she applied for an emergency NHA licensure and was granted a temporary permit for an emergency situation on 10/3/23, in order to assume the role of the facility ' s NHA position. The DON/NHA said she assumed the roles of the facility ' s full-time DON, NHA and was acting as the facility ' s infection preventionist. The facility had a plan to start a new nurse in the role of ADON and infection preventionist starting the first Monday of November 2023. The DON/NHA said a typical day in her position included making rounds, reviewing shift reports, examining reported resident health concerns like falls, medication issues, new illnesses, new and readmissions and other clinical concerns. After that, the DON said she attended morning meetings with other members of leadership to discuss clinical and administrative concerns then she met with floor staff and other managerial staff to pass along needed information for daily care matters. The DON/NHA also met with the interdisciplinary team to discuss QAPI plans for service improvement areas, attended weekly nutrition and sometimes helped with admissions and monitored wound rounds. The DON/NHA said the OM worked under her direction and assisted with investigating day-to-day concerns from residents and staff. Once identified the OM manager brought the findings to her attention and she made all of the clinical and administrative decisions and delegated resolution actions to the OM and other key staff. The DON/NHA said corporate leadership provides additional support by phone and with occasion onsite visits. There was no set onsite visit schedule and most support was provided by phone. The CNC was interviewed on 10/19/23 at 842 a.m. The CNC said the facility underwent an ownership change in February 2023, the previous NHA left soon after the new acquisition. Corporate leadership then hired a temporary NHA and started a search for a permanent full-time NHA but had difficulty getting candidates approved through the State licensing board due to a number of extenuating circumstances. The CNC said finding a permanent NHA was the facility's top priority. In the interim, the CNC said she was helping as needed with operational tasks and providing additional training for the OM who was new to the long-term care industry. The regional vice president of operations (RVPO) was interviewed on 10/19/23 at 5:15 p.m. The RVPO said the corporation had been in touch with the State licensing board but was having difficulty getting a consistent response from the licensing board. The corporation had submitted a number of candidates for application to sit for the NHA State licensure exam but several applications were denied for various different reasons and it was difficult to determine a consistent factor in the licensing board's decision making. The RVPO said the corporation continued to seek candidates for the facility NHA position and had a positive interview with a potential candidate who was currently licensed in the State as an NHA and was hopeful that the candidate would accept and start in the position in the next couple of weeks. Once an NHA candidate started in the position; the plan was to relieve the DON of the NHA duties.

Based on observations and interviews, the facility failed to provide a comfortable environment and homelike environment in three out of three units. Specifically, the facility failed to ensure: -Residents were not subjected to foul odors in their rooms and common hallways for two of three units; -Resident rooms were clean and in good repair on two of three units; -Common areas and dining room were clean and maintained in good repair; and, -Outside areas were maintained. Findings include: I. Facility policy The Homelike Environment policy, revised February 2021, was provided by corporate nurse consultant (CNC) #1 on 10/25/23 at 11:05 a.m. It read in pertinent part: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include institutional odors. II. Ensure residents were not subjected to foul odors A. Observations On 10/17/23 to 10/19/23 and 10/23/23 to 10/24/23, the skilled and long-term care unit hallway and resident rooms were observed throughout the day between approximately 9:00 a.m. to 6:00 p.m., the unit had lingering odors comprised of body odor, urine and feces. The urine smell was stronger at several times throughout the observation and lingered throughout the day at times other than the normal rounding time when staff were assisting residents with routine incontinence care. On 10/23/23 to 10/24/23, the memory care unit was observed etween approximately 9:00 a.m. to 6:00 p.m. to have a lingering odor of urine throughout both days of observation. III. Ensure resident rooms were clean On 10/18/23 and 10/23/23 resident rooms in the skilled and long-term care unit were observed. Observations revealed the floors in resident rooms #38, #39 #40, #30, #41, #25 and #16 were soiled with dust, dirt and food crumbs debris particularly under the beds and around the edges of the room. room [ROOM NUMBER] at the resident space closest to the door was particularly soiled with dust and debires. The floor under the bed was covered with a thick layer of debris, crumbs and dust; the nightstand which held a television was heavily soiled with a thick whitish-gray layer of dust. The floor in room [ROOM NUMBER] was heavily soiled with dried liquid food spills and food crumbs. On 10/24/23 at 1:30 p.m., housekeeping services were observed. Housekeeper #1 was observed cleaning room [ROOM NUMBER]. HSKP #1 swept the resident's room starting on the far side of the room; the HSKP swept partially under both residents' beds leaving a layer of debris behind failing to thoroughly sweep all food and dust/dirt debris from the resident's room floor particularly in the corners of the room, at the edge of the wall and under the resident's beds (cross-reference to F925 failure to maintain effective pest control). B. Resident interview Resident #8 was interviewed on 10/17/23 at 3:10 p.m. Resident #8 said the facility did not keep up with housekeeping and several resident rooms had food debris on the floors and under their beds. He had assisted several residents to bring this to the attention of leadership but the problem had not been resolved. This was also contributing to the facility having mice in the building (cross-reference F925). IV. Ensure resident common areas (inside and outside) and dining room were clean and maintained in good condition A. Resident interviews Resident #59 was interviewed on 10/18/23 at 2:05 p.m. Resident #59 said she reportedthe baseboards in the dining room and her television were falling apart. Resident #66 was interviewed on 10/18/23 at 2:55 p.m. Resident #66 said he reported there was a hole in the wall in his room, but no one repaired the damage. He pointed to the wall behind the front door of his room. Residents #8 and #39 were interviewed on 10/23/23 at 1:30 p.m. The residents said the dining room ceiling had prior leakage and the ceiling tiles were dropping white debris on the table where they ate and they were concerned that the ceiling debris would get into their food. Resident #8 said the outside ramp leaving the building was cracked and uneven and the landscaping outside of the building made the sidewalk narrow and he was worried that he or someone would get injured. B. Observations On 10/18/23 at 2:55 p.m., room [ROOM NUMBER] had a hole on the wall behind the front door of the room that was patched and not painted. It was a white color while the rest of the room was a cream color. On 10/19/23 at 2:07 p.m. the common area, television room and dining room in the behavioral secured unit were observed. The baseboards underneath the sink in the dining room were falling apart. The baseboards on the left side of the entrance to the television room were falling apart. The baseboard on the left side of the door in the dining room to the unit's patio was falling apart. At 3:18 p.m. the patio for the behavior secured unit was observed. There were approximately eight black patio chairs against three walls in the patio. Every single chair had white [NAME] droppings on the patio chairs. There were several pigeons sitting on the top of the fence in the patio area. At 4:45 p.m. the outside ramp at the main entrance was cracked and uneven. On 10/23/23 at 1:38 p.m. the ceiling tiles in the main dining room were worn and shedding debris. V. Staff interviews The operations manager (OM) was interviewed on 10/17/23 at 4:21 p.m. The OM said he was responsible for troubleshooting and observing day-to-day activities and when problems were discovered he brought the concerns to the attention of the nursing home administrator (NHA) for a solution and further direction. The OM said since the new ownership transition several months ago the facility started a project to improve the look of the building. The outside of the building was repainted and they were now looking into making cosmetic improvements inside of the building. The OM did not have a specific list of improvements yet to be addressed but said leadership was still looking into it. Licensed practical nurse (LPN) #2 was interviewed on 10/24/23 at 12:51 p.m. He said the baseboards were falling apart because there was a female resident who picked at the baseboards until they started to fall apart. LPN #2 said the staff tried to redirect the resident from picking at the baseboards. LPN #2 said he was aware of the patch in resident room [ROOM NUMBER] and said the wall had to be repaired a month ago after the resident in that room punched a hole in the wall. He was not able to speak to the [NAME] feces on the chairs on the patio but said there were a lot of pigeons around the building, so he would not be surprised if there was [NAME] feces on the patio chairs on the patio. LPN #2 said he would tell the maintenance staff verbally and through their work order software system if something needed to be fixed. The maintenance director (MTD), the regional corporate consultant (RCC) #2 were interviewed on 10/24/23 at 9:05 a.m. The MTD was not aware that the baseboards in the secured unit needed to be repaired. He was aware that the wall in resident room [ROOM NUMBER] needed to be sanded and painted. After the interview, a walk-through was completed with the MTD and RCC #2. The RCC said the chairs in the patio should be power washed. The MTD said the chairs should be wiped and cleaned daily. 41032

Based on record review and interviews the facility failed to keep two residents (#1 and #2) free from resident to resident physical abuse of five sample residents. The facility failed to protect Resident #2 from resident to resident physical abuse from Resident #1 and then failed to protect approximately one hour later, Resident #1 from retaliatory physical abuse from Resident #2 on 4/19/23. During the first altercation, Resident #1 tapped Resident #2 on the shoulder and put up his balled fists. Resident #2 lunged at Resident #1, put his hands on Resident #1's neck and a fight began which required nursing staff to separate the two men. The police were called to come to the facility due to the first altercation. Within approximately one hour after the first altercation, Resident #2 left his room and walked to the dining room where he found Resident #1. Resident #2 then began another fight with Resident #1 and the nursing staff separated the men again. After the first altercation both men had documented that the facility staff checked on them every 15 minutes. The nursing home administrator (NHA) in an email (see facility follow-up) wrote that because police were in the building staff had their physical presence and attention removed from the residents and the retaliatory incident happened as a result. Resident #1 and Resident #2 both lived in a secured unit, and both men had histories of verbal and physical aggression. Findings include: I. Resident census and conditions demographic The Resident Census and Condition was provided by the nursing home administrator (NHA) on 5/4/23 at 3:15 p.m. It revealed that 90 residents resided in the facility. The form further documented that 47 residents had a psychiatric diagnosis, 44 had dementia, and 18 had behavioral healthcare needs. The facility had two secured units. The secured unit called Legacy was where Resident #1 and Resident #2 lived. II. Professional reference According to the Centers for Disease Control (CDC) website, Preventing Elder Abuse https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 5/9/23), Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse. Physical abuse is when an elder experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning. III. Facility policies and procedures Three different abuse policies were provided by the nursing home administrator (NHA) on 5/4/23 at 3:00 p.m. Each policy contained pertinent information. The Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 revealed in pertinent part, Residents have the right to be free from abuse. This includes physical abuse. The resident abuse, neglect, and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect residents from abuse by anyone including, other residents. