Every finding on record at The Estates at Lynnhurst LLC

Based on interview and record review the facility failed to ensure residents were free from abuse for 2 of 5 residents (R2, R3) when another resident (R9) who when intoxicated made sexually inappropriate comments toward the residents, touched their arms, legs and attempted to touch their breasts. R9 was intoxicated nearly every day and had care planned interventions for alcohol use but did not have interventions for sexually abusing residents. Even though the facility notified the police and educated staff on abuse, residents continue to fear R9's sexual abusive behaviors. Findings include: R2's nursing progress note dated 7/25/26 at 8:03 p.m. indicated R2 arrived at the facility at approximately 11:30 a.m. R2 understood her wound management and neck mobility restrictions. She had limited assistance with ambulation and toileting. She was able to make needs known. R2's nursing progress note dated 7/26/26 at 8:55 p.m. indicated R2 was sent to the hospital. R2 did not return to the facility. R2 did not have an admission Minimum Data Set (MDS) as she was only at the facility for less than two days. Upon interview on 8/12/26 at 12:31 p.m. R2 stated she arrived at the facility 7/25/26 in the late morning. That afternoon, R2 went to activities and R9 approached her commenting about how sexy she was. He was intoxicated reeking of alcohol. R9 asked R2 if she wanted to go to his room for drinks and a good time. R2 ignored R9 and then he started touching her arm and tried to touch her breasts. R2 stated she reported the incident to staff but could not remember who. She was new to the facility and did not know anyone yet. On 8/26/26 R2 was sent to the hospital for a fall and refused to go back to the facility after being sexually traumatized and falling. R3's quarterly MDS dated [DATE] indicated R3's Brief Inventory of Mental Status (BIMS) score was a 10 indicating she was cognitively impaired. R3 did not have any behaviors. R3's patient health questionnaire (PHQ-9) indicated R3 had a score of 22 indicating she had severe depression. She was dependent upon staff for toileting hygiene and showering; she required maximum assistance with dressing and moderate assistance with transferring. She was always incontinent of bowel and bladder. Her pertinent diagnoses were non-traumatic brain dysfunction, anoxic brain damage, and substance abuse. A facility incident note dated 7/26/26 indicated R3 reported feelings of sexual harassment by a male resident who she believed was flirtatious and making her uncomfortable. She was placed on safety checks and advised to stay away from the perpetrator. The administrator was informed. R3's providers note dated 7/28/26 indicated R3 presented acutely following a sexual harassment event where another resident was saying appropriate comments and touched her arm without her consent. R3 reported she was doing o.k. and was being followed by psychiatry. Upon observation and interview on 8/13/26 at 1:45 p.m. R3 was lying in her bed watching television. She attempted to sit up to have a conversation but struggled and needed staff assistance. During the interview she had difficulty expressing her words. She stated she was scared of R9. She was glad her bed was by the window so he would have to walk by her roommate to get to her. She wished R9's room was not directly across from hers. She did not remember whether she told the staff or not that she feared him living right across from her. She stated she was in the dining room and R9 approached her telling her she was sexy and touched her leg, arm and tried to put his hand down her shirt and touch her breast. She mentioned she was sexually abused by an alcoholic in her youth, and this event has caused her depression to become worse. She did see psychiatry. R9's care plan dated 4/27/26 indicated R9 had a history and diagnosis of substance use. R9's interventions were:4/27/26 Monitor resident for intoxication or impairment4/27/26 When resident is noted to have been smoking illegal substances like marijuana, cocaine, or meth etc. OR is intoxicated (unsteady gait, slurred speech, pinpoint pupils etc. Do not administer any medications. Update the provider for more directions.7/28/26 Monitor resident behaviors as needed.5/29/26 Resident is actively currently drinking alcohol. R9's care plan dated 4/27/26 indicated a focus R9 gets sexually inappropriate when intoxicated, uses inappropriate language towards female residents and staff, touches female residents inappropriately. There was no goal related to R9's sexual abuse and no interventions to prevent R9 from sexually abusing other residents. R9's nursing progress note dated 7/25/26 at 10:44 a.m. indicated R9 was heavily intoxicated and remained verbally abusive and sexually inappropriate towards female residents. Staff called the police and paramedics to have R9 sent to the hospital for detox but both refused the referral indicating R9 has freedom of speech, the facility should handle the behavior if the resident violates the facilities policies. Other residents advised to stay away from the perpetrator. R9's nursing orders dated 7/26/26 at 10 p.m. indicated to complete 15-minute checks for sexually inappropriate behavior. R9's nursing dated 7/27/26 indicated R9 met with social services to complete a BIMS assessment, PHQ-9, and a trauma questionnaire. He was cognitively intact, had no minimal signs of depression. R9's nursing progress note dated 7/27/26 at 8:11 p.m. indicated R9 was intoxicated making sexually inappropriate comments to multiple female employees. At 8:14 asked another nurse to grab his genitals. R9's quarterly MDS dated [DATE] indicated R9's BIMS score was 15 indicating he was cognitively intact. R9 had verbal behaviors towards others (threatening, screaming, and cursing) which occurred 4-6 days, but not daily. He had other behaviors not directed at others (hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing, or smearing foot or bodily wastes, screaming disruptive sounds), behavior occurred every 1-3 days. R9 was independent with dressing, hygiene and transferring. R9's pertinent diagnoses were alcohol use, housing and economic circumstances, and hip pain. R9's progress note dated 7/29/26 at 9:02 a.m. indicated R9 was intoxicated, raising his voice, talking inappropriately to staff and inappropriately touching staff. He was already on 15-minute safety checks. R9's hospital encounter note dated 7/29/26 was held at the hospital related to intoxication. R9's nursing progress note dated 8/8/26 at 1:38 p.m. indicated R9 was verbally inappropriate toward female residents making them uncomfortable per female resident verbalization. When the police arrived R9 was sleeping and the police decided not to take him in hoping he would wake up sober. R9's nursing progress note dated 8/9/26 at 8:56 a.m. indicated R9 was intoxicated, refused vital signs. R9's nursing progress note dated 8/9/26 at 7:45 p.m. indicated R9 was intoxicated and refused vital signs. R9's nursing progress note dated 8/9/26 at 7:51 p.m. indicated R9 was sitting in a chair outside, red faced and intoxicated. He did have his a.m. meds held due to intoxication and took a nap, but was intoxicated by 4:00 p.m. He refused vital signs; he becomes angrier the more intoxicated he becomes. R9's nursing notes dated 8/10/26 at 10:18 a.m. indicated R9 met with social services and reviewed the Substance Use Policy and got a signature from R9. His room was searched and an empty bottle was found in the trash can. R9's nursing note dated 8/13/26 at 10:28 a.m. indicated R9 met with social services to review and sign the Substance Abuse Policy again. R9's nursing note dated 8/15/26 at 11:45 a.m. indicated R9 appeared intoxicated, his face was ruddy and speech slurred. He was encouraged to drink water. He is continued on 15-minute checks. R9's nursing note dated 8/15/26 at 2:43 p.m. indicated R9 was intoxicated and bothering another resident by talking too much. He was redirected to lay down. An undated facility document appearing to be an interview of R9 indicated Yes, I was drunk and I touched her, but it was all innocent and didn't mean nothing by it. Resident also stated that he doesn't remember what he said. Upon interview on 8/13/26 at 10:14 a.m. R9 was resting in bed with a heavy alcohol scent in his clothes and room. He did not appear intoxicated. He stated he only touches and speaks about sex to women when he was intoxicated and the police had been to the facility about it. He stated the facility had offered him treatment but did not want to stop drinking. He then asked the surveyor to leave his room. Upon interview on 8/12/26 at 11:54 a.m. (RN)-D, nurse manager stated she did not get a chance to meet R2 because she was only at the facility from a Saturday morning until Sunday p.m. (RN)-D was briefed on her allegations of sexual harassment. R9 only had a problem with his sexual behaviors when he was intoxicated because he became agitated with staff and other residents. When the allegations of abuse occurred other residents were interviewed, but the facility did not have a plan for R9's intoxication to protect other residents other than to check on him every 15 minutes and have social services have R9 sign the substance abuse facility form. R3's abuse allegations of abuse were told directly to (RN)-D. (RN)-D performed a physical assessment on R3 without any findings. R3 has a history of sexual abuse as a child. Her provider was updated on the allegations and R3 stated she felt safe at the facility. Upon interview on 8/12/26 at 12:23 p.m. (NA)-C stated R9 drinks almost daily and makes [NAME] sexual comments to residents and staff often. He witnessed R3 attempting to get away from R9 in the dining room, but he did not see R9 touch R3. R3 told him she was trying to get away from him because he was trying to touch her breasts and was making sexual comments. NA-C reported the allegations immediately to the nurse manager. Upon interview on 8/12/26 at 1:10 p.m. (NA)-D stated R9 had a reckless mouth and hands when he was intoxicated. He was sexual and mean to both staff and residents. Upon interview at 8/13/26 at 9:15 a.m. R10 stated she has witnessed R9 speak sexually to multiple woman residents. When he was drunk, almost daily he would make sexually inappropriate comments to the woman, sometimes aimed at a specific resident and sometime at woman. R10 had been sober 18 years and stated she was bothered by smelling the alcohol and watching R9's actions when he was drunk since the residents were not supposed to drink at the facility. Upon interview on 8/13/26 at 9:25 a.m. R11 stated she had been sexually harassed about a month ago when he was intoxicated. She did not report it, she just blew it off. She stated she did fear him and made an effort to stay away from him. Upon interview on 8/13/26 at 9:40 a.m. the social worker, (SW)-A stated she was not employed by the facility when R2 made her allegations of sexual abuse. She stated R3's sexual allegations were witnessed by another resident who was no longer there. It happened in the dining room, when he touched her arm and leg, and she attempted to get away from him. R3 had difficulty moving and speaking so she struggled with his inappropriate encounter. The SW had been checking on R3 since the incident. She stated the facility prevented abuse by completing frequent checks on residents to see if they had been sexually assaulted. The facility lets the resident know they all have an open door policy. In the situation with R9 she stated when he was intoxicated the facility reviewed and had him sign the substance abuse policy. R9 had a right to drink if he chose to and he did not want assistance with sustaining from alcohol. Residents and staff only had complaints about R9's behaviors when he was intoxicated. She was not certain how the staff assessed him and what the plan was or if there was a plan in place when he was intoxicated to prevent abuse. 