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents. Protect residents from further harm during investigations. The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy, September 2022, revealed in pertinent part, The administrator ensures that the resident and the person(s) reporting violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. The Abuse and Neglect Clinical Protocol, March 2018, revealed in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. IV. Resident to resident physical abuses between Resident #1 and Resident #2 on 4/19/23 at approximately 4:00 p.m and on 4/19/23 approximately one hour later. The 4/19/23 facility incident report which involved Resident #1 and Resident #2 was provided by the NHA on 5/4/23 at 10:00 a.m. It revealed in pertinent part, On 4/19/23 at approximately 4:00 p.m. Resident #1 walked up to Resident #2 and tapped him on the back of his shoulder and put his hands up with balled fists. Resident #2 then lunged at Resident #1 and the two men began striking each other. Staff responded and put the two men on 15 minute checks for monitoring. Within approximately one hour Resident #2 came out of his room and found Resident #1 who was in a common area and slapped him. The facility put Resident #1 on one-to-one monitoring at that time (See social services assistant interview below that there was no one-to-one tracking documentation from this monitoring). Resident #1 had slight redness and a small abrasion to his arm. Resident #2 had slight redness to his neck which was no longer visible within a few hours (The report did not say how many hours until the redness was gone). The facility staff said they heard the two men yelling, and observed Resident #1 strike Resident #2, and Resident #2 put his hands on Resident #1's neck. The staff said about an hour later Resident #2 entered a common area where Resident #1 was seated and struck him with an open hand. Resident #1 was placed on one-to-one monitoring and Resident #2 was redirected to his room. The incident report documented the video footage was reviewed which revealed Resident #1 tapped Resident #2 on the shoulder. Resident #1 put up balled fists at Resident #2 who responded by hitting Resident #1. Then about one hour later Resident #2 struck Resident #1. Resident #1 was placed on every 15 minute monitoring which progressed to one-to-one care by staff. -The facility documented 15 minute checks for both men but not one-to-one care for Resident #1 as was documented in the medical records. The facility concluded there was insufficient evidence to substantiate resident to resident physical abuse because there was no willful infliction of injury including physical harm, pain, or mental anguish. The facility documented willful was characterized by an awareness of consequences which Resident #1 was unable to understand due to dementia with severe agitation and a traumatic brain injury (TBI). There was nothing in the facility's conclusion about Resident #2 who retaliated and was the aggressor in the second incident. Agency staff were interviewed on the day of the investigation which revealed, Agency LPN (licensed practical nurse) said she saw Resident #1 choking Resident #2 but did not see the event leading up to it. She separated the two residents immediately. She said about one hour later Resident #2 approached Resident #1 who was in the dining room and slapped him from behind. The agency certified nurse aide (CNA) said she saw the first altercation when Resident #1 put his fists up and then Resident #2 started to hit Resident #1. The documentation of 15 minute checks was provided by the NHA on 5/4/23 at 3:30 p.m. which revealed, -Resident #1 was placed on 15 minute checks at 4:00 p.m. During this time the second incident occurred. The initials which verified he was observed every 15 minutes were not clear enough to determine who signed the 15 minute checks. The NHA said the initials did not look like the agency LPN that was on duty that day. The NHA said he would look at the employee time cards and verify the initials. -The facility did not provide who the initials represented for facility staff who did the 15 minute checks. The facility documented Resident #1 was on 15 minute checks for the next three days but did not have any documentation of Resident #1 with a one-to-one person or sitter. -Resident #2 was put on 15 minute checks which began at 3:00 p.m. according to the documentation, which was an hour before the altercation. The initials were the same on the staff checks as with Resident #1, which was not verified as to who initialed the 15 minute checks for the next several hours. The 4/19/23 nursing progress note revealed that Resident #1 approached Resident #2 when he raised his fists and hit Resident #2 in the chest. Before the nurse could intervene to separate the two men Resident #2 responded with physical violence by a swing which hit Resident #1. Then Resident #1 began to choke Resident #2. The nurse was able to get Resident #1 to release his hand grip from around Resident #2's neck. At 5:09 p.m. Resident #2 hit Resident #1 in the face. The NHA notified that the resident was to be put on one-to-one care. One of the residents said, He hit me, he shouldn't have hit me. I'll beat his (expletive). The social services assistant (SSA) video camera footage description was provided by the SSA on 5/4/23 at 4:05 p.m. It revealed that the SSA watched the video footage of the incident. It was observed Resident #1 walked up to Resident #2 in the hallway, tap him on the shoulder, and put up his balled fists. Resident #2 lunged at Resident #1 and started to hit him, leaving visible scratches on Resident #1's arm. She documented Resident #2 said Resident #1 choked him. The SSA told the staff on the unit to place the two residents on 15 minute checks. Resident #2 said he hit Resident #1 because he was mouthing off. The SSA was notified of the second incident at 5:20 p.m. Resident #1 was to be placed on one-to-ones with an agency nurse. V. Resident #1 A. Resident status (perpetrator in the first incident and victim in the second incident) Resident #1, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2023 computerized physician orders (CPO) the diagnoses included unspecified dementia, severe, with agitation, traumatic brain injury (TBI), cognitive communication deficit, chronic obstructive pulmonary disease (COPD) and altered mental status. The 3/8/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He had disorganized thinking. He did not reject care from staff. He required supervision with bed mobility, transfers, walking in his room and in the corridors, dressing, eating, toilet use, and personal hygiene. B. Record review The 7/18/22 suicide homicide risk evaluation for Resident #1 revealed the resident had made homicidal remarks. (See social service assistant was unaware of the note in the electronic medical records EMR). The resident reported I am going to kill someone. Social service interviewed him and he said he was not going to hurt anyone. He said he made statements like this when joking. The comprehensive care plan on 3/20/22 and revised on 8/29/22 revealed in pertinent part, Focus: The resident had impaired cognitive function/dementia or impaired thought process with dementia. The resident had dementia with behavioral disturbances. The resident had physically aggressive behaviors. -Resident had a history of being verbally aggressive towards peers and staff. Also history of antagonizing peers. At times resident makes threatening statements and balls fists though reports he was joking. -Resident had a history of hitting other residents. Goal: Resident will not harm self or others through the review date. (Revised on 4/10/23, nine days before the incident) He will verbalize the need to control physical aggressive behaviors through the review date. Interventions: Behavior monitoring revised on 2/18/23. Identify/document potential causative factors and eliminate/resolve where possible. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff will redirect if (the) resident becomes verbally aggressive. The behavior progress notes documented, -On 3/22/23 the resident was on frequent checks due to a recent altercation with another resident. -On 4/7/23 the resident threatened to hit another resident two times on the same day while walking past the resident. -On 4/19/23 the resident made (a) physical altercation with another resident in the hallway, obtained bruising/abrasion to lower left arm and above the elbow. Resident was to remain on one-to-one supervision with staff until he could be evaluated the next morning. (See interviews below that the resident was not placed on one to one supervision) The April 2023 treatment administration record (TAR) documented a daily tracking of the following: -Target behavior (physical aggression, strikes out) at the end of each shift, mark frequency how often behavior occurred and intensity. How (the) resident responded to redirection. Intensity code: zero equaled did not occur, one equaled easily altered, and two equaled difficult to redirect every shift. -On 4/19/23 the day of the altercation, the facility did not record any intensity codes on the TAR about behaviors for physical aggression. The nurse practitioner (NP) progress note on 4/15/23 (four days before the physical abuse incident) revealed in pertinent part that staff reported he had a history of seeking out more vulnerable residents and physically assaulting/attempting to physically assault them. The nurse practitioner (NP) progress note on 4/20/23 revealed in pertinent part, the resident had an altercation with another resident on 4/19/23 and had a bruise and abrasion to the left lower arm above the elbow. The NP documented the resident was in another skilled nursing facility and went to the hospital on 10/2/22 where he was aggressive and required restraints. The resident previously had heavy alcohol use and he used crack cocaine. VI. Resident #2 A. Resident status (victim in the first incident, and perpetrator in the second incident) Resident #2, age 70, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included unspecified dementia, moderate, without mood disturbances, cerebral infarction (stroke), hypertension (high blood pressure), stage 4 chronic kidney disease, anxiety disorders, alcohol abuse in remission, depression, cognitive communication deficit and difficulty in walking. The 3/13/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. The resident had verbal behavioral symptoms directed toward others. The resident did not reject care from staff. The resident required supervision with bed mobility, transfers, walking in his room and corridors, dressing, eating, and toilet use. He needed limited assistance with personal hygiene. B. Record review The comprehensive care plan 4/11/23 revealed in pertinent part, Focus: Resident had a history of being verbally aggressive. Had a potential for injury to self or others which was manifested by constant yelling, kicking, verbal outbursts, and delusional behaviors. Interventions: Monitor/record occurrences of target behavior symptoms, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol. The April 2023 TAR documented a daily tracking of the following: -Target behavior (physical aggression, strikes out) at the end of each shift, mark frequency how often behavior occurred and intensity. How (the) resident responded to redirection. Intensity code: zero equaled did not occur, one equaled easily altered, and two equaled difficult to redirect every shift. -On 4/19/23 the day of the altercation, the facility did not record any intensity codes on the TAR about behaviors for physical aggression. The NP progress note on 4/20/23 revealed in pertinent part, the resident (had) fingerprint markings on his neck from an altercation with another resident on 4/19/23. The NP documented when the resident went to a hospital on 2/24/23 he punched a security guard in the face. The behavior progress note on 4/20/23 documented Resident #2 said That guy is dangerous. -The note did not document whom the resident said was dangerous. (See SSA interview below) VII. Staff interviews LPN #1 was interviewed on 5/4/23 at 12:10 p.m. She said she worked on the Legacy unit where Resident #1 and Resident #2 lived. She said she had complained prior about the agency nurses that were on the unit the day of the incident. She said the agency CNA the day of the incident had prior told her that she did not get involved with fights between residents. She said if the men were being watched after the first altercation there would not have been a second altercation. She said Resident #2 may not remember the incident but he still gets nervous and agitated when he sees Resident #1 in the hallway. She said the staff tried to keep Resident #2 from seeing Resident #1 but it was difficult on a small secured unit. The SSA was interviewed on 5/4/23 at 4:00 p.m. The SSA said she said she was the social worker responsible for the Legacy unit. She said after the second incident she told the agency nurse on the unit to start one-to-one staff supervision with Resident #1. She said she had no documentation that she told the nurse and there was no documentation any staff had provided one-to-one supervision with Resident #1. She said he needed to be watched 24/7 by nursing staff until he could be medically evaluated the next day. She was unaware only 15 minute checks were done for three days. She said Resident #1 had altercations with others prior to the incident. She said because Resident #2 had not had altercations with others prior to the incident he was not put on one-to-one supervision. She said she was unaware that there was a homicide/suicide evaluation done for Resident #1 in the electronic medical records (EMR). She said after the first incident with Resident #1, Resident #2 retaliated. She said she did not know why the staff on the unit did not notice Resident #2 had left his room to go to the dining room to seek out Resident #1. She said Resident #2's intervention after the incident was to be discharged to another state to go live with his former wife. She said she was unaware of a note in the medical record on 4/20/23 the day after the incident which documented Resident #2 had said that guy was dangerous. The social service director (SSD) was interviewed on 5/4/23 at 4:10 p.m. She said Resident #1 had other altercations with other residents on the unit. She said Resident #1 balled up his fists at others to be funny. She said some residents understand his humor and others hit him. She said after the first altercation the two men were separated. She said Resident #2 came out of his room and found Resident #1 and retaliated for what happened about an hour prior. She said she did not know what other interventions could have been put in place to protect the two residents except 15 minute checks because that usually worked. She did not know how the two men were not watched closely enough that a second incident happened. The NHA was interviewed on 5/4/23 at 4:20 p.m. He said he would read the employee time cards and if he found who initialed the 15 minute checks for Resident #1 and Resident #2 and he would provide the documentation. -No documentation was provided during or after the survey on 5/5/23. He said there was no documentation that Resident #1 was put on one-to-one care after the second incident. He said the nurse on duty documented the events in the resident's medical records. He said he was not sure the agency nurse that day viewed the altercation correctly. VIII. Facility follow-up On 5/5/23 at 4:34 p.m. the NHA emailed the following information. Resident #1 had aggressive behaviors in the past, and the facility had tried with no success to refer him to get accepted by other facilities to care for his needs. After the first altercation on 4/19/23 police were called and refused to transport Resident #1 on assault charges. The NHA said after viewing the video footage of the first incident he felt the nurse on duty that day had her back to the residents and did not see the incident correctly. The NHA requested the police department who responded to the event in the facility to send their report and a copy of the video footage. The facility had not received a response from the police department as of 5/5/23 (16 days after the incident). The NHA also wrote that when the police were in the building within an hour of the first altercation, the staff had removed their physical presence and attention to monitoring that would have otherwise been in place. The presence of the police and the proximity of the residents during the police interviews led to the retaliatory incident.

Based on record review, observations and interviews, the facility failed to ensure three (#60, #41 and #27) of four residents received adequate supervision to prevent accidents out of 31 sample residents reviewed. Specifically, the facility failed to develop and implement a person-centered care plan that identified the resident's current medical status, fall risk status and put effective interventions into place to reduce falls and prevent injury for Resident #60. Resident #60, who was admitted to the facility on [DATE], was an identified to be at high risk for falls upon admission due to a recent fall at another facility, which resulted in a subdural hematoma (blood collection on the brain). The facility failed to implement effective person-centered interventions, which considered the resident's compromised medical status to prevent further falls and major injuries. Since the resident's admission to the facility, he experienced seven falls on 7/9/22 with two falls, 7/10/22 with two falls, 7/15/22, 7/16/22 and 7/17/22, two of which resulted in a major injury (7/10/22 with a distal nasal fracture and 7/17/22 with multiple rib fractures). Resident #60's care plan was put into place on 6/20/22 but not revised until 7/11/22 (after the resident had fallen at the facility four times).The facility failed to identify the resident's pattern of weakness related to self-care upon admission, evaluate interventions already in place for effectiveness, identify the resident's pattern of cognitive impairment and initiate effective interventions to prevent the resident from sustaining major injuries from falls. Additionally, the facility failed to: -Ensure an assessment was completed by a registered nurse (RN) following a fall sustained by Resident #27; and, -Ensure medications were not left on the counter for Resident #41 to consume without supervision. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, revised on 9/10/19, was provided by the nursing home administrator (NHA) on 9/15/22 at 3:30 pm. It revealed, in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. A fall reduction program will be established and maintained to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Research has shown that a structured fall reduction program can substantially reduce the rate of falls and related injuries in nursing facilities; however falls may likely occur. Identify risk factors, followed by timely and appropriate interventions, is the key to a successful program. Risk factors that are internal to the resident include the resident's physical health and functional status. External risk factors include medication side effects, the use of appliances, and environmental conditions. To be effective, a reduction program is characterized by four components: fall risk evaluation, care planning and implementation of interventions, ongoing evaluation process Quality Assurance Performance Improvement (QAPI) and a commitment by caregivers to make it work. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Resident and resident representatives will be invited to all care plan meetings. Please note interventions are to be re-evaluated when a resident falls. The following interventions are to be initiated and or considered: a physical therapy (PT) evaluation and/or screen should be initiated; medications will also be reviewed; evaluate physical health status - have pertinent laboratory test been performed; assess the environment and make appropriate changes; offer frequent toileting or follow individualized toileting schedule; assess the need for a potential room change; positioning devices; protective devices; restorative nursing; always assess for the least restrictive devices; notify Quality Improvement Specialist (QIS) consultant with frequent fallers and falls resulting in significant injury; and complete a thorough analysis of the fall - time of day, location of the fall, causative factors, identify whether the interventions were in place at the time of the fall. Falls review will include the following: Review the IDT risk management incident to ensure complete and appropriate interventions have been implemented, review that a care plan has been initiated, provide revision to the plan of care as necessary after falls. II. Failure to ensure effective interventions were in place to prevent falls with a major injury A. Resident #60 1. Resident status Resident #60, age 65, was admitted to the facility on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnosis included a history of falls, [CONDITION(S)] (a disease in which the functioning of the brain is affected by some agent or condition), cerebral infarction due to embolism of left middle cerebral artery (a stroke that occurs when a blood clot that forms elsewhere in the body breaks loose and travels to the brain by the bloodstream), and seizures. The 7/27/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. He required limited assistance of one person assistance with transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. It indicated the resident had not sustained any falls since the resident's readmission to the facility. 2. Observations On 9/14/22 at 10:01 a.m. Resident #60 was observed moving about his room without the use of an assistive device. The resident had removed all his personal items off the walls and around the room and placed them in his wheelchair and on top of his bed. Resident #60 said he was confused about where he was and why he was there. A sign, directing the resident to call for assistance before walking or to use an assistive device for walking, was not found in the resident's room (an intervention documented as put into place following the fall the resident sustained on 7/16/22). 3. Record review a. Resident #60's status upon admission The 6/20/22 physician progress note documented the resident was admitted to the facility that day. The resident was recently hospitalized for a prolonged period of time due to seizures and was discharged to a subacute facility, where he experienced falls which led to another hospitalization . It indicated the resident was having falls at the previous skilled nursing facility, likely due to poor safety awareness, the [MEDICATION(S)] medication being reduced and his ammonia level was very high. The physician documented the resident had poor memory. The 6/20/22 nursing progress note documented the resident was a new admission to the facility with a prior history of frequent falls and weakness with his activities of daily living (ADLs). It indicated the resident had numerous falls at many different facilities and the resident's responsible party was concerned. It indicated the resident had poor cognition, poor safety awareness, poor memory and poor self-awareness of his physical abilities. The fall care plan initiated on 6/20/22, documented the resident was at risk for falls, had poor self awareness of his physical ability, seizures, a history of falls, would spontaneously get out of bed or up from the wheelchair, and was forgetful with poor cognition. The interventions, upon admission, included: anticipating and meeting the resident's needs, ensuring the resident's call light was within reach, encouraging the resident to use the call light for assistance, encouraging rest periods when signs of fatigue were noted, encouraging the resident to be compliant with [CONDITION(S)] medications, encouraging the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensuring adequate lighting and visual aids are in place on admission, ensuring appropriate positioning in the center of the bed, ensuring the resident wore non-skid footwear when ambulating or mobilizing in the wheelchair, ensure the resident's environment was uncluttered and personal items were within reach, and review information on past falls and attempt to determine the cause of the falls and remove any potential causes. The fall care plan did not identify the causes of any previous falls sustained at other facilities or attempt to provide person-centered approaches to prevent falls and potential major injuries. The activities of daily living (ADL) care plan, initiated on 6/20/22, documented the resident had an ADL self-care performance deficit related to weakness, a history of falls, poor cognition, and needed reminders and supervision. It indicated the resident required the use of a wheelchair for mobility, side-by assistance for ambulation, and supervision from the facility staff to move between surfaces. The interventions included encouraging the resident to use the call light for assistance. The cognitive care plan, initiated on 6/20/22, documented the resident had impaired cognitive function/dementia or impared thought processes related to dementia and had difficulty making decisions. The interventions included: ensuring the resident's call light was within reach, encouraging the resident to use the call light for assistance as needed, encouraging the resident to use the wheelchair for ambulation and toileting, ensuring resident is wearing non-skid footwear when ambulating or mobilizing in wheelchair, and ensuring a fall mat was beside the bed. b. Fall incidents on 7/9/22 - witnessed The 7/9/22 nursing progress note documented at approximately 1:54 p.m. the RN was alerted to come to the resident's room by the certified nurse aide (CNA). The CNA said the resident had fallen, but did not hit his head. The resident told the nurse that he got light headed and fell into the wall. The RN completed an assessment and provided education to the resident to use his call light when he needed assistance. -At 3:30 p.m. the resident sustained another witnessed fall. The resident fell against the door in his room. It indicated the resident was assisted by three staff members to stand. The resident had on slippery socks and was provided non-skid socks by the facility staff. It indicated the resident's lab work had shown a high ammonia level of 130. The 7/11/22 interdisciplinary team (IDT) risk management review note documented the resident sustained two witnessed falls on 7/9/22. For the first fall, on 7/9/22, the root cause was determined to be poor safety awareness related to [CONDITION(S)] with an intervention of non-skid socks and re-education provided to the resident to use the call light to ask for assistance. -However, the intervention of non-skid socks was put into place upon the resident's admission on 6/20/22. For the second fall, on 7/9/22, the root cause was determined to be poor safety awareness, the resident's history of falls and the resident had complained of feeling dizzy. The lab results showed high ammonia levels with an intervention of diagnostic orders from the physician. The review of the incident did not show the facility had evaluated the resident's history along with his current medical status, other than the lab work ordered by the physician. The facility identified the resident had cognitive impairment and continued to get up without assistance in his weakened state, but continued with the intervention to educate the resident to use the call light for assistance. The 7/9/22 x-ray imaging report documented the resident sustained an acute, minimally depressed distal nasal bone fracture. c. Fall incidents on 7/10/22 - unwitnessed with a nasal fracture The 7/10/22 nursing progress note documented at approximately 6:10 a.m. the RN was called to Resident #60's room by the licensed practical nurse (LPN). The RN found the resident sitting in the wheelchair bleeding from the left side of his nose. The CNA reported she found Resident #60 in his bed, lying on his left side, bleeding. Resident #60 was observed with swelling above the left eye with a slight abrasion and a swollen area to the right side and middle of his nose. It indicated the resident was confused and weak. The nurse applied a cold pack and called the physician for an x-ray of the resident's facial bones. The 7/10/22 nursing progress note documented she informed the physician the x-ray had revealed the resident had sustained a nasal bone fracture and bleeding from the right nostril. -At 8:58 p.m. the nurse documented the resident was being helped to the bathroom. During the transfer, the resident's legs became weak and was lowered to the ground. It indicated the resident was confused during the transfer, however did not sustain any injuries. The nurse contacted the physician and the resident's responsible party and placed the resident on 15 minute safety checks. The 7/11/22 physician progress note documented the resident had multiple falls at another skilled nursing facility and continued to fall at this facility. It indicated the resident had poor memory and poor safety awareness. It indicated the resident had fallen that weekend and sustained a distal nasal bone fracture. The 7/11/22 IDT risk management review note documented the resident was assisted to the floor by staff members because he became weak and was unable to ambulate. The interventions included for the resident to use a wheelchair for ambulation. -However, based on the resident's continued impulsive behavior of getting up without using the call light and without asking for assistance, the facility failed to implement an effective intervention that actually had the potential to reduce future falls for the resident. The facility failed to actively evaluate interventions put into place to determine their effectiveness. d. Fall incident on 7/15/22 - unwitnessed The 7/15/22 nursing progress note documented Resident #60 was sitting on the bathroom floor with his hands clasped to the toilet grab bars. There was diarrhea covering the wall behind the resident and the resident was incoherently cursing himself. The resident was provided incontinence care and assisted back to bed with two staff members. It did not indicate the previous interventions had been reviewed for effectiveness or a new intervention put into place. e. Fall incident on 7/16/22 - unwitnessed The 7/16/22 nursing progress note documented the call light in the bathroom was activated and Resident #60 was found, by the CNA, kneeling on one knee in front of the bathroom commode. The resident had bare feet and was ambulating to the bathroom without assistance. Resident #60 said he went to the bathroom