8/13/25 at 4:19 p.m. R12 stated she feared R9 and did not feel safe at the facility. R9 had never attempted to touch her but had made sexual comments to her often when he was intoxicated. She had witnessed him touch staff, get angry and scream at staff, he got out of control. She denied reporting his verbal comments to staff and denied staff interviewing her about him. Upon interview on 8/17/26 at 2:25 p.m. the director of social services stated when R9 drank the facility would attempt to get him to eat, drink, and rest. The facility would try to redirect him away from other residents, because sexual harassment was upsetting to vulnerable residents. The facility was at a standstill as they were trying to discharge him, but he was not appropriate to be discharged yet. Upon interview on 8/17/26 at 4:18 p.m. (RN)-B stated he was not aware of R3's sexual abuse allegations. On 8/26/26 he was told by R2 that R9 was flirtatious and trying to touch her. He reported the allegations to the Administrator immediately and placed both R2 and R9 on safety checks. Upon interview on 8/17/26 at 3:32 p.m. the Administrator stated he became aware of R2's allegations of sexual abuse on 8/26/26. He stated the therapeutic recreational aide did witness R9 trying to touch R2. He stated the facility nursing staff were re-educated on the facilities abuse policy following the incident. He denied any follow-up audits of the investigation. He stated the facility did not have a working plan in place for R9's alcohol intoxication to prevent abuse to the other residents. The staff monitors R9 and reports to the police or the administration depending on how R9's behaviors were. R3's allegations were substantiated by the facility as a former resident had witnessed R9 attempting to touch R3. R9 was ready for discharge, and the facility was going to discharge him to a hotel, but R9 did not have identification to check into one. The facilities Quality Assurance and Performance Improvement (QAPI) team had not reviewed the sexual abuse allegations. Upon interview on 8/17/26 at 3:45 p.m. the director of nursing, DON stated the therapeutic recreational aide did not witness R2's allegations of sexual abuse. R3's allegations were witnessed by another resident. R9 touched R3 and then attempted to follow her out of the dining room when she tried to get away from him. When R9 was intoxicated the facility staff was to call the ambulance and have him sent to detox where sometimes they would take him and sometimes they would not. The facility did follow-up with other residents and if they did have concerns regarding R9 they offered the residents psychiatric services. She stated the facilities' hands were tied because they were not able to discharge residents to a shelter. Multiple attempts were made to reach out to the therapeutic recreational aid, but no response was received. A facility policy titled Abuse Prohibition/Vulnerable Adult Policy with a revision date of 11/2025 indicated: Purpose:To protect residents against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse.To promptly report, document and investigate all incidents of alleged or suspected abuse/neglect.To promptly investigate, report and determine probable cause of unknown origin injuries.To identify and remedy any potentially abusive situations.Interpretation and implementation:If it is a resident-to-resident abuse, the abused resident will be removed to a safe environment.

Based on interview and record review the facility failed to ensure adequate assessment and monitoring following an unwitnessed fall the 1 of 3 residents (R2) reviewed for change of condition. R2 had a fall on 7/26/26 and subsequent hospitalization.Findings include: R2 nursing incident note dated 7/25/26 at 1:59 p.m. (late entry) indicated R2 fell in the bathroom. R2 indicated she fell in the bathroom and was able to get herself back-up. There were no signs or symptoms of an injury. Vitals signs were stable. Range of motion completed/hit head or received blood thinners with verified as yes. The incident note documentation of a neurological assessment for potential injury or ongoing monitoring for delayed signs or symptoms. R2's nursing progress note dated 7/25/26 at 8:03 p.m. indicated R2 arrived at the facility at approximately 11:30 a.m. R2 understood wound management and neck mobility restrictions. She had limited assistance with ambulation and toileting. She was able to make needs known. R2's nursing progress note dated 7/26/25 at 9:07 p.m. indicated R2 was sent to the emergency department (ED) for a fall with a head strike and dizziness. Her blood pressure was 155/90 (normal range > 120/80), pulse 66 beats per minute and regular (range 60-100 bpm). Oxygen saturation was 97% on room air (normal 92% - 100%). Pain level was 5/10 ( 0 no pain and 10 the greatest pain ever felt). R2's hospital Discharge summary dated [DATE] indicated R2's ED to hospital admission total time was three days. R2 was admitted for acute neck pain after tripping and hitting her head. She had a headache, stabbing neck pain, worsening left arm numbness and weakness since the fall. Her (computer tomography) CT scans of her head and cervical spine were without acute abnormalities or fractures. R2 did not have an admission Minimum Data Set (MDS) as she was only at the facility for two days. Upon interview on 8/13/26 at 12:31 R2 stated she was admitted to the facility in the late morning of 7/25/26. On 7/26/25 at around 3:00 a.m. she was waiting about 10 minutes for someone to assist her to the bathroom. She got herself up to the bathroom. In the bathroom she tripped and fell against the bathroom sink striking her head. She told the nurse, who was working, and was told by that the nurse to try to stay awake for a few hours. The nurse did not take any vital signs or assess her. She stated that was the last time she saw the nurse. On the 7/26/26 she had pain and numbness in her arm throughout the day. She had mentioned the pain, numbness and fall to nurse in the morning. In the early evening, on 7/26/26 she became nauseated with vomiting and dizziness. The same nurse was working. He took her vital signs and stated he would call the on-call doctor. She was sent to the hospital where she spent three days on pain medications, wearing a cervical collar and underwent multiple tests. She was discharged on 7/29/26 to a different nursing facility. Upon interview on 8/13/26 at 2:59 p.m. the hospital social worker indicated on 7/25/26 when R2 left the hospital to be admitted to the facility her pain was under control. When she returned to the hospital on 7/26/26 she spent three days there for pain control and testing. Upon interview on 8/13/26 at 4:18 p.m. registered nurse (RN)-B stated he worked the morning and evening on the day R2 allegedly fell. He stated the first he found out about it when she came to him on 8/26/26 in the early evening. He stated she mentioned a fall, he had not received report from any staff about a fall, but due to what she was telling him regarding dizziness and vomiting he called the provider and had her to the transferred to the ED. Upon interview on 8/13/26 at 11:54 a.m. RN-D the nurse manager stated she worked on Monday 7/27/26 and she was the nurse who documented the late incident report on that day through hearsay of what had happened on the weekend. She stated the overnight nurse should have completed an incident report and started monitoring R2 along with notifying the staff to monitor her. Or if the nurse was unaware of the fall, she still should have still been monitoring R2 as a recent admission following surgery. RN-D was going to investigate R2's fall incident when R2 returned after her hospital stay but found out R2 was not returning. Upon interview on 8/17/26 at 8:24 a.m. RN-C stated she worked the night shift on 7/25/26 and she completed rounds on her residents every two hours, so she checked on R2 at 2 a.m. and 4 a.m. and R2 was asleep. She denied know anything about a fall. The facilities fall prevention and management policy with a revision date of 11/2025 indicated:When a Fall occurs:When a resident has fallen, or is found on the floor, nursing staff will provide comfort but not move the resident until evaluated for injury.The nursing staff will record vital signs (including orthostatic BP), when appropriate.If a bump to the head is suspected or confirmed complete neuro checks and update the provider timely. Nursing should utilize the neuro flow sheet per policy.If resident is noted to be on a blood thinning medication and sustains a fall there is significant risk of bleeding. This should be reported to the provider in a timely manner.If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. If a fracture is suspected, do not move resident, but stay with resident and wait for instructions from medical provider or for emergency medical staff to arrive.Once an assessment rules out significant injury, nursing staff will assist the resident off floor utilizing a total (Hoyer) lift to a comfortable sitting, lying, or standing position, and then document relevant details.Nursing staff will notify the residents' medical provider and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the provider by phone. When a fall does not result in significant injury or a condition change, nursing staff will notify the practitioner routinely (e.g., by fax, phone, or in-house communication book, the next office/visit day).Nursing staff will observe for delayed complications of a fall. Could include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function.Nursing staff will complete an incident review and analysis.Defining Details of Falls:After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred, where it occurred and what the individual was trying to do at the time the fall occurred.Identifying Causes of a Fall or Fall Risk:Nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc.Staff will evaluate chains of events or circumstances preceding a recent fall, could include:Time of day of the fall;What the resident was doing or attempting to do;Whether the resident was standing, walking, reaching, or transferring from one position to another;Whether the resident was among other persons or alone;When was the last time the resident was repositioned or toileted;Time of the last meal;Whether any environmental risk factors were involved (e.g., slippery floor, poor lighting, furniture, or objects in the way); and/orWhether there is a pattern of falls for this resident.The interdisciplinary team will review falls daily at morning meeting.The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found.As indicated, the provider may examine the resident or may initiate testing to try to identify causes.If the cause of a fall is unclear or cannot be readily identified and accompanied by other signs/symptoms (e.g., confusion, lethargy, restlessness), or the fall has a significant medical cause such as a transient/Ischemic attack or an adverse drug reaction (ADR), or if the resident continues to fall despite attempted interventions, the nursing staff will discuss the situation and consider a possible underlying acute medical cause with the provider or Medical Director.If it is determined and documented that falls may be unavoidable, staff will implement appropriate interventions to prevent serious injury from falls.Care plans will be updated to reflect fall interventions.DocumentationWhen a resident falls, the following information should be recorded in the resident's medical record:The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair).Assessment data, including vital signs and any obvious injuries.Interventions, first aid, or treatment administered.Notification of the provider and responsible party, as indicated.Appropriate interventions taken to prevent future falls.The signature and title of the person recording the data.