and got weak when he was trying to get up. The RN performed an assessment with no injury noted. It indicated the resident was provided education on proper footwear and using the call light before getting out of bed. It did not indicate any additional interventions were put into place. f. Fall incident on 7/17/22 - unwitnessed with a major injury The 7/17/22 nursing progress note documented the CNA found the resident kneeling on the floor in the bathroom in front of the commode. The wheelchair was in the bathroom with the resident, but the brakes were not engaged. Resident #60 said he was trying to stand up and slipped and fell to the ground. It indicated the CNA had checked on the resident 20 minutes prior and the resident was in bed, asleep. The resident was assisted back to the wheelchair and then back to bed. A small abrasion was noted to his left knee. The nurse reminded the resident to use the call light for assistance with transfers and going to the bathroom. -At approximately 2:30 a.m., during a neurological check, Resident #60's left pupil was dilated and was nonreactive to light. He said his left eye was blurry and said he hit his head when he fell earlier. The physician was contacted and ordered for the resident to be sent to the hospital for an evaluation. The 7/17/22 hospital physician consultation notes documented the resident sustained a fall at the facility of unknown cause. It indicated the resident was confused and ordered imaging of the resident's brain. The physician documented the resident's chronic left sided weakness, from his history of a fall with a subdural hematoma, was what made him off balance and was likely why he fell . It indicated the resident sustained an acute to subacute fracture of the 10th and 11th rib based on the physician's assessment, the resident's complaint of acute abdominal pain and imaging. The 7/17/22 radiology study for a CT (computerized tomography) of the resident's chest, abdomen and pelvis, with contrast, revealed bilateral lower medial rib fractures and a correlation with point tenderness was needed to evaluate for an acute fracture. The 7/21/22 physician progress note documented the resident was readmitted to the facility on [DATE] from a fall sustained at the facility. While at the hospital, the resident was found to have right 10th and 11th rib fractures. It indicated the resident was placed on hospice services on 7/20/22 due to multiple falls, cognition, poor safety awareness and not using the call light. The 7/25/22 IDT risk management review note documented the resident had an unwitnessed fall and the resident continued to transfer and toilet himself despite nursing education to use the call light for assistance. It indicated the resident was placed on frequent checks and re-educated to call for assistance as needed. III. Staff interviews CNA #2 was interviewed on 9/15/22 at 8:33 a.m. She said there were pictures of leaves on the resident's room door that identified if the resident was considered a fall risk. She said each resident group assignment had a staff sheet that included information about each resident and any special needs they required. She said the report sheet indicated whether or not a resident was on frequent checks because they were considered a high fall risk. She said the restorative aide was responsible to update the report sheet and ensure it was current. CNA #1 was interviewed on 9/15/22 at 8:46 a.m. She said the leaf picture on the outside of a resident's door was just a decoration and did not have any meaning. She said point click care (PCC, the electronic charting system) contained a sheet that indicated if a resident was at risk for falls. She said any frequent checks were documented on the sheet in PCC. She said she provided care to Resident #60. She said the staff would encourage him to use his wheelchair. She said Resident #60 was not on frequent checks. The NHA and the director of nursing (DON) was interviewed on 9/15/22 at 9:15 a.m. The DON said the facility IDT reviewed each fall, discussed the circumstances around the fall and tried to determine the root cause. She said the IDT would review the immediate intervention put into place by the nurse and determine if that intervention was effective and should be continued moving forward. She said the IDT was responsible for updating the care plan with the new interventions. She said all interventions should be reviewed quarterly and with any change of condition to determine their effectiveness. The NHA said the facility could not prevent falls, but attempted to prevent major injuries. The DON said Resident #60 was admitted to the facility with a significant history of falls at the hospital and at another facility. She said he was not medically stable and had recently been discontinued from hospice to receive physical therapy services. She said the physician ordered lab and medication monitoring to stabilize the resident's ammonia levels. She said Resident #60 had cognitive impairment and was impulsive. She said the resident constantly got up and ambulated around his room and to the bathroom without calling for assistance. She said Resident #60 was not placed on frequent checks during the time when he sustained seven falls at the facility. She said during that time, the resident was impulsive and made poor decisions. She said she was unsure if the intervention to provide the resident with education, which was documented on multiple falls, was an effective intervention due to his cognitive status. III. Failure to ensure an assessment was completed by an registered nurse (RN) following a fall A. Facility policy and procedure The Fall Documentation policy and procedure, revised 11/26/19, was provided by the nursing home administrator (NHA) on 9/15/22 at 5:30 p.m. It revealed in pertinent part, Documentation of care delivered to residents who have fallen, or who have preventative interventions in place to prevent a fall includes, but is not limited to the following: the initial nursing note/assessment following a fall should contain the following and include a description of what was done: vital signs, to include neurological assessment if indicated, where the resident was observed and the time of the day, first on scene, describe the resident's location, appearance and mental status, if visible injury, identify any assessment that was performed, document all attempts to notify the physician and family and document immediate interventions implemented to prevent another fall. B. Resident #27 1. Resident status Resident #27, age 65, was admitted on [DATE]. According to the August 2022 CPOs, the diagnoses included alcohol dependence with alcohol induced persisting dementia, major depressive disorder, [CONDITION(S)] (decrease in [CONDITION(S)] function), and dysphagia (difficulty swallowing). The 6/22/22 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. She required one person physical assistance with bed mobility, transfers, dressing, personal hygiene and toileting. 2. Record review The 4/24/22 nursing progress note documented a certified nurse aide (CNA) witnessed the resident self-transfer from the wheelchair to the bed. The resident fell to her knees between the bed and the wheelchair. -The progress note was completed by a licensed practical nurse (LPN). A review of the resident's medical record on 9/15/22 at 2:30 p.m. did not reveal documentation an RN assessment had been completed following the fall sustained by Resident #27 on 4/24/22. D. Staff interviews LPN #6 was interviewed on 9/15/22 at 1:22 p.m. She said when a resident sustained a fall, the RN should be notified immediately to conduct an assessment of the resident. She said the RN would assess the resident for any injuries. She said she was unable to perform an assessment because it was outside of her scope of practice. The director of nursing (DON) was interviewed on 9/15/22 at 4:10 p.m. She said the RN should complete an assessment of the resident immediately following a fall. She said an LPN was unable to perform an assessment because it was outside of their scope of practice. She said the RN assessment should be documented in the resident's medical record. IV. Failure to ensure medication was consumed by Resident #41 A. Facility policy The Medication Management policy for the nursing department, revised 11/26/19, was provided by the nursing home administrator (NHA) on 9/15/22 at 5:30 p.m. It revealed in pertinent part, Residents' medications are administered in an accurate, safe, timely, and sanitary manner. Observe that the resident swallows oral drugs. Do not leave medications with the resident. Residents are allowed to self administer medication when specifically authorized by the attending physician and in accordance with the guidelines for self administration of medication. B. Resident status Resident #41, age 77, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included paranoid [CONDITION(S)], vascular dementia, heart failure, chronic obstructive pulmonary disease and hypertension (high blood pressure). The 6/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 13 out of 15. The resident was independent with mobility and with his activities of daily living. He needed assistance with medication management and administration. He was on oxygen therapy. C. Observations On 9/13/22 at 10:02 a.m., Resident #41 was observed standing at the nurses station window located on the behavioral unit. The window was open and a cup of water and approximately eight oral medications in a clear cup was sitting on the ledge of the window. Resident #41 was standing at the window and was observed taking his cup of medications and swallowing with a cup of water. Licensed practical nurse (LPN) #3 placed the cup of oral medications on the window ledge and proceeded to enter the bathroom in the nurses station. When Resident #41 was observed to take his medications, LPN #3 was in the bathroom with the door closed. There were two certified nurses assistants at the nurses station, however there was not a licensed nurse observing the resident at the time he took his medications. Resident #41 finished taking the medication and threw the empty clear cup and cup of water into the trash receptacle behind the window inside the nurses station and proceeded to walk away. LPN #3 exited the bathroom and sat down at the computer at the nurses station. There were approximately three other residents in the dining room area and multiple residents outside in the smoking courtyard during observation time. The dining room was connected to the nurses station and the courtyard was within close proximity to the medication window. D. Record review A review of the residents medication administration record (MAR) on 9/13/22 at 10:43 a.m. revealed the resident received the following morning medications at 10:00 a.m. to include; -[MEDICATION(S)] 5 milligram (MG) tab for benign prostatic hyperplasia; -[MEDICATION(S)] 20 mg tab for congestive heart failure; -[MEDICATION(S)] 100 mg tab for hypertension; -[MEDICATION(S)] 50 mg tab for hypertension; -Potassium chloride 750 mg tab for hypertension; -[MEDICATION(S)] 5 mg for afibrillation; -Senna plus 8.6-50 mg tab for bowel care; and, -Acetaminophen 650 mg tab for back pain. A review of the residents care plan revised on 6/28/22 revealed the resident was on [CONDITION(S)] medications and had a history of poor compliance with medications. The intervention in place was to have nursing staff administer medications as ordered by the physician. Staff will offer assistance with medication monitoring and prompting to take medications and will reapproach after 15 minutes if the resident refuses to take the medication. -Review of the resident's medical record revealed no self administration assessment for the resident to independently administer his medications. E. Interviews Licensed practical nurse (LPN) #3 was interviewed on 9/13/22 at 10:05 p.m. He said Resident #41 just completed taking all of his scheduled physician ordered morning oral medications. LPN #3 said Resident #41 did not have an order to self administer his medications and he should have been observed to swallow all of his medications. LPN #3 said the resident did not have a history of refusing his medications and he was compliant with medication administration. -However, according to the resident's care plan he had a history of poor compliance with medication. LPN #3 said although he did not have concerns about Resident #41 taking his medication, he should have been observed during the entire medication administration process. He said he should not have left the cup of medications on the window ledge with the resident while he went to the bathroom. He said he did not observe the resident swallow the medications and that was against the medication administration protocol. LPN #4 was interviewed on 9/15/22 at 12:56 p.m. He said all the residents on the behavioral unit needed the nurse to administer their medications. He said he administered all the medications during his shift which included administering and observing the resident swallow or take their medication. He said he would not leave the resident alone with the medications because that was against the medication administration policy. He said there was a risk that some residents might pocket their medications and not swallow them or potentially another resident could get ahold of the medication if the nurse did not complete the medication administration process. The director of nursing (DON) was interviewed on 9/15/22 at 3:40 p.m. She said the medication administration protocol was the same on every unit in the facility. She said the nurse should be following the same process which would include administering the medication and observing the resident swallow or take the medication. She said Resident #41 should have been observed during the medication administration process. She said LPN #3 was trained in the medication administration process and should have watched the entire process. She said he should not have gone to the bathroom and left the cup of medications on the window ledge of the nurses station. She said leaving the medication on the window ledge unattended did have the potential of putting residents at risk.

Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents reviewed received the care and services necessary to meet their nutrition needs and maintain their highest physical well-being level out of 31 sample residents. Specifically, the facility failed to consistently monitor weights, identify significant weight loss, and timely address Resident #6's nutritional needs. Resident #6 experienced a significant, unplanned weight loss of 13% in six months. The facility failed to implement appropriate interventions timely to address Resident #6's significant weight loss. Findings include: I. Facility policy and procedure The Weight Management policy and procedure, revised on 1/17/2020, was provided by the nursing home administrator (NHA) on 9/15/22 at 5:30 p.m. It revealed in pertinent part, Residents are monitored per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents identified with significant weight change will be assessed by the IDT (interdisciplinary team). Further interventions will be implemented to minimize the risk of additional weight change and promote weight stability. Residents will be screened for the risk for weight change on admission quarterly, annually, and with a significant change of condition with completion of the MDS. Weigh all residents upon admission, then monthly or indicated as physicians order. Document the results in the medical record. Residents with weight variance loss or gain are reweighed. A significant weight variance is a 3% (percent) weight loss/gain in one month. Residents identified at risk for weight change and will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD (registered dietitian) evaluation, assisted dining, etc. The nurse identifying the weight variance (loss or gain) will record findings on the 24 hour report. The following categories of residents should be weighed weekly unless otherwise indicated. Residents with significant weight change until weight is stabilized as defined in the Policy. As determined by the physician, Director of Nursing, or IDT team direction. The IDT meets weekly to review the resident with identified weight change, develops a plan, implements, evaluates, and reevaluates interventions to minimize the risk for weight change. Nursing staff is responsible to communicate weight changes to the attending physician and resident's family. The nurse documents the notification in the medical record. Nursing staff is to notify food and nutrition services and the RD of a resident weight change. The RD further assesses the resident and makes recommendations as indicated to reduce or stabilize the weight change. Nursing staff are to notify the speech therapist if swallowing problems are suspected. The Director of Nursing or designee will analyze results for trends and patterns in residents identified with weight changes and report findings to the QA(quality assurance) committee for review and recommendations. II. Resident #6 A. Resident status Resident #6, over the age of 65, was admitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/24/22 minimum data set (MDS) assessment documented that the resident had short-term and long-term memory impairment and had difficulty in a new situation of making decisions for daily life. She required supervision with bed mobility, and extensive assistance of two people with transfers, toileting, grooming and personal hygiene. It indicated the resident required supervision with setup assistance with eating. It indicated the resident had not experienced any weight loss, however, according to record review, the resident had lost 15 pounds (lbs) since April 2022. B. Record review Resident #6's record revealed she experienced a significant, unplanned weight loss of 19.2 lbs , 13.06 % in six months, from March 2022 to 9/6/22. 1. Resident #6's nutritional status on April 2022 The cognitive care plan, initiated on 9/10/15 and revised on 12/6/19, documented that the resident had a cognitive loss. It indicated the resident was able to communicate her needs verbally. The interventions included encouraging the resident to participate and attend any activities of hobbies she enjoyed and provide positive mental stimulation as well as increased socialization and community participation. The assessment for mental status completed on 8/24/22 documented that the resident had memory problems and has modified independence with making decisions about tasks of daily living. The activities of daily living (ADL) care plan, initiated on 9/15/15 and revised on 3/3/22, documented the resident had a self-care performance deficit related to limited mobility, impaired balance and cognitive impairment. It indicated the resident required supervision and set up assistance with eating. The nutritional care plan, initiated on 6/18/19 and revised on 12/14/21, documented the resident had potential for unintended weight loss related to advanced age with associated decreased intake. It indicated the resident required an altered textured diet related to a dysphagia diagnosis, the resident preferred to have her meals in bowls and the resident was provided double portions of oatmeal and soup to assist with meal intake (initiated on 6/27/19 and revised on 11/1/21). The interventions included providing adaptive equipment at meals as the resident preferred her food in bowls, monitoring the residents weights as ordered, monitoring for significant weight changes, obtaining the resident's food preferences, offering food alternates of equal nutritional value, providing and serving supplements as ordered and evaluations and changes to the resident's diet per RD recommendations. According to the comprehensive care plan, changes or updates to the nutritional interventions had not been made since 10/18/21. 2. Resident #6's significant weight loss Resident #6's weights were documented as follows: -The facility failed to obtain a weight for the resident for March 2022. -On 4/7/22, the resident weighed 147 lbs, -On 4/14/22, the resident weighed 146 lbs. -On 4/28/22, the resident weighed 142.2 lbs, a 4.8 lbs (3.27%) weight loss in 21 days. -The facility failed to obtain a weight for the resident in May 2022. -On 6/14/22, the resident weighed 138.2 lbs, an 8.8 lb (5.99%) weight loss since 4/7/22. -On 7/21/22, the resident weighed 132.4 lbs, a 14.6 lb (9.93%) weight loss in three months. -On 8/4/22, the resident weighed 132 lbs. -On 9/6/22, the resident weighed 127.8 lbs, a 19.2 lb (13.06%) weight loss since 4/7/22. The June 2022 CPO documented the following physician order: -Boost Plus one time per day for weight management-ordered 6/1/22. The 6/3/22 nutritional assessment, completed by the RD, documented Resident #6 was on a regular diet with a diet texture of mechanical soft with thin liquids. The resident had a physician ordered supplement of Boost Plus one time per day. -It indicated the resident weighed 142.2 pounds. It did not document that the weight was from 4/28/22 and the facility had not documented a recent weight for Resident #6 for the month of May 2022or for the RD to complete an accurate nutritional assessment. The 6/3/22 assessment further documented the resident required setup assistance with meals. The nutritional interventions included: providing the resident her food in bowls per her preference, monitoring the resident's weights as ordered, monthly, and monitoring any significant weight change. The RD documented the goal was for the resident to maintain sufficient nutritional status by maintaining a weight within 5% of 142 lbs and consuming at least 50% of at least two meals daily. It indicated the RD attempted to visit the resident, however she was sleeping. The RD requested a more recent weight be obtained for the resident. The 8/24/22 nutritional assessment, completed by the dietary manager, documented the resident's weight was 132 lbs, down 8.71% in 180 days. It indicated the resident liked the food, but did not eat much. -The assessment did not include any nutritional interventions to address the resident's weight loss of 15 lbs since April 2022. The September 2022 meal intake records documented that the resident consumed the following from 9/1/22 - 9/14/22: -75-100% of meals on 22 occasions; -51-75% of meals on nine occasions; -26-50% on six occasions; and, -refused on one occasion. The September 2022 (9/1/22-9/12/22) snack intake records documented that the resident consumed a snack on six occasions and refused on three occasions out of 12 occasions. The September 2022 (9/1/22-9/14/22) Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . III. Staff interviews Certified nurse aide (CNA) #7 was interviewed on 9/15/22 at 10:00 a.m. She said Resident #6 was independent with eating her meals. She said the resident ate in her room. She said the facility did not have a restorative program for meal assistance. CNA #8 was interviewed on 9/15/22 at 2:40 p.m. She said Resident #6 required total assistance with her ADL care. She said Resident #6 ate alone in her room and did not require any assistance or supervision with meals. The RD was interviewed on 9/14/22 at 3:19 p.m. She said weights should be obtained on every resident at least once per month. She said the facility had decided to place every resident on weekly weights, however it had been difficult for the CNAs to obtain the weights. She said when the weights were obtained, she entered the weights into each resident's medical record. She said she reviewed every resident's weight at the facility. She said all residents with weight loss or weight gain were reviewed every Thursday during the clinical meeting. She said the IDT would discuss any weight changes and potential nutritional interventions. She said she would conduct an assessment for any resident who had experienced significant weight loss and put intervention into place to address the weight loss. She said she was familiar with Resident #6, however, would like to review her notes regarding her weight loss. The RD was interviewed again on 9/14/22 at 4:34 p.m. She said she attempted to get a reweigh on the resident that day (9/14/22, during the survey process). She said the resident had consumed her meals pretty well in the past 14 days. She confirmed the resident's medical record had shown the resident consistently losing weight since June 2022. She said she was aware the facility did not obtain a weight for Resident #6 for March 2022. She said the computer system did not trigger the resident as having a significant weight loss. She said she would have had to calculate it by hand. She confirmed it was her responsibility to monitor each resident's weight, whether the computer triggered it as a significant weight loss. She confirmed the resident experienced a significant weight loss. She confirmed the nutritional intervention put into place was Boost Plus on 6/1/22. She said she did not put any other interventions into place to combat the resident's continued weight loss. The director of nursing (DON) was interviewed on 9/15/22 at 3:40 p.m. She said each resident's weight should be obtained every week. She said the CNAs were responsible for obtaining weekly weights. She said getting weekly weights on all residents had been a challenge because of staffing issues. She said she was aware the facility was having difficulty obtaining weights on residents for a few months. She said the RD was responsible to review all weights for weight loss, weight gain and provide direction on nutritional interventions. She said the RD was responsible to conduct an assessment, provide nutritional interventions and update the care plan for all residents who experienced weight loss or weight gain. She said nutritional interventions should be put into place immediately following an identified weight loss. She confirmed the weight loss for Resident #6 was not identified until the survey process.