Based on interview and record review the facility failed to ensure a resident was transferred using the required safety techniques for 1 of 3 resident (R1) who was reviewed for accidents when R1 sustained a humeral shaft fracture (upper arm). Two staff members were attempting to lay R1 down in bed after using a mechanical lift and repositioned her using her arms rather using a lift sheet as ordered on her care plan. The noncompliance that began on 8/1/26 was corrected prior to the start of the survey when the facility implemented a corrective action plan on 8/4/26 . This is issued in past noncompliance. Findings include: R1's care plan dated 11/13/15 indicated R1 had impaired physical ability with dependence on staff with bed mobility, transfers, feeding, cares, and activities of daily living (ADL)'s related to bilateral hands/wrists contractures. Her interventions were assistance of two for bed mobility and to educate staff to be gentle when lifting upper and lower extremities and to use a draw sheet when turning and repositioning in bed. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 was unable to complete a Brief Inventory of Mental Status (BIMS). R1 did not have any behaviors. She had an impairment of both her upper and lower extremities. R1 was dependent upon staff for eating, transferring and all other activities of daily living (ADL's). R1 was always incontinent of bowel and bladder. Her pertinent diagnoses were other neurological conditions, epilepsy, coronary artery disease, arthritis, dementia, seizure disorder, bipolar disorder, joint stiffness, and dysphagia (difficulty swallowing liquids and foods). R1's nursing progress note dated 8/1/26 at 2:13 p.m. indicated the writer was informed by two nursing assistants (NA)'s that during cares while trying to reposition R1 they did lift both of her arms up and heard a pop from the left arm. The writer performed an assessment. There was no redness or swelling at the site. R1 did complain of pain when writer touched the left arm. The provider was called and informed about the residents' change of condition and an onsite x-ray was ordered. R1's nursing progress note dated 8/1/26 at 5:55 p.m. indicated the mobile x-ray team was unable to do the x-ray at the facility and R1 was sent to the hospital. A written statement dated 8/3/26 by (NA)-A indicated two nursing assistants laid R1 down to change her and (NA)-A realized R1 was too close to the edge of the bed, and he grabbed both of her arms to position R1 and heard a popping sound and reported it to the nurse. An additional statement on 8/3/26 by (NA)-A indicated R1 was completing his rounds and noticed R1 was almost going to fall off the edge of the bed. He rushed over to her and held both of her arms to turn her to her right side and heard a popping sound. He left R1 on her bed and reported the incident to the nurse. A written statement on 8/3/26 by (NA)-B indicated her and (NA)-A were laying R1 down in bed. She was maneuvering the mechanical lift while (NA)-A assisted with putting R1 in and latching her straps. After they placed R1 in bed, (NA)-B started getting the briefs and wipes ready while (NA)-A was by her and said he heard a pop. R1 was in the middle of her bed, but did not have a draw sheet under her, NA-B didn't think about getting one. R1 as falling out of bed and (NA)-A grabbed her to move her to make sure she did not fall and then the popping happened. A written statement dated 8/4/26 by registered nurse (RN)-E stated the NA's come to her and stated they were repositioning R1 and heard a pop. (RN)-E did not know R1 well, so the asked the onsite supervisor to reassess R1. The provider was called and wanted nursing to monitor her and ordered an x-ray. (RN)-E did not see a mechanical lift in R1's room. Facility education signature sheets dated 8/4/26 indicated all nursing staff were re-trained on instructions for assessing and documenting a change of condition, the facilities Abuse Prohibition/Vulnerable Adult Policy, and the facility's Safe Resident Handling Program Policy. A facility inspection document dated 8/4/26 indicated the maintenance director completed an inspection of the mechanical lift used on R1 with no repair concerns. R1's nursing progress note dated 8/6/26 at 5:57 p.m. indicated R1 returned from the hospital with a brace on her left arm for a left humeral shaft fracture (bone of the upper arm). A facility termination letter dated 8/7/26 indicated (NA)-A was terminated due to failing to follow a residents care plan which resulted in harm. Upon observation on 8/12/26 at 11:58 a.m. R1 was lying in comfortably in bed with a cast on her left arm. She was alert with her eyes open, however was unable to speak when a conversation was attempted. Upon interview on 8/12/26 at 12:49 p.m. (NA)-A stated R1 was just laid down in bed with the mechanical lift, and it appeared she was falling out of the bed. He grabbed both of her hands with both of his hands. (NA)-B was at the foot of the bed getting supplies when the pop sound happened. He did not feel he grabbed her arms hard enough to break a bone and would never intentionally hurt her. (NA)-A stated he changed his story with the facility because he was nervous about being interviewed for R1's fractured arm. Upon interview on 8/12/26 at 1:19 p.m. (NA)-B stated her and (NA)-B had just laid R1 down in bed. R1 was centered correctly in bed. (NA)-B was at the foot of the bed and noticed (NA)-A roughly pulling R1's left arm straight up. She described his pulling A way you wouldn't position a resident, a strange motion. He had both of his hands on her left arm. She was unable to describe how he was pulling her arms any further. (NA)-B did not mention to the nursing staff that she believed (NA)-A was handling her rough because of retaliation and just wanted R1 to get help in case she was injured. Upon interview on 8/12/26 registered nurse (RN)-F, nurse manager stated (NA)-A and (NA)-B were repositioning R1 without the lift sheet and R1 started to fall. (NA)-A grabbed her arm to stop the fall. After (NA)-A heard (NA)-B's story he changed his story to they were both in the room from, he was passing the by the room and found R1 falling out of bed. (RN)-F stated she did not know what to believe as both (NA)-A and (NA)-B have lied in the past, so she was not certain exactly what happened with R1. Upon interview on 8/12/26 at 2:44 p.m. the director of nursing, (DON) stated she got the call on 8/1/26 that R1 was being sent to the emergency department (ED) due to a staff member grabbing her arm as she was falling out of bed. The DON started calling other staff members and found that there were two staff member in the room when R1's arm popped. The DON stated the root cause of the injury was that the staff were not using the lift sheet on R1 and resorted to pulling on her arm causing an arm fracture. The DON stated (NA)-A was asked why his story changed and he stated he was scared he would get into trouble for harming R1. (NA)-A was suspended and then terminated. Upon interview on 8/13/26 at 4:18 p.m. (RN)-B stated the (RN)-F and agency nurse who came and asked him to assess R1 as she did not know R1 very well. When (RN)-B went into R1's room she was in bed wincing in pain. (NA)-A told (RN)-B R1 was falling out of bed and the aides did not have a lift sheet, so (NA)-A grabbed R1 by the arms. (RN)-B did not hear any concerns regarding rough cares. Attempts were made to interview (RN)-F; however, no response was received. A facility policy on accidents was requested, however none received. Actions taken included, the facility identified concerns regarding proper mechanical lift procedures and use of a draw sheet. A facility investigation was completed where conflicting information regarding the event was found. (NA)-was terminated and (NA)-B was re-educated. The maintenance director inspected the mechnical lift used. The facility re-educated staff regarding proper mechanical lift use, safe handling of residents, abuse of vulnerable adults and instructions for assessing and documenting change of condition along with pain management.