Based on observations, record review and interviews, the facility failed to ensure that residents were free from abuse, neglect, and exploitation for four (#46, #30, #36 and #31) out of eight residents reviewed for facility-reported incidents of abuse out of 38 sample residents. Specifically, the facility failed to recognize and prevent resident-to-resident altercations involving verbal and physical aggression between Resident #46 and #30 and Resident #36 and #31. As a result of the 5/1/21 resident to resident altercation between resident #46 and Resident #30; Resident #46 suffered psychosocial harm causing distress for three days following the incident. Resident #46 experienced behavioral changes resulting in decreased participation in normal activities; increased anxiety and anger; and he seemed fearful and watchful of others. In addition to mood and behavior changes Resident #46 experience hip pain after being pushed to the floor by Resident #30. Resident #30 experienced mild change in mood following the resident to resident altercation and showed increased irritation for one day following the incident. The facility was aware that Resident #46 had a tendency to become agitated when other residents got too close to him and did not have sufficient interventions in place to prevent this alteration from occurring. It was not until after this third resident to resident altercation initiated by resident #46 that the facility began to assess the resident behaviors and implemented more effective interventions. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 6/6/21 to 6/10/2, resulting in the deficiency being cited at past non-compliance with a correction date of 5/6/21. I. Facility policy The Abuse policy, revised 10/28/2020, was provided by the nursing home administration (NHA) on 6/6/21 at 7:30 p.m. The policy read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents . -Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. -Standards: Providing a safe environment for the resident is one of the most basic and essential duties of our facility. -Resident abuse is defined as the willful infliction of injury .Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. -If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. II. Resident to resident altercation between Resident #46 and #30 Facility reported incident investigation dated 5/1/21 for an allegation of resident-to-resident physical abuse was provided by the social services director (SSD) on 6/8/21 at 12:13 p.m. The investigation revealed the allegation of physical abuse between Resident #46 and #30 was substantiated by the facility based on video surveillance evidence. Staff did not witness the incident but video surveillance revealed Resident #46 became agitated when Resident #30 walked close to where he was standing in the hallway. Video surveillance revealed the two residents exchanged words; however, the recording did not have audio so what was said was unknown. Resident #46 raised his walker with a threatening motion towards Resident #30. Resident #30 turned his back towards Resident #46 and started to walk away. Resident #46 picked up his walker and hit Resident #30 in his lower back and back of the legs with the walker two times. Resident #30 turned back facing Resident #46 and with both hands pushed Resident #46 in his chest. Resident #46 lost his balance and fell backwards to the floor, landing on his back and buttocks. Resident #46 complained of right hip pain; Resident #30 did not complain of pain after the incident. A mobile x-ray revealed Resident #46 had no fractures. The two residents were immediately separated and placed on increased monitoring. Immediately following the incident, Resident #30 said Resident #46 came after him. Resident #46 was not able to verbalize what happened. Per the investigative report, neither resident was able to explain what had happened the day after the incident when the investigator interviewed them. Following the 5/1/21 facility reported incident allegation of physical abuse between resident #46 and #30, non-interviewable resident observations were conducted to monitor the residents for changes in condition. Observation notes of the non-interviewable resident revealed the following changes in the resident's baseline mood and behavior following the incident: Resident #46 -On the evening and through the night of 5/1/21, Resident #46 presented with a decrease in participation in completing activities of daily care, recreational activities, was more anxious, and slept less. -On 5/2/21, Resident #46 ate his meals in his room instead of the dining room, was more irritable with others, more anxious, seemed angrier, and seemed fearful (not wanting to be alone and/or was more watchful of others). -On 5/3/21 Resident #46 was isolating, agitated, anxious and angrier during the day. By nighttime, Resident #46 was at baseline. Resident #46 showed signs and symptoms of mood change in the three days following the incident. In addition to mood and behavior changes, the resident also expressed physical pain in his hips and elbows in the three days following the incident for which prescribed tylenol was effective. Resident #30: -On 5/2/21 Resident #30 was more irritable. -On 5/3/21 Resident #30 was at baseline. A. Resident #46 1. Resident status Resident #46, age 65, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/18/21 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a score of four out of 15 on the brief interview for mental status (BIMS). The resident had difficulty communicating some words or finishing thoughts but was able, if prompted and given time, to make himself understood but missed some intent or parts of communication from others. The resident did not reject care or exhibit any behaviors during the time of the assessment. The resident's balance was not steady but was able to walk with the assistance of a front wheeled walker. 2. Record review Resident #46's comprehensive care plan revealed a care focus for behavior; the care focus was initiated 3/11/21 and was revised 5/5/21. The behavioral care focus revealed Resident #46 had poor impulse control and a potential to be physically aggressive with peers, when they got too close to his personal space. -Resident #46 can become physically aggressive with peers displaying behaviors such as slapping, punching and slamming his walker into peers. Resident #46 has a difficult time recognizing his needs and verbalizing them. At times Resident #46 will use non-verbal communication; for example, when he is angry he will raise his fist in the air. When he is happy, he smiles and nods his head. Interventions initiated 3/11/21 included: -Document observed behavior and attempted interventions in behavior log. -Administer medications as ordered. Monitor and document for side effects and effectiveness. -Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. -Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. -Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff members when agitated. -Give the resident as many choices as possible about care and activities. -Modify the environment to decrease stimuli and provide resident with space when the resident becomes agitated. -Monitor, document and report any signs and symptoms of resident posing danger to self and others. -Offer and document non-pharmacological interventions prior to administering medication. Additional interventions initiated on 5/6/21, following the 5/1/21 resident-to-resident altercation included: -Allow compassionate care visits with his sister on a regular basis when she is available. -Resident #46 will meet with activities for one to one therapeutic support. -The social services director will meet with Resident #46 one time a week for therapeutic check-ins. The medical record confirmed interventions were initiated and both the social worker and activities staff were providing the resident with additional support. A review of Resident #46's medical record revealed that Resident #46 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . -On 3/9/21 Resident #46 became aggressive towards a female peer as she tried to enter the television room he was blocking her entry. Video footage showed Resident #46 was standing in the doorway blocking the female resident from entering. The female resident tugged at his shirt then tried to enter. Resident #46 reached out to slap at the female resident and the two residents began to punch at each other. Resident #46 ended up elbowing the female resident in the face four to five times causing her to sustain a swollen right lip. Resident #46 ended up with a scratch on his right arm. The residents were separated and placed on 15-minute monitoring checks. -On 3/15/21 Resident #46 became aggressive towards his roommate when the roommate got too close to his side of the room by Resident #46's bed. When the roommate would not leave his bedside Resident #46 pushed the roommate in the chest area. Staff walked in on this incident and separated the two residents immediately and neither was injured. Progress notes revealed the facility contacted Resident #46's physician and power of attorney; the interdisciplinary treatment team began to assess the resident for underlying causes of aggression and implemented interventions to prevent future resident to resident altercations initiated by Resident #46 form reoccurring. These events showed that Resident #46 had a potential for aggression directed towards his peers without incitement; the facility had an obligation to provide oversight and monitoring to prevent further incidents until they could be sure the interventions were effective to prevent future recurrence. Progress notes revealed that while the facility developed interventions after the first resident-to-resident altercation on 3/9/21 and were working on interventions, none were fully effective until the interdisciplinary team (IDT) and physician initiated additional interventions on 5/6/21 as documented above, and made adjustments in the resident's [CONDITION(S)] medications (see documentation of progress notes below for more information). Progress notes documented the following information: -The physician/medical provider note dated 3/10/21 at 2:12 p.m., read in pertinent part: Resident seen acutely for dementia with increased agitation .Psychological: angry: positive .Plan: resident with advanced dementia. Nursing reporting increased agitation over the last few days. Agitated again today. He takes [MEDICATION(S)] 0.25 milligrams (mg) at bedtime. Agree that benefits of decreased aggression outweigh potential side effects. Plan: increase [MEDICATION(S)] to 0.5 mg daily at bedtime. -Incident note dated 3/15/21 at 7:02 a.m., read in part: Resident's roommate encroached on resident personal space (and) this made him upset. Resident pushed his roommate. -Incident note dated 4/2/21 at 10:53 p.m., read in part: Staff heard two walkers clang together and a resident say 'hey what was that for;' when investigated, Resident #46 was hitting another resident's walker angrily and stopping them from going around him. He shoved the walker against the other resident's walker. No physical contact happened and no injuries were noted. -The physician/medical provider note dated 4/15/21 at 11:45 a.m., read in pertinent part: Reason for visit: follow up on dementia with behaviors .Resident was reviewed at psych-pharmacology meeting earlier in the week and due to his frequent behaviors of striking other residents (has happened multiple times), to make medication change to decrease his dangerous behavior .Has been combative with other residents consistently since his transfer to the facility. Was on [MEDICATION(S)] but had no notable effect. Recommended by psych-pharmacology to trial [MEDICATION(S)] at 2.5 mg and titrate up to 5 mg [MEDICATION(S)] (olanzapine)- allows for increased overall well being, increased participation in activities and happiness. Benefits of this med regimen at this time, outweigh potential risks of, but not limited to agitation, depression and hallucinations as listed in clinical pharmacology. -Nursing note dated 4/25/21 at 10:47 p.m. read: Resident asleep and resting well, with no adverse reaction to being on [MEDICATION(S)], no behavior concerns at present time. -Nursing note dated 5/1/21 at 5:44 p.m. read in part: At 2:22 p.m., nurse heard two raised male voices in the hall and ran to find this resident laying on the floor with his walker tipped on its side next to him. Resident #30 was walking away from this resident. Nurse asked what happened and Resident #30 pointed at this resident and stated, 'he came after me'! Resident #46 was assessed .Both residents were placed on frequent checks for safety. Video footage viewed for this incident: Resident #46 became agitated when resident #30 walked close to where he was standing in the hallway. Resident #46 picked up his walker and threatened resident #30 with it. Resident #30 turned his back and began walking away. Resident #46 picked up his walker and struck Resident #30 in the lower back and back of thighs with his walker. Resident #30 then pushed this resident by the chest, which caused him to fall down onto the floor . -Nursing note dated 5/2/21 at 4:21 a.m., read: X-ray results, no fracture or dislocation. -Nursing note dated 5/10/21 at 11:06 a.m. Order dated on 5/7/21 discontinue [MEDICATION(S)] 2.5 mg at bedtime; start [MEDICATION(S)] 5 mg every morning for dementia with behavioral disturbance. Residents with a known recent history of aggression towards peers were able to initiate another resident-to-resident altercation on 5/1/21 as documented above. The resident's medical record failed to document a full assessment of care-planned interventions for effectiveness in preventing resident-to-resident altercations and physical aggression or need for temporary intervention until the newly prescribed Zyprexia was titrated to full dose and assessed for effectiveness. B. Resident #30 1. Resident status Resident #30, age 72, was admitted on [DATE]. According to the June 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/1/21 MDS assessment revealed the resident had severely impaired cognition as evidenced by a score of seven out of 15 on the BIMS. The resident was able to make himself understood and was able to understand communication. The resident did not reject care or exhibit any behaviors during the time of the assessment. The resident was steady at times and used a four-wheeled walker to walk and get around the unit. 2. Record review Resident #46's comprehensive care plan reviewed care focus for behavior: The care focus was initiated 5/7/21. The behavioral care focus revealed Resident #30 had the potential to be physically aggressive with peers when they hit him. Progress notes reviewed one note regarding physical aggression towards a peer. -Nursing note dated 5/1/21 at 5:55 p.m., read in part: At 2:22 p.m., nurse heard two raised male voices in the hall and ran to find Resident #46 laying on the floor with his walker tipped on its side next to him. Resident #30 was walking away from Resident #46. Nurse asked what happened and Resident #30 pointed at Resident #46 and said, he came after me! C. Interviews Resident #46 was interviewed on 6/6/21 at 5:30 p.m. Resident #46 was nonverbal and answered with hand and facial gestures. When asked how things were going he gestured with a wide smile, eyebrows raised and hand movement with his pointer finger at his temple making a swirling circular motion. He was unable to express his thoughts in words. Resident #30 was interviewed on 6/7/21 at 9:10 a.m. Resident #30 was not very talkative, but did give some short answers to questions. When asked if everyone was getting along he said most of the time. He did not name any one in particular with whom he might have had concerns about and diverted his attention back to his television show. Registered nurse (RN) #2 was interviewed on 6/9/21 at 3:01 p.m. RN #2 said no staff witnessed the resident to resident altercation between Resident #46 an Resident #30 but they were able to get a sense of what happened from the hallway video surveillance. Based on the video footage Resident #46 became aggressive towards Resident #30 as he was walking past. Resident #46 was known to get agitated with peers who got too close to his personal space. When Resident #30 walk past Resident #46 raised his walker and threw it towards Resident #30 hitting Resident #30 on the back of his body as he was walking away with the walker; Resident #30 turned around and raised his hands in response and pushed Resident #46 backwards. Resident #46 fell back and hit his hip on the floor. It all happened very quickly. Both Residents were separated and examined for possible injury and placed on increased supervision. Resident #46 was wearing hipsters at the time and had no broken bones. Since this altercation, Resident #46 was placed on 15-minute checks at all times to ensure he kept a distance from his peers to prevent aggressive behavior. The goal was to ensure a safe environment. Resident #46 showed a decline in the past month; he was now using a manual wheelchair to get around the unit. Since a medication change to from [MEDICATION(S)] to [MEDICATION(S)] Resident #46's behavioral aggressions had decreased. He is less aggressive with peers. III. Resident to resident altercation between Resident #36 and #31 Facility reported incident investigation dated 4/13/21 for an allegation of resident-to-resident physical abuse was provided by the SSD on 6/8/21 at 12:13 p.m. The investigation revealed the allegation of physical abuse between Resident #36 and #31 was not substantiated by the facility despite a staff witness describing Resident #31's actions as being purposeful. -After this review of the investigative report, supporting evidence and staff interviews, this allegation was substantiated. The investigative summary documented: on 4/13/21 at approximately 5:44 p.m. Resident #36 requested to call his wife. Staff were busy helping other residents with dinner service and asked Resident #36 to wait until they were available to assist him with the call. Resident #36 became very aggressive and agitated and upset with staff because he was not able to call his wife when he asked. Resident started to call the staff names and when that did not get his desired result, Resident #36 purposefully ran his wheelchair into Resident #31, who was sitting in the hall in her wheelchair. Staff intervened and separated Resident #36 and #31 and placed the two on 15 minute monitoring checks to ensure safety. Behavior tracking for Resident #36 revealed: On 4/13/21 at 6:30 p.m. CNA #4 observed Resident #36, being physically and verbally aggressive, and attempted to bump into the nurse and other resident. In response to the resident behavior staff offered one to one validation, verbal redirection, and distraction. After the interventions, Resident #36 appeared to be better. The investigation and witness interview did not start until 4/19/21. By that time, the video footage of the occurrence had been recorded over and was no longer accessible and one of the staff witnesses was on vacation and was not interviewed. The residents involved were interviewed by the licensed practical nurse (LPN) on duty the day after the resident-to-resident altercation. Resident #31 was not able to recall the altercation. When the LPN asked Resident, #36 why he had been so upset to hit another resident and told Resident #36 that it was not ok to hit another resident; Resident #36's recorded response was I don't care. The interview report failed to document Resident #36's response to the first question asked about why he was so upset. It was unclear if the resident recalled the event that next day or if he was indifferent to the questioning. There were other residents in the area when this incident occurred but the witnessing resident interviews were not conducted until 4/19/21, six days after the incident. None of the residents present were able to recall the altercation. Staff interviews were not obtained until 4/19/21. Certified nurse aide (CNA) #4 reported witnessing Resident #36 run his wheelchair into Resident #31 but gave no detail as to how hard or how many times he hit Resident #31 with his chair or if he hit any part of her body. After running into Resident #31, Resident #36 ran his chair into staff once, was told to stop, and he did. CNA #5 was on vacation at the time staff interviews were conducted and a witness statement was not obtained from CNA #5. The LPN on duty gave a witness statement but gave no additional insight into the incident. Video surveillance, which is only maintained for a limited number of days, was no longer available at the time of the investigation to view as evidence. Following the 4/13/21 facility reported incident allegation of physical abuse between resident #36 an #31, non-interviewable resident observations were conducted but not started until three days after the incident on 4/16/21 and only completed for Resident #31. The documentation revealed the following changes in the resident's baseline mood and behavior following the incident: Resident #36: -On 4/19/21 Resident #36 was at baseline -There was no documented observation of Resident #36's mood and behavior in the first couple of days after the incident from 6/13/21 and 6/18/21. There was no assessment of the Resident #36's mood and behavior following the 4/13/21 resident to resident altercation. Resident #31: -On 4/16/21 Resident #31 was displaying increased signs of agitation; was sleeping less; was out of her room more; and was more fearful (not wanting to be left alone, or was watchful of others). -On 4/17/21 Resident #31 was displaying increased signs of agitation; was sleeping less; and was more fearful (not wanting to be left alone, or was watchful of others). -On 4/18/21 Resident was at baseline. -There was no documented observation of Resident #31's mood and behavior in the first couple of days after the incident from 6/13/21 and 6/15/21. Because there was no documentation of the resident's mood and behavior immediately after the incident there was no way to determine how severely the incident affected the resident's psychosocial demeanor. The resident did have some mood and behavioral changes in the days after this event, based on documentation as described above, which may have been a response to the altercation she had with Resident #36 on 4/13/21. A. Resident #36 1. Resident status Resident #36, age 80, was admitted on [DATE]. According to the June 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/18/21 MDS assessment revealed the resident had moderately impaired cognition as evidenced by a score of 10 out of 15 on the BIMS. The resident was able to communicate needs and make himself understood. The resident did not reject care or exhibit any behaviors during the time of the assessment. The resident used a manual wheelchair as a primary mode of transportation. 2. Record review Resident #36's comprehensive care plan reviewed care focus for behavior: The care focus was initiated 4/16/21 and was revised 4/20/21 and 5/26/21. The behavioral care focus revealed Resident #36 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #36's behavioral symptoms included name calling, cursing at and threatening staff. Resident #36 also displayed physical aggression with using his wheelchair as a tool of aggression towards his peers and staff. Interventions included: -Behavioral monitoring. -Conduct 15-minute checks for safety. -Assist the resident with making the phone call when he requests, no matter time or day. -Anticipate and meet the resident's needs. -Assist the resident to develop more appropriate methods of coping and interacting (specify:) No interventions were specified. -Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him as passing by. -Encourage the resident to express feelings appropriately. -Explain all procedures to the resident before starting and allow the resident to adjust to changes. -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. -When behaviors occur, intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from the situation and take to alternate location as needed. Progress notes revealed: -Nursing note dated 4/13/21 at 5:57 p.m., read in part: Resident has increased agitation because he dislikes the telephone schedule that was placed by his wife. Resident called several staff members disrespectful names, raised his hand to a staff member in anger as if going to hit them, ran into a resident with his wheelchair 3-4 times while I was helping to protect another resident from being hit. -Nursing note dated 4/16/21 at 2:49 p.m., read in part: The SSD and NHA contacted resident's wife to discuss facility's plan of care for Resident #36 regarding his behaviors. Resident is on 15 minute checks and we cannot tell him he cannot call her, as this causes the behaviors. The SSD asked the resident's wife, if it was ok with her, we would like for her to ignore the call if he calls and she is busy so it eliminates behaviors. The resident's wife was in agreement to this and stated she would answer on the times she can. The resident's wife understands that Resident #36 can be tough sometimes and is willing to do what she needs to make his stay here better. The SSD and NHA also discussed compassionate care visits. The resident's wife loved the idea of being able to visit in person. The resident's wife thinks this could help him and hopefully make him happier. - Nursing note dated 4/21/21 at 9:16 a.m., read in part: Resident is upset that I can no longer call his wife at this time. He has called her three times and his wife is hanging up on him. When I spoke with his wife before she stated that the resident accuses her of cheating and so she will hang up on him when he does this. The resident is becoming very agitated and will sit at the nurse station and call staff names if not able to call his wife over and over for him. -Physician/medical provider note dated 4/21/21 at 5:03 p.m., read in pertinent part: Medical necessity of visit: request to be seen, by nursing, wife and social worker. Chief complaint: patient is being seen to address dementia with behaviors. History of present illness: increasing behavior that are causing him distress .agitation, physically and verbally abusive hallucinations and paranoid delusions .Assessment and plan: consulted the geriatric psychiatrist who recommends discontinuing [MEDICATION(S)] as this can cause [CONDITION(S)] and hallucinations. I will also check labs to rule out organic causes. If the labs are normal and he is still having behaviors .Staff will monitor and keep providers up to date on behaviors. -Physician/medical provider note dated 4/26/21 at 4:52 p.m., read in pertinent part: Date of encounter: 4/26/21. Request to be seen by nursing and family. Chief complaint: patient with uncontrolled diabetes and dementia with behaviors. History of present illness: Dementia with behaviors- patient is having increasing behaviors that are causing him distress. He is calling his wife constantly and will accuse her of cheating on him. This prompts her to hang up on him. If staff does not call her when he wants, he becomes agitated and physically and verbally abusive. He also is hallucinating about a family of owls outside in a tree near the patio. His paranoid delusions about his wife have increased recently .Assessment and plan: consulted with the geriatric psychiatrist who recommends starting patients on [MEDICATION(S)]. Will start with 2.5 mg twice a day. Can increase dose if needed .Staff will monitor and keep providers up to date on behaviors. -Psychosocial note - late entry dated 5/24/21 at 2:45 p.m., read: SSD followed up with Resident #36 regarding the nursing note that was documented on 5/24/21. He reported he was agitated because he wanted to call his wife. SSD and resident called his wife together. Unfortunately, she did not answer. SSD did role-playing with resident and it seemed to help de-escalate the situation. SSD stated to resident since your wife did not answer, pretend I am your wife, say the things to me that you would say to your wife if she answered. Resident said I care about you a lot and would like to see you. SSD and Resident looked at pictures together of him and his wife. SSD asked resident to share some stories/memories of them together. Resident was able to share some memories with SSD. Resident was laughing and reminiscing about past events with his wife and children. At the end of our conversation, Resident was in a pleasant mood and did not seem to be in any distress. -Psychosocial progress note dated 6/6/21 at 8:45 p.m., read in pertinent part: Changes to medical status: Started on [MEDICATION(S)] on 4/26/21. Had an increase in verbal/physical aggression directed at staff (due to his wife not answering the phone when he calls). Cognition and communication status BIMs eight out of 15, previous score 10. Resident is able to verbalize his needs. Mood and behaviors .documented behaviors in the quarter, (2/6/21-5/6/21): verbal aggression: five times; refusal of care: three times; disruptive or intrusive: one time; mood issues: one time; repetitive statements: one time and physical aggression: one time. Psychoactive medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Resident #31 1. Resident status Resident #31, over the age of 85, was admitted on [DATE]. According to the June 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/30/21 MDS assessment revealed[TRUNCATED]