Based on observation, interview, and record review the facility failed to maintain a clean and comfortable environment for 6 of 6 resident rooms (rooms 100, 101, 102, 104, 109 and 112) found to have severe drywall bubbling, plaster erosion on walls and ceiling and broken floor heater boards. This deficient practice has the potential to impact on all residents who reside in these rooms by exposing them to potential microbial growth, physical injury from falling debris and an unhomelike environment. Findings include: Upon observation 8/13/26 at 10:15 a.m. the following rooms were observed to have erosion on the walls and/or ceiling, bubbling, or blistering of the paint on the walls and drywall separation from the floorboard heating system:room [ROOM NUMBER] had visible multiple areas of cracking and peeling on the ceiling. The wall had several cracks and one where a section of drywall was lifted and hanging away from the wall.room [ROOM NUMBER] had a large horizontal crack and gap directly above the floorboard heater and the front panel of the floorboard heater was coming off the heater board. In addition, the wall above the heater board had cracking and peeling paint.room [ROOM NUMBER] had visible deterioration around the wooden frame of the window, and the towels were placed on the windowsill to absorb condensation. The wall beneath the window had peeling and cracking paint on the drywall. The wallboard was separated from the floorboard heater. The ceiling had multiple cracks and blistering paint.room [ROOM NUMBER] had a large horizontal crack and gap directly above the floorboard heat and the front panel of the floorboard heater was coming off the heater board. In addition, the wall above the heater board had cracking and peeling paint.room [ROOM NUMBER] had a large horizontal crack and gap directly above the floorboard heat and the front panel of the floorboard heater was coming off the heater board. In addition, the wall above the heater board had cracking and peeling paint.room [ROOM NUMBER] had grey paint on the wall which had large areas of severe bubbling and appeared warped. There were several large areas where the pain had been peeled or scraped exposing the drywall underneath. room [ROOM NUMBER] had spots of dried brown circular droplets randomly scattered on the ceiling over the bed closest to the door. The size of droplets ranged from pin prick drops to pea sized drops. Upon interview on 8/13/26 at 11:30 a.m. the maintenance director stated the damage to the wall was because there was a bathroom on the other side of the wall with a shower and the shower needed to be resurfaced and then the wall could be fixed. She stated she had asked the corporate office for permission to fix the shower and the wall months ago and had not heardback. Upon observation and interview on 8/17/26 at 10:15 a.m. the maintenance director was in a community bathroom fixing the shower and painting. The facility had also moved R13 out of her room to get the wall painted. The maintenance director stated she had been working on the bathroom and room [ROOM NUMBER] all weekend. Upon interview on 8/17/26 at 2:20 p.m. the Administrator stated he was aware of the environmental needs of the building and had reported it to the corporate office and was waiting to hear back from them. A facility policy regarding homelike environment was requested, however none received.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan to address a residents known risk for sexually inappropriate behavior toward other residents when intoxicated for 1 of 5 residents (R9) reviewed for care plan interventions. Findings include: R9's care plan dated 4/27/26 indicated R9 had a history and diagnosis of substance use. R9's interventions were:4/27/26 Monitor resident for intoxication or impairment4/27/26 When resident is noted to have been smoking illegal substances like marijuana, cocaine, or meth etc. OR is intoxicated (unsteady gait, slurred speech, pinpoint pupils etc. Do not administer any medications. Update the provider for more directions.7/28/26 Monitor resident behaviors as needed.5/29/26 Resident is actively currently drinking alcohol. R9's care plan dated 4/27/26 indicated a focus R9 gets sexually inappropriate when intoxicated, uses inappropriate language towards female residents and staff, touches female residents inappropriately. There was no goal related to R9's sexual abuse and no interventions to prevent R9 from sexually abusing other residents. R9's nursing progress note dated 7/25/26 at 10:44 a.m. indicated R9 was heavily intoxicated and remained verbally abusive and sexually inappropriate towards female residents. Staff called the police and paramedics to have R9 sent to the hospital for detox but both refused the referral indicating R9 has freedom of speech, the facility should handle the behavior if the resident violates the facilities policies. Other residents advised to stay away from the perpetrator. R9's nursing orders dated 7/26/26 at 10 p.m. indicated complete 15-minute checks for sexually inappropriate behavior. R9's nursing dated 7/27/26 indicated R9 met with social services to complete a BIMS assessment, PHQ-9, and a trauma questionnaire. He was cognitively intact, had no minimal signs of depression. R9's nursing progress note dated 7/27/26 at 8:11 p.m. indicated R9 was intoxicated making sexually inappropriate comments to multiple female employees. At 8:14 asked another nurse to grab his genitals. R9's quarterly MDS dated [DATE] indicated R9's BIMS score was 15 indicating he was cognitively intact. R9 had verbal behaviors towards others (threatening, screaming, and cursing) which occurred 4-6 days, but not daily. He had other behaviors not directed at others (hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing, or smearing foot or bodily wastes, screaming disruptive sounds), behavior occurred every 1-3 days. R9 was independent with dressing, hygiene and transferring. R9's pertinent diagnoses were alcohol use, housing and economic circumstances, and hip pain. R9's progress note dated 7/29/26 at 9:02 a.m. indicated R9 was intoxicated, raising his voice, talking inappropriately to staff and inappropriately touching staff. He was already on 15-minute safety checks. R9's hospital encounter note dated 7/29/26 was held at the hospital related to intoxication. R9's nursing progress note dated 8/8/26 at 1:38 p.m. indicated R9 was verbally inappropriate toward female residents making them uncomfortable per female resident verbalization. When the police arrived R9 was sleeping and the police decided not to take him in hoping he would wake up sober. R9's nursing progress note dated 8/9/26 at 8:56 a.m. indicated R9 was intoxicated, refused vital signs. R9's nursing progress note dated 8/9/26 at 7:45 p.m. indicated R9 was intoxicated and refused vital signs. R9's nursing progress note dated 8/9/26 at 7:51 p.m. indicated R9 was sitting in a chair outside, red faced and intoxicated. He did have his a.m. meds held due to intoxication and took a nap, but was intoxicated by 4:00 p.m. He refused vital signs; he becomes angrier the more intoxicated he becomes. R9's nursing notes dated 8/10/26 at 10:18 a.m. indicated R9 met with social services and reviewed the Substance Use Policy and got a signature from R9. His room was searched and an empty bottle was found in the trash can. R9's nursing note dated 8/13/26 at 10:28 a.m. indicated R9 met with social services to review and sign the Substance Abuse Policy again. R9's nursing note dated 8/15/26 at 11:45 a.m. indicated R9 appeared intoxicated, his face was ruddy and speech slurred. He was encouraged to drink water. He is continued on 15-minute checks. R9's nursing note dated 8/15/26 at 2:43 p.m. indicated R9 was intoxicated and bothering.another resident by talking too much. He was redirected to lay down. Upon interview on 8/13/26 at 9:40 a.m. social worker (SW)-A stated since assessing for intoxication was done by the nursing staff, they would be the ones to update the care plan. Upon interview on 8/13/26 at 11:54 a.m. registered nurse (RN)-D states she was not certain what was on R9's care plan regarding substance abuse and if the 15-minute checks were on there. She stated she would find out. Upon interview on 8/17/26 at 3:32 p.m. the Administrator stated his expectation was all the care represents all the tasks completed on the residents and the care plans should include safety measure interventions when R9 was intoxicated. A comprehensive care plan policy was requested; however, none was provided.

Based on interview and record review, the facility failed to maintain a medical record for 2 of 2 residents (R3, R9) that was accurate and reflective of the actual care provided when reviewed. Registered nurse, RN-(A) failed to document in real time 15-minute safety checks on R3 and R9 who were involved in a sexual assault allegation. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated R3's Brief Inventory of Mental Status (BIMS) score was 10 indicating moderate cognitive impairment. R3 had no identified behaviors. R3 required substantial staff assistance with upper and lower body dressing, dependent on staff for personal hygiene and transferring. Her pertinent diagnoses were nontraumatic brain dysfunction, psychotic disorder, and substance dependence. R3's progress note dated 7/26/26 at 11:58 p.m. indicated R3 had reported feeling of sexual harassment by a male resident who she believed was flirtatious and made her uncomfortable. R3 was placed on frequent safety checks. R9's clinical physician orders dated 7/26/26 indicated R9 was to have 15-minute safety checks completed for sexually inappropriate behavior. R9's quarterly MDS dated [DATE] indicated R9's BIMS score was 15 indicating he was cognitively intact. R9 had verbal behaviors towards others (threatening, screaming, and cursing) which occurred 4-6 days, but no daily. He had other behaviors not directed at others (hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing, or smearing foot or bodily wastes, screaming disruptive sounds), behavior occurred every 1-3 days. R9 was independent with dressing, hygiene and transferring. R9's pertinent diagnoses were alcohol use, housing and economic circumstances, and hip pain. R9's nursing progress note dated 8/12/26 indicated he went out on a leave of absence (LOA) and did not sign out. He continued 15-minute safety checks. Upon interview on 8/13/26 at 9:40 a.m. the social worker, (SW) stated nursing staff was still completing frequent safety checks on R3, and R9 following the sexual abuse. She was not certain exactly how frequent the checks were because nursing handled the checks.Facility 15-minute safety checks indicated R3 and R9 were to have 15-minute checks. Both hard copy forms indicated the night staff completed checks from 12:00 a.m. through 7:30 a.m. There was no documentation for any checks after 7:30 a.m. Upon interview on 8/13/26 at 2:45 p.m. RN-A stated she did complete the safety checks in real during her shift because she worked with the residents often and knows their schedules. She documented her checks all at once at the end of her shift. Upon interview on 8/13/26 at 4:45 p.m. the director of nursing, (DON) stated the staff had been educated about documenting the 15-minute checks in real time and that was her expectation. A facility policy regarding accuracy of medical records we requested, however, none was received.