Based on record review and interviews, the facility failed to ensure one (#2) of three out of five sample residents reviewed for accidents remained free from falls. The facility failed to ensure Resident #2, who was admitted after a fall at home and sustained a left [MEDICAL CONDITION] and was a known fall risk, received care and services necessary to keep her safe from falls. Resident #2 fell on [DATE] in the doorway of the bathroom at 1:00 a.m. The resident got up from bed, walked to the bathroom and fell in the doorway of the bathroom. Subsequently, Resident #2 sustained a left humerus (arm) fracture and a left [MEDICAL CONDITION]. The facility failed to ensure the resident was checked on and provided toileting assistance every two hours, as was documented in her plan of care, throughout the night. The facility documented the resident was provided care 8:28 p.m., approximately five hours prior to the resident's fall, when the staff assisted the resident to bed. The facility did not document checking on the resident or providing care between 8:28 p.m. and 1:00 a.m. The facility failed to ensure fall interventions were in place to prevent falls for Resident #2, who had dementia and was a known fall risk. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, reviewed November 2019, was provided by the director of nursing (DON) on 1/26/21 at 2:21 p.m. It revealed, in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Research has shown that structured fall reduction program can substantially reduce the rate of falls and related injuries in nursing facilities. Identify risk factors, following by timely and appropriate interventions, is the key to a successful program. To be effective, a fall reduction program is characterized by four components: - fall risk evaluation; -care planning and implementation of interventions; -ongoing evaluation process (Quality Assurance Performance Improvement); and -a commitment by caregivers to make it work. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. II. Failure to ensure Resident #2 received the necessary supervision, which resulted in a fall with multiple sustained fractures. A. Resident responsible party interview The resident's responsible party was interviewed on 1/26/21 at 11:34 a.m. She said the resident had been admitted to the facility because she had fallen and sustained a [MEDICAL CONDITION] while she was staying with another family member. She said the resident was scheduled to discharge home on 10/9/2020. She said she received a call on 10/9/2020, very early in the morning, informing her the resident had fallen. She said the nurse told her the resident complained of pain to the left arm and the facility would get an x-ray. She said the nurse called back to inform her the x-ray was taking too long and they would send the resident to the hospital. She said at the hospital, the x-ray showed a fracture to the humerus. She said the resident returned to the facility. She said later in the day, the nurse from the facility called her back and told her the resident was complaining of pain to the left hip. She said they got an x-ray and sent her to the hospital for a comparison of the previous left hip x-ray from her previous fall before she was admitted to the facility. She said the x-ray came back with a new left [MEDICAL CONDITION]. She said the resident was required to have surgery on her hip and was no longer able to walk. B. Resident #2 status Resident #2, age 83, was admitted on [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 9/25/2020 minimum data set (MDS) assessment revealed the resident had short term and long term memory impairment with moderate impairment making decisions regarding tasks of daily life. She required extensive assistance of two people with bed mobility and transfers. She required extensive assistance of one person with dressing, toileting and personal hygiene. C. Record review Based on the record review and interviews (see below), the facility had knowledge and identified on 9/20/2020 upon the residents admission of the resident's functional limitations (unsteady gait, history of falling and weakness) requiring one-person hands on assistance with transfers, toileting and ambulation prior to the fall on 10/9/2020. The facility identified the resident should be provided toileting assistance every two hours and as needed. The facility did not ensure the resident was checked on and offered toileting assistance to prevent the resident from getting up and going to the bathroom without staff assistance. Further, the facility did not put fall interventions into place to prevent falls when the facility identified the resident's unsteady gait, history of falling and cognitive impairment. The 9/20/2020 weekly nursing progress note revealed the resident had poor memory recall, was incontinent of bowel and bladder and required one to two person assistance with mobility. It documented the resident was a high fall risk. The 9/23/2020 skilled nursing progress note identified the resident to have unsteady gait, weakness and required supervision. The 9/20/2020 fall risk evaluation revealed the resident was a high risk for falls. It indicated the resident was disoriented, had one to two falls in the previous 90 days, was wheelchair bound and required assistance with elimination. The activities of daily living (ADL) care plan revealed the resident had a self-care performance deficit related to the resident's [DIAGNOSES REDACTED]. It documented the resident required standby assistance for bed mobility and staff assistance of one person with dressing. The interventions included to encourage the resident to use the call light for assistance. The cognitive loss care plan revealed the resident had impaired cognitive function and impaired thought processes related to the resident's [DIAGNOSES REDACTED]. The interventions included to keep the resident's routine consistent. The incontinence care plan revealed the resident had mixed bladder incontinence related to a decreased urge to void, dementia, diabetes mellitus type two and muscle weakness. It indicated the resident used disposable briefs and should be provided incontinence care every two hours and as needed. The fall care plan, initiated on 9/23/2020 and revised on 10/9/2020 (the day of the resident's fall), revealed the resident was a high risk for falls related to poor safety awareness, muscle weakness and dementia. The interventions included: anticipate and meet the resident's needs, ensure the resident's call light is within reach and encourage the resident to use it for assistance, educate the resident and family of safety reminders, encourage the resident to participate in activities and ensure the resident is wearing appropriate footwear. The interventions were updated on 10/9/2020, after the resident's fall, to put bed bolsters in place and place a floor mat next to the resident's bed. D. Fall review The 10/9/2020 nursing progress note revealed the nurse heard a loud noise from the resident's room at approximately 1:00 a.m. The nurse observed the resident lying on her left side, next to the bathroom door. The resident complained of pain to the left arm. The nurse practitioner ordered an x-ray to the left shoulder, left clavicle and left humerus. It indicated the resident did not use the call light to go to the restroom. At 6:50 a.m. the nurse documented the resident was sitting at the nursing station. The resident guarded her left upper extremity with a noted light blue contusion under the left arm and the upper posterior forearm. It indicated the resident was unable to report her pain level due to her dementia. The resident had facial grimacing. At 7:11 a.m. the nurse documented the resident was experiencing an increased amount of pain. The nurse indicated she was unable to get an estimated time of arrival for the x-ray. The resident's representative requested the resident be sent to the hospital for an evaluation. At 8:30 a.m. the ambulance arrived, splinted the resident's left upper extremity and transported the resident to the hospital. At 12:12 p.m. the nurse documented the resident returned from the hospital with new findings of a fracture to the resident's left humerus. The 10/9/2020 physician progress notes [REDACTED]. The resident returned from the hospital with her arm in a sling. The physician ordered additional pain medications to address the resident's pain. The 10/9/2020 nursing progress note revealed when the resident returned back from the hospital she had complaints of left hip pain. The on-call physician ordered a left hip x-ray. The x-ray showed a left [MEDICAL CONDITION]. The physician ordered for the resident to be sent to the hospital for a comparison of the new [MEDICAL CONDITION] with the previous [MEDICAL CONDITION] prior to the resident's admission to the facility. The 10/9/2020 hospital discharge instructions revealed the resident sustained [REDACTED]. The hospital placed the resident's left arm in a sling until the arm was stable to begin range of motion exercises. The 10/9/2020 radiology results revealed the resident sustained [REDACTED]. The October 2020 certified nurse aide (CNA) ADL task documentation revealed the resident was provided assistance with bed mobility, dressing, personal hygiene, transfers and toileting at 8:28 p.m., five hours before the fall. The resident's medical record was reviewed on 1/26/2020 at 9:00 a.m. It did not reveal documentation to indicate the resident had been checked on or provided assistance between 8:28 p.m., when she went to bed, and 1:00 a.m. when she was found on the ground. E. Staff interviews Registered nurse (RN) #1 and the DON were interviewed on 1/26/2020 at 1:18 p.m. RN #1 said each resident should be checked on consistently throughout the shift by both the nurse and CNA. He said his standard of practice was to check in with each resident at least every hour. He said residents, who were identified as being a fall risk, should be checked on more often during the day. He said as time allowed, each CNA and/or nurse should lay their eyes on each resident every 15 minutes. He said those residents who were a high fall risk and had dementia did not always use the call light when they needed assistance. He said by checking on them frequently throughout the shift, ensured the resident was safe and did not require assistance. He said each resident, who were incontinent of bowel and bladder, should be provided toileting assistance every two hours, unless they were on a toileting schedule. He said when a resident was admitted , the nurse conducted a fall risk evaluation to determine if the resident was a fall risk. He said the floor nurse should initiate a fall risk care plan and put appropriate interventions into place. He said a resident, who was admitted with a fracture due to a fall, with dementia, was considered a fall risk and should have appropriate interventions to prevent falls and should be checked on frequently throughout each shift. RN #1 said he did not remember Resident #2. The DON said each resident's fall risk level was determined upon their admission to the facility. She said the floor nurse should initiate the baseline care plan and put appropriate interventions into place. She said for a resident with dementia and a fall risk, appropriate interventions should include a low bed with a floor mat in place or potentially bed bolsters. She said each resident should be checked on every two hours. She said that was the standard of practice at the facility. She said if the resident did not want to be bothered, then either the CNA or nurse should put their eyes on the resident to ensure the resident's safety. The DON confirmed Resident #2 care plan did not contain appropriate interventions for the resident since she was a high fall risk with a [DIAGNOSES REDACTED]. The DON was interviewed on 1/26/21 at 12:05 p.m. She said Resident #2 had been found on the ground at approximately 1:00 a.m. on 10/9/2020 outside the bathroom. She said the facility was unable to get an x-ray to come fast enough to the facility, so the nurse sent the resident to the hospital to be evaluated. She said Resident #2 was complaining of pain to the left arm. She said the resident returned to the facility with a [DIAGNOSES REDACTED]. When the resident was back in the facility, she said the nurse was concerned because of her previous history that the resident was experiencing additional pain to the left hip. She said due to the resident's dementia, the resident could not rate her pain level. She said the nurse contacted the physician to get an x-ray of the left hip. The DON said the x-ray returned with a left [MEDICAL CONDITION] and the resident was sent to the hospital for a comparison of her previous [MEDICAL CONDITION] prior to her admission and treatment. She said Resident #2 did not return to the facility. She confirmed the facility did not complete a fall investigation or follow-up risk management because the resident did not return to the facility from the hospital. She confirmed the documentation indicated the resident was last checked on at 8:28 p.m., five hours before she fell attempting to go to the bathroom. She said she expected the staff to check on each resident every two hours and as needed.