Based on interview and record review the facility failed to ensure its facility assessment accurately reflected its current resident's population. The facility assessment did not identify the 37 residents with substance use disorders (SUD) or identify the related care and services needed of this population in the facility. Although the facility provided the staff education addressing SUD and mental health through online training, the facility assessment did not accurately reflect the population requiring these services.Findings include: The facility assessment with a revision date of 1/2026 indicated:Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care included:Psychiatric/mood disorders - Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Anxiety Disorder, Depressive Disorders, Bipolar Disorder, Borderline Personality Disorder, Schizophrenia, Post-Traumatic Stress Disorder ,Behavior that Needs InterventionsHeart/Circulatory System - Congestive Heart Failure, Coronary Artery Disease, Angina, Dysrhythmias, Hyper/hypotension, Orthostatic Hypotension, Peripheral Vascular Disease, Risk for Bleeding or Blood Clots, Deep Venous Thrombosis (DVT), Pulmonary Thrombo-Embolism (PTE)Neurological System - Parkinson's Disease, Hemiparesis, Hemiplegia, Paraplegia, Quadriplegia, Multiple Sclerosis, Alzheimer's Disease, Dementia, Seizure Disorders, CVA, TIA, Stroke, Traumatic Brain Injuries, Neuropathy, AphasiaVision - Visual Loss, Cataracts, Glaucoma, Macular DegenerationHearing - Hearing lossMusculoskeletal System - Fractures, Contractures, Osteoarthritis, Other Forms of Arthritis.Neoplasms - CancersMetabolic Disorders - Diabetes, Thyroid Disorders, Hyponatremia, Hyperkalemia, Hyperlipidemia, ObesityRespiratory System - Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease, Respiratory Failure, Congestive heart failure (CHF)Genitourinary System - Renal Insufficiency, Nephropathy, Neurogenic Bowel or Bladder, Renal Failure, End Stage Renal Disease, Benign Prostatic Hyperplasia, Obstructive Uropathy, Urinary IncontinenceDiseases of the Blood - AnemiaDigestive System - Gastroenteritis, Cirrhosis, Peptic Ulcers, Gastroesophageal Reflux, Inflammatory Bowel Disease, Bowel IncontinenceIntegumentary System - Skin Ulcers, InjuriesInfectious Disease - Skin and Soft Tissue Infections, Respiratory Infections, Urinary Tract Infections, Infections with Multi-Drug-Resistant Organisms, Septicemia, Clostridium difficile, Influenza The Facility Assessment did not include Substance abuse in their resident profile.A facility Diagnosis Report dated 8/13/26 indicated 37 residents of the 57 residents who resided at the facility had a diagnosis of substance abuse disorder. Upon interview on 8/17/26 at 2:20 p.m. the Administrator identified substance abuse was not listed on the residents' profile and verified the facility had 27 residents with substance abuse. He stated the staff is trained on substance abuse upon hire and yearly. A facility policy was requested however none was received.

Based on interview and document review, the facility failed to ensure sufficient dietary staff were available to prepare and serve meals in accordance with the planned menu and residents' physician-ordered diets for 5 of 5 residents (R1, R61, R52, R62, R23) interviewed regarding food services. This had the potential to affect all 68 residents resided in the facility. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, was able to eat regular diet and ate independently after setup. The facility Diet Type Report dated 7/13/26, identified R1 had ordered regular diet with regular texture. R61's quarterly Minimum Data Set (MDS) dated [DATE], identified R61 had intact cognition and was independent with eating. The facility Diet Type Report dated 7/13/26, identified R61 had ordered renal diet with regular texture. R52's quarterly MDS dated [DATE], identified R52 moderately impaired cognition and was independent with eating. The facility Diet Type Report dated 7/13/26, identified R52 had ordered regular diet with minced and moist texture. R62's quarterly MDS dated [DATE], identified R62 was able to communicate her needs and understand others. A Brief Interview for Mental Status was not conducted. R62 was independent with eating. The facility Diet Type Report dated 7/13/26, identified R62 had ordered regular diet with regular texture. R23's annual MDS dated [DATE], identified R23 had intact cognition, and ate independently. The facility Diet Type Report dated 7/13/26, identified R23 had ordered consistent carbohydrate diet with regular texture. During interview on 7/13/26, at 11:03 a.m., R61 stated the kitchen cook had left the day before, and residents did not receive supper until after 8:00 p.m. R61 stated the facility ordered pizza for everyone, but it was so late by the time they ate. R61 stated not having an evening cook had happened too many times. R61 stated the facility had asked the morning cook to stay and prepare supper, but she refused and went home. R61 stated that was not the first time that had happened.During interview on 7/13/26, at 12:04 p.m., R52 stated he did not receive supper until late the night before. R52 stated he received pizza soup, but it was not good and he could not eat it.When interviewed on 7/13/26, at 12:36 p.m., cook (CK)-A stated there had been no pm cook the day before. CK-A stated the facility could not mandate her to stay, so she left when her shift ended. CK-A stated she had done everything she was supposed to do by sending a group text notifying staff there was no pm cook. CK-A stated CK-B had been scheduled to work; however, CK-B told her he had notified the manager he would not be able to work. CK-A stated dietary aide (DA)-A asked dietary manager (DM)-A if he should make sandwiches, and DM-A instructed him to do so. CK-A stated staff were told the following morning that someone had come in and ordered pizza for all the residents. CK-A stated she did not know what residents with special diets had received because that was not her responsibility.During interview on 7/13/26, at 3:41 p.m., R1 stated there had been no cooks the night before, and residents did not receive supper until after 8:00 p.m., when the facility ordered pizza for them.During interview on 7/13/26, at 3:54 p.m., R23 stated he never received supper the night before. R23 stated that at approximately 7:00 p.m., residents began asking where supper was and complaining they were hungry, so staff handed out either one-half of a ham and cheese sandwich or a peanut butter and jelly sandwich. R23 stated one-half of a sandwich was not enough, so staff ordered pizza; however, he did not get to eat until approximately 9:00 p.m. R23 stated that was not the first time it had happened and he was sure it would not be the last.During interview on 7/13/26, at 4:47 p.m., dietary manager (DM)-A stated he completed the staffing schedules for the kitchen staff. DM-A stated he had regular staff and could also utilize a corporate float team. When there were staffing holes in the schedule, he requested corporate float staff. DM-A stated that if dietary staff did not report for their shift, nursing staff could contact him or the administrator, and many staff also knew how to contact the regional director. DM-A stated there had been unique situations when he could not come in to help. The director of nursing (DON) had a corporate credit card and could order pizza or other food in emergency situations, and nursing staff knew where the disposable dishes were kept. DM-A stated the day before had been a bad situation because neither he nor the administrator had been available when both scheduled pm cooks did not report for their shift. DM-A stated both day-shift cooks had attitudes and refused to stay when the next shift did not report. DM-A stated he was not sure when the pizza had been served to the residents and only knew there had been boxes of pizza in the kitchen. DM-A stated the nurses would know how to prepare pureed or minced and moist foods and believed some had been trained to do so. DM-A stated he did not know whether any residents had not received a supper meal the day before because meal percentages had not been completed. DM-A stated the aides documented who had been fed and how much they ate; however, he would not know that information because it was not his department.During interview on 7/15/26, at 3:34 p.m., R62 stated there had been no pm cook the day before. R62 stated residents did not receive supper until an hour or more after it was due. R62 stated one-half of a sandwich was distributed at approximately 6:30 p.m., and the facility ordered pizza about an hour later. R62 stated she did not notice what residents who could not eat pizza received. R62 stated she remembered a similar incident had occurred shortly after her admission when there had not been a cook for the evening shift. R62 stated she did not think the residents had received anything to eat that time.During interview on 7/15/26, at 4:13 p.m., DA-A stated the cook had not reported to work the day before. DA-A stated he prepared trays with sandwiches and fruit and sent them to the residents. DA-A stated the regional manager later came to the facility and brought pizza. The facility timecards and staffing schedules from June 11, 2026, through July 20, 2026, were reviewed and identified the following:6/12/26: The pm cook was scheduled to work from 12:00 p.m. to 8:00 p.m., punched in at 11:55 a.m., and punched out at 12:58 p.m.6/16/26: The pm cook was scheduled to work from 12:00 p.m. to 8:00 p.m., punched in at 1:39 p.m., and punched out at 2:30 p.m.7/12/26: No pm cook was scheduled, and no pm cook punched in or out for the pm shift. Dietary aide (DA)-A punched in for the scheduled shift from 2:00 p.m. to 8:00 p.m.During interview on 7/16/26, at 10:43 a.m. during interview on 7/16/26, at 10:43 a.m., DM-A stated he frequently had to fill in when the pm cook called in, which had been very difficult for him. DM-A stated the float director supplied float staff when they were available; however, there were only a limited number of float staff. DM-A stated the facility hired staff sporadically, and those hired were not always a good fit for the dietary department. DM-A stated he noted the pm cook had punched in on 6/12/26 and punched out an hour later, which may have been the problem. DM-A stated the pm cook who worked on 6/17/26 would have been a float. DM-A was unable to provide any evidence of a pm cook on the payroll for 6/12/26, 6/17/26, or 7/12/26. DM-A stated the plan when there was no pm cook was to attempt to contact him or the administrator. The administrator would then contact the corporate regional director. DM-A stated he took phone calls after work hours; however, he was not scheduled as formal on-call staff. During telephone interview on 7/16/26, at 11:33 a.m., the dietary regional director (RDM)-B stated she had been contacted by the regional administration and notified the facility did not have a cook for the pm shift on 7/12/26. The culinary director could not be reached, so she notified them she would order and bring pizza to the facility. Upon arrival, RDM-B had staff begin handing out pizza to residents on regular diets while she prepared the alternate diet meals. She filled to-go containers with the prepared alternate diet meals and taped each resident's meal ticket to the appropriate container. She prepared pureed pizza with applesauce and pudding or a sandwich with diced peaches for residents requiring alternate diets. RDM-B stated she had never previously been required to come in to cover for a pm cook. She stated she did not spend time determining why the shift had not been covered because her priority was to ensure the residents were fed. RDM-B stated that when a pm cook called in, the facility was usually aware by 2:00 p.m., allowing time to arrange coverage for the shift. However, on 7/12/26, the situation occurred at the last minute. RDM-B stated she received the call at approximately 7:00 p.m. and had all residents fed by 8:00 p.m. RDM-B stated she believed management was investigating the incident to determine what had occurred because they wanted to hold the employees accountable. When interviewed on 7/16/26, at 3:15 p.m., DM-A stated he remembered a pm cook had worked on 6/12/26 and 6/17/26; however, he was unable to provide the corresponding timecards. DM-A provided the Daily Labor Report dated 6/12/26, which identified culinary service employees' hours worked; however, the only cooks listed had worked the day shift, and the report did not identify a pm cook. DM-A also provided the Daily Labor Report dated 6/17/26, which identified culinary service employees' hours worked; however, the only cooks listed had worked the day shift, and the pm cook was documented as having worked only 0.75 hours. Another culinary services director was listed as having worked 3.50 hours; however, DM-A stated he believed that employee was in upper management and that the entry was an error because the employee had not worked at the facility that day. Although DM-A recalled pm cooks had worked those shifts, he was unable to provide schedules, timecards, payroll records, or other documentation to support that statement, and the Daily Labor Reports did not identify a pm cook working those shifts. During telephone interview on 7/16/26, at 5:19 p.m., the dietitian (D)-E stated she visited the facility one to two times per week. D-E stated she had not been aware of pm cook staffing issues other than occasionally overhearing DM-A state he had been filling in. D-E stated that if a pm cook did not report for the shift, she would expect the facility to attempt to obtain another cook. If that was not possible, the facility would need to notify the administrator. The administrator could order food, and at that point, the responsibility would fall to upper management. D-E stated that even without a pm cook, the facility would still need to follow the planned menus. She would expect the facility to order appropriate food items to prepare pureed and texture-modified meals. If the facility ordered food from a pizza restaurant, D-E stated staff could coordinate with her and she would assist in identifying menu items appropriate for residents with special diets, such as selecting a white sauce pizza for residents on low-sodium diets. D-E stated residents on renal diets should not receive pizza, although receiving it on one occasion would not be the end, but it was not something they should receive regularly. D-E stated she would assist the facility even if she was not on call. She stated she had not been aware the facility lacked a pm cook on 6/12/26, 6/17/26, or 7/12/26. D-E stated she would have wanted to know the facility's plan going forward and what staff should do if a pm cook did not report for a scheduled shift. D-E stated the facility should have had a written plan of action. The facility policy Food and Nutrition Services, dated October 2017, identified each resident would be provided with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs. Meals and nutritional supplements would be provided within 45 minutes of either the resident request or scheduled mealtimes. Food and nutrition staff would inspect food trays to ensure that the correct meal was provided to each resident and the food appeared palatable and attractive.

Based on observation, interview and document review, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 3 resident (R3) reviewed with an indwelling catheter; and the facility failed to ensure hand hygiene was performed during medication administration for 3 of 4 residents (R8, R44, R54) observed to receive their medications; and the facility failed to ensure laundry services were conducted in a manner to promote sanitary conditions. Findings include: R3 R3's annual Minimum Data Set (MDS) dated [DATE], identified R3 was rarely/never understood, had a cognitive impairment and had diagnoses that included obstructive and reflux uropathy (blockage of urine flow anywhere in the urinary tract), bladder neck obstruction and urine retention. R3 was always continent of bowel and used an indwelling catheter. R3's care plan, revised 6/8/26, identified R3 required EBP due to an indwelling Foley catheter. The care plan directed staff to follow infection control protocols, post an EBP sign on the resident's door, provide treatment for current infections as ordered, explain the reason for the precautions, communicate the need for EBP, and put on and take off appropriate personal protective equipment (PPE) when providing high-contact care. During an observation on 7/14/26 at 8:25 a.m., R3 was lying on the lower half of the bed on his right side wearing a hospital gown with no blankets covering him. R3's catheter leg bag was secured to his left leg. An EBP identifier was displayed next to R3's name on the doorway nameplate, and an EBP sign was posted on the resident's door. A plastic three-drawer tote located in the hallway outside R3's room contained surgical masks, disposable gowns, gloves, and eye protection. Licensed practical nurse (LPN)-C put on gloves and entered R3's room to obtain vital signs but did not put on a gown. R3 sat on the edge of the bed while LPN-C stood in close proximity and applied and removed the blood pressure cuff. LPN-C removed her gloves, performed hand hygiene using alcohol-based hand sanitizer, and retrieved R3's medications from the medication cart. LPN-C then returned to R3's room without putting on gloves or a gown, administered R3's medications, touched the overbed table, water mug, and personal belongings, and exited the room. During an observation on 7/15/26 at 10:31 a.m., NA-G entered R3's room without a gown or gloves and stood against R3's bed with the bed linens touching NA-G's uniforms. NA-G asked R3 if he wanted to freshen up but R3 said no. NA-G exited the room after using hand sanitizer. At 10:44 a.m., NA-G stated staff were made aware a resident needed EPB because EBP was on their doorway name plate and there was a sign on the resident's door. NA-G stated she should have put on a gown before going into R3's room but she was only asking him if he wanted to reposition. If R3 had said yes, NA-G would have put on a gown at that time. However, NA-G stated that her uniform was up against R3's linens and overbed table. Because of this, NA-G should have put on a gown prior to talking to R3. During an observation on 7/15/26 at 4:11 p.m., R3 was sitting at the edge of his bed and registered nurse (RN)-C applied a topical cream to R3's legs. RN-C was wearing gloves, but no gown. At 7/15/26 at 4:14 p.m., RN-C stated staff were only expected to wear a gown when they are emptying R3's catheter. Staff did not need to wear gowns any other time while caring for R3. During an interview on 7/16/26 at 11:27 a.m., RN-B stated she was the nurse manager for R3. All staff were expected to wear a gown and gloves whenever coming into close with R3. During an interview on 7/16/26 at 3:50 p.m., the director of nursing (DON) stated all staff were expected to follow EBP per Centers for Disease Control and Prevention (CDC) guidelines to prevent the possible transmission of infections. During an interview on 7/16/26 at 3:51 p.m., the administrator stated staff to follow EBP per CDC guidelines to prevent possible infections. The facility policy Enhanced Barrier Precautions revised 7/2026, identified it was the practice of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms. EBP refers to the use of gowns and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a [NAME] as well as those at increased risk of [NAME] acquisition (e.g., residents with wounds or indwelling medical devices). 4. High-Contact resident care activities include a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. h. Wound care: any skin opening requiring a dressing. HAND HYGEINE R8's diagnosis report dated 7/16/26, identified R8 had diagnoses of depressive disorder, hypothyroidism, dementia, unspecified psychosis, and vitamin D deficiency. R44's diagnosis report dated 7/16/26, identified R44 had diagnoses of chronic obstructive pulmonary disease (COPD) (a condition of the lungs), anxiety disorder, history of alcohol dependence, vitamin B12 deficiency, and epilepsy. R54's diagnosis report dated 7/16/26, identified R54 had diagnoses of neurocognitive disorder with Lewy Bodies (a type of dementia), depressive disorder, insomnia (difficulty sleeping), and high blood pressure. During observation and interview on 7/14/26 at 9:27 a.m., trained medication aide (TMA)-A was prepared medications for R44. TMA-A was not observed to wash or sanitize their hands. TMA-A brought R44 the medications and he took them without difficulty. TMA-A then returned to the medication cart and started to prepare medications for R54. TMA-A did not sanitize or wash their hands. TMA-A then brought R54 their medications and they took them without difficulty. TMA-A then returned to the medication cart and went across the hall to R8's room and prepared their medications. TMA-A did not sanitize or wash their hands. TMA-A entered R8's room and gave them their medications. Once back to the cart TMA-A stated she did not sanitize her hands and only did that if she had some powdery medications or was giving lactulose (a medication used for chronic constipation). During an interview on 7/15/26 at 10:26 a.m., the director of nursing (DON) stated it was expected that staff sanitized their hands before and after preparing medications for a resident and between residents. Washing or sanitizing hands between residents reduces the possibility of spreading illnesses and infections between residents. The facility's Medication Administration policy dated April 2018, identified good hand hygiene (washing hand or sanitizing hands) is to be done before medication was passed, prior to handling any medications, and after coming in contact with a resident. Laundry On 7/15/26 at 10:55 a.m., the soiled laundry room contained a large round yellow soiled laundry bin, two large grey round soiled laundry bins and a square soiled laundry bin. HSK-B stated the laundry shift started at 6:00 a.m., and linens were the first laundry items sorted. No gowns or gloves were available in the soiled laundry room and HSK-A opened the laundry washing room door and pointed out 2 washable gowns hanging from a hook behind the door. There were boxes of gloves as well. HSK-A stated she only wore a gown when she was removing items from the soaking bin, or the laundry was in a biohazard bag. All other times, HSK-A wore only gloves to sort soiled laundry items. During an interview on 7/16/26 at 8:34 a.m., HSK-C stated she was the supervisor for housekeeping, which included laundry. HSK-C stated staff were expected to wear a gown and gloves whenever they were working with dirty laundry and were also expected to remove the gown and gloves prior to working with clean laundry. During an interview on 7/16/26 at 4:56 p.m., the administrator stated staff were expected to follow facility policy regarding sorting of laundry to prevent the spread of infection. A laundry policy was requested but not received.

Based on observation, interview, and document review, the facility failed to provide a calm, comfortable, low-stimulation environment appropriate to the needs of residents residing on the secured unit by allowing loud, violent television programming to be played in the common dining area for 2 of 2 residents (R2, R46) reviewed for quality of life. This deficient practice had the potential to adversely affect all 27 residents residing on the secured unit.Findings include:During an observation of the dining room and common area on the facility's secured unit on [DATE] at 11:52 a.m., a large-screen television was positioned in a central location of the dining room, with residents seated directly in front of and beside the television. The television volume was very loud while a movie played. The movie contained dark scenes that could not be clearly viewed unless a resident was seated directly in front of the television. Loud screaming, hollering, gunfire, crying, and weeping were heard throughout the movie, with sudden loud bursts of sound during action scenes.R2's admission Minimum Data Set (MDS) dated [DATE] identified R2 had moderate cognitive impairment. Diagnoses included hemiplegia, generalized anxiety disorder, mild neurocognitive disorder, and cerebral infarction (stroke). R2's care plan, revised [DATE], identified an alteration in mood and behavior. R2 had a history of agitation, verbal behaviors toward others, resident-to-resident altercations, and use of profanities. Interventions included providing written or verbal information about the area, encouraging discussion about the resident's social history, allowing R2 to sit in the hallway and look out the window, redirecting R2 to a quiet area when agitated, offering music with headphones when available, approaching R2 in a calm manner, and maintaining a consistent environment.On [DATE] at 4:17 p.m., R2 was seated in a wheelchair near the dining room/common area. R2 angrily talked to himself, stating he needed to leave the facility because the staff were so fucking stupid. R2 pointed toward the television and stated it was too loud and too dark to see or follow what was happening. R2 repeatedly expressed frustration with the television programming, stated no one could see what was playing, and continued to express a desire to leave the facility.R46's quarterly MDS dated [DATE] identified R46 had moderate cognitive impairment. Diagnoses included dysphagia, restlessness, agitation, seizures, and anxiety. R46's care plan, revised [DATE], identified an alteration in mood and behaviors. Interventions included redirecting R46 by bringing the resident to the day room to watch television and praising positive behaviors.During observation of the evening meal on the secured unit on [DATE] at 6:17 p.m., approximately twelve residents were seated in the dining room as supper was served. A large-screen television remained positioned in the center of the dining room, where residents seated throughout the room were exposed to the programming. The television volume was very loud while a movie played depicting an older man hanging by ropes while two other men repeatedly beat him in the torso. The man's shirt was bloodied, blood was visible on his face, and loud gunfire, shouting, crying, and wailing occurred throughout the scene. Only one resident occasionally looked toward the television.During the same observation, R46 repeatedly wheeled to the light switch and turned the dining room lights off. Several residents immediately shouted for the lights to be turned back on. After staff turned the lights back on, R46 again turned them off. This occurred two additional times. When an unidentified nursing assistant attempted to block R46 from reaching the light switch, R46 appeared increasingly frustrated and struck out at the nursing assistant.During an interview on [DATE] at 6:24 p.m., licensed Practical Nurse (LPN)-E stated the Activity Director selected the movies played in the dining/common area. LPN-E stated the movie playing during supper was not appropriate for residents with dementia and was not appropriate during the evening meal. LPN-E further stated loud, violent movies could contribute to resident anxiety and were not appropriate for dementia care.During an interview on [DATE] at 6:27 p.m., registered Nurse (RN)-A stated the movie was not an appropriate choice for residents and could contribute to increased anxiety.During an interview on [DATE] at 6:28 p.m., activity director (AD)-G stated the facility typically used a program called [NAME], which provided positive news, sports, and comedy programming. AD-G stated the movie playing in the dining room was not part of the [NAME] programming. Because residents often wanted different programming, nursing assistants had access to the television remote control and were permitted to change the channel. AD-G acknowledged residents residing on the secured unit had dementia, cognitive impairment, and aggressive behaviors and stated the facility had previously discussed appropriate television programming.During an interview on [DATE] at 6:36 p.m., LPN-D stated loud, violent movies did not help calm residents and could contribute to increased agitation. LPN-D further stated the dining room environment that evening had not been a low-stimulation environment.During an interview on [DATE] at 10:14 a.m., the director of nursing (DON) stated she believed the television had been programmed through the facility's [NAME] system and had not been aware nursing staff were selecting television programming. The DON stated residents residing on the secured unit had dementia diagnoses and aggressive behaviors and that providing a calm approach and calm environment was one of the primary interventions for dementia care. The DON further stated loud, dark, violent action movies would not create a calm environment and had the potential to increase resident anxiety.The facility's Dementia Training policy, revised [DATE], identified the facility's philosophy was to provide quality long-term care in a loving, caring, and safe environment. The policy further identified staff would receive training on caring for residents with dementia, cognitive impairment, behavioral symptoms, and standards of dementia care.

Based on interview and document review, the facility failed to provide the care and services needed to safely manage diabetes for 1 of 3 residents (R23) reviewed for diabetes management by failing to assess and monitor the resident after the resident reported concern about low blood sugar during the night following a rapid decrease in blood glucose.Findings include:R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had a mild cognitive impairment and diagnoses that included insulin-dependent type 2 diabetes.R23's care plan revised 2/5/26, identified R23 had a potential for alteration in blood sugar related to diabetes. Staff were directed to monitor for signs and symptoms of high and low blood sugar, monitor blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care.R23's nursing progress note dated 7/15/26 at 12:25 a.m., identified R23 had a blood glucose reading of 330 before dinner and received 4 units of sliding scale insulin as ordered. R23 expressed concern about receiving the full insulin dose because of fear the blood sugar would drop during the night. Approximately one hour later, R23's blood glucose had decreased to 97. Staff provided 15 grams of carbohydrates and one glass of juice, after which the blood glucose increased to 160. R23 requested blood glucose checks every two hours during the night because R23 was afraid the blood sugar would fall below 50. The nurse documented the night nurse was notified. However, R23's medical record failed to identify blood glucose monitoring, reassessment, or follow-up during the night.During an interview on 7/15/26 at 3:58 p.m., R23 stated blood sugar problems had occurred the previous evening. R23 stated concern that the blood sugar would continue to drop overnight and requested nursing check the blood sugar twice during the night. R23 stated staff did not check the blood sugar until breakfast the following morning and stated, They don't like checking it.During an interview on 7/16/26 at 11:05 a.m., RN-B stated staff believed the night nurse provided education to R23 and that was why blood glucose was not checked overnight. RN-B stated staff were expected to document resident education, and residents could request blood glucose monitoring if they felt it was needed.During an interview on 7/16/26 at 3:50 p.m., the director of nursing (DON) stated staff were expected to document resident education and provide reassurance when R23 expressed concerns regarding blood sugar levels.During an interview on 7/16/26 at 3:51 p.m., the administrator stated he expected staff to document resident care and provide the care necessary to ensure resident quality of life.The facility Medication Not Available in Medication Cart or in Medication Room in Overflow Bin algorithm undated, identified when a medication/supply was not available staff were to notify the provider and obtain further instruction; call the pharmacy to ensure the medication/supply would be sent on the next delivery and document in the resident medical record. The floor nurse and/or clinical leader was to complete a communication form to update what had happened.The facility policy Combined Federal and Minnesota State [NAME] of Rights undated, identified residents had the right to a prompt and reasonable response to their questions and requests. Residents had the right to be cared for with reasonable regularity and continuity of staff assignment as far as facility policy allowed.

Based on observation, interview, and document review, the facility failed to provide appropriate dementia care treatment and services by failing to comprehensively evaluate repeated resident-to-resident altercations, identify behavioral triggers, and develop and implement individualized interventions to prevent recurrence for 1 of 6 residents (R41) reviewed for dementia care; and failed to follow established dementia care interventions for 1 of 6 residents (R13) reviewed for dementia care. Findings include: R41 R41's significant change Minimum Data Set (MDS) dated [DATE], identified R41 had moderate cognitive impairment, required supervision or setup with grooming and eating and was independent with dressing, transfer, ambulation and toileting. R41 exhibited behaviors of rejection of care and wandering one to three days in the observation period. Diagnoses included insomnia, dementia, and anxiety. R41's care plan dated 6/4/26, identified R41 had an alteration in mood and behavior which included repetitive questions, wandering into other's rooms and being involved in resident-to-resident altercations in which R41 was the victim. Interventions included to have psychology clinic to follow, monitor and document mood and behavior on occurrence, praise positive behaviors, approach in a calm manner, if became anxious, to remove from crowded areas, one to one visit and to introduce R41 to other residents with similar interests. A self-care deficit was also identified. R41 was provided with a different color of pillow to carry for forgetfulness and accidentally picking up other resident's pillows. Staff were directed to offer reminders for R41 to carry his special pillow when they saw him carrying a white pillow. R41's progress notes identified the following: 5/6/26, R41 was moved to a new room due to a disagreement with his roommate R6. R6 stated R41 struck him in the eye. R6 calmed significantly after R41 was moved to a different room. 6/20/26, R41 and R60 almost began physically fighting and needed to be separated. R60 claimed R41 took his pillow and then hit him. R41 was restricted to his room until R60 calmed down. 6/25/26, R41 slapped another resident on the hand in the dining room during supper. 7/3/26, R41 kicked R60 in the groin and took his pillow. R60 complained of not feeling safe with R41 and R41 was moved to the room next door. When R41 tried to return to his original room he became combative when nurse attempted to redirect him to his new room. R41 was sent to the emergency room to be evaluated. Review of the medical record following the resident-to-resident altercations on 6/20/26, 6/25/26, and 7/3/26 failed to identify evidence staff reassessed the underlying causes of the behaviors, evaluated the effectiveness of prior interventions, identified individualized behavioral triggers, or revised the resident's dementia care plan with new person-centered interventions. On 7/14/26, at 8:37 a.m. R41 was observed seated in the dining room eating breakfast at a table by himself. An unidentified nursing assistant (NA) removed another resident's breakfast tray to return to the cart. The tray had some food remaining on it as well as a full glass of orange juice. R41 got up and followed the NA, tapping him on the shoulder in a forceful manner and stated give me the f**king juice, give me the f**king juice. R41 was verbally redirected to go back to his table. R41 approached another resident, attempting to take a glass off his tray and stated, you did not want your juice, can I have it? R41 was again redirected to his table. On 7/14/26, at 11:52 a.m. R41 was observed walking to the dining area carrying a pillow with a white pillowcase. R41 put the pillow in a chair in the dining room to sit on. Registered nurse (RN)-E was also seated in the dining room at another table. RN-E stated R41 always liked to have a pillow with him to sit on. As far as she knew, it was a comfort thing for him. During interview on 7/14/26, at 2:39 p.m. NA-H stated R41 was independent with most of his care, although needed reminders at times. R41 did sometimes take things from other rooms and that could set the other residents off. During interview on 7/14/26, at 4:06 p.m. NA-I stated he had seen R41 hit other residents in the past. R41 would go and take things from the other residents such as a pillow and the other resident would want it back. He had seen when R41 had taken R60's pillow and when R60 tried to get it back R41 had kicked R60. The facility put R41 on one-to-one supervision and moved him to a different room, then he would start with that roommate and would have to move rooms again and so on. The staff did one to one supervision with R41 and tried to anticipate what he needed to prevent resident to resident altercations. When interviewed on 7/14/26, at 4:39 p.m. licensed practical nurse (LPN)-B stated R41 accelerated when other residents got loud. The staff tried to keep him away from certain residents. When altercations did occur, they separated the residents and did 15-minute checks. Then they notified the director of nursing (DON) or the administrator and/or call the emergency room. R41 had frequent room changes due to not getting along with his roommates, but she thought the last room change had helped. With the other rooms he resided in, he was by the window and had to go past the roommate's space to go out or to the bathroom and that kind of got the behaviors going. Now R41 did not have to do that, as his bed was by the door and the bathroom. During interview on 7/15/26, at 1:12 p.m. R60 stated he had been R41's roommate but then R41 had come up to R60 when he was in bed and pulled the pillow from under his head and tried to leave the room with it. When R60 tried to get his pillow back, R41 had punched him in the stomach and kicked him in the balls. It had hurt at the time, enough to know he had been punched. R60 reported it to the nurse, and they took R41 out of the room, then the police came and took him, but he came right back. They did put him in the room next door to him after that. R60 stated he was not afraid of R41 but he did not want to be around him or be near him. R60 stated R41 was crazy. When interviewed on 7/15/26, at 4:03 p.m. LPN-D stated she was working when R41 hit R60. R41 liked to wander with his pillow, and he would take other's pillows if he could not find his. R41 took R60's pillow and when R60 tried to get it back, R41 kicked him. R60 reported the incident to her and said he did not feel safe rooming with R41. When R41 was in the common area, LPN-D changed his room. When LPN-D tried to direct R41 to his new room he became combative and punched her in the chest and shoved her into the wall. LPN-D stated R41 had scared her, so she left the room and got the roommate out of the room and called the DON, who instructed her to call 911. LPN-D had filled out a risk management report on the incident. LPN-D stated she thought there was a team who reviewed and investigated all the risk management reports in order to prevent further incidents. During interview on 7/16/26, at 10:14 a.m. the director of nursing (DON) stated she was sure R41's care plan addressed his behaviors and what triggered resident to resident altercations, however, was unable to provide documentation of the updated plan of care. The DON stated staff had tried different colored pillowcases in the past, but then other residents wanted that pillow. If they had assigned him a chair in the dining room with a pillow on it, other residents would have just sat in that chair. R41 had a number of room changes but would have altercations with the new roommates as well. The staff had tried a number of things to prevent the resident-to-resident altercations, however, was not able to provide documentation of care planned behaviors, triggers and interventions to try to prevent R41's behaviors. R13's R13's quarterly MDS dated [DATE], identified R13 had severe cognitive impairment with disorganized thinking and inattention. R13 had verbal behaviors directed towards others 1 to 3 day per week. R13 was dependent on staff for putting on footwear and partial to moderate assist with dressing. It identified R10 as independent with bed mobility and ambulation. Diagnoses included Huntington's disease (an inherited, progressive neurodegenerative disorder that causes nerve cells in the brain to break down over time), psychotic disorder, restlessness and agitation. R13's care plan dated 6/26/26, identified R13 had an alteration in mood and behavior related to Huntington's disease as evidenced by running in the hallway, hitting out at staff, refusal of medications and dressing. Interventions included when there was increased activity in the dining room she may benefit from sensory-based activities, providing resident with a calm and quiet environment during periods of agitation. If resident was becoming physical with staff, they should give R10 some space and reapproach or have a different staff help her. In addition, the care plan identified was at risk for falls and included interventions of ambulating with resident, encourage resident to gripper sock, obtain slip-on shoes, reduce noise, offer snacks with observed running in the hallway and assist her back to her room, offer wheelchair when observed running in the hallway, and redirect resident to slow down when running in the hallway. The undated nurse's aide care sheet identified interventions to try with R10 included to ensure wearing gripper socks, offer snacks when meals are late and in between meals when she was running, ensure a quiet environment, offer wheelchair when running in hall. For behavioral episodes ensure R10 and other residents are safe, move R10 out of sight of what or who she was agitated with. Offer some food or drink when agitated (oatmeal products are the most successful). During observation on 7/13/26 at 5:11 p.m., R13 repeatedly exited her room barefoot and ran through the hallway. Staff observed the behavior but did not provide gripper socks or shoes, walk with the resident, redirect her to slow down, or offer other care-planned interventions. During the same observation, the dining room television was playing violent scenes at a volume loud enough to interfere with conversation, despite the care plan identifying the need to reduce environmental stimulation and provide a calm environment during periods of agitation. During observations on 7/14/26, over approximately 11/2 hours, R13 repeatedly ran in and out of her room fourteen times while barefoot. Staff did not provide footwear, ambulate with the resident, redirect her to slow down, or implement other behavioral interventions outlined in the care plan. The resident was redirected back to her room only once and resumed running again after approximately four minutes, with no additional interventions attempted. During an interview on 7/14/26 at 4:30 p.m., nursing assistant (NA)-I stated R13 was difficult to redirect when she was out walking, when staff got closer to her, she would become more agitated. Staff usually, would step back because we did not want to agitate her and cause a fall. During an interview on 7/15/26 at 4:28 p.m., NA-E and NA-M stated sometimes we offered cookies or pudding when R13 was running around because it seemed like she did that more when she was hungry. They attempted to get her to wear gripper socks, but R13 became agitated, and would step back and try to reapproach. Licensed practical nurse (LPN)-E stated he would check the care plan when he got to work to see if there were any changes. During an interview on 7/16/26 at 8:03 a.m., the DON stated R10 was receptive of help from different staff from time to time. We would approach each day and assess who R10 would prefer that day. When R10 was out and running around we just monitored her, when we tried to intervene R10 would strike out at staff. Sometimes we would offer cookies or snacks to resident to help her calm down or we would have a different staff person approach. New staff were directed to the nurse aide care sheets to identify R10's needs. The DON stated R10's care plan should be followed to ensure good dementia care and safety. A policy for resident assessment was requested; however, none was received.

Based on observation, interview, and document review, the facility failed to replace a torn, stained mattress and ensure urine-soiled bedding was changed timely for 1 of 1 resident (R46) reviewed for activities of daily living; and failed to remove residents' meal plates, beverages, and utensils from institutional serving trays before meal service for all 27 residents residing on the secured unit.Findings include: R46's quarterly Minimum Data Set (MDS) dated [DATE], identified R46 had moderate cognitive impairment and required maximum assistance with dressing, grooming and toileting hygiene. R46 required moderate assistance with transfers and used a wheelchair for mobility. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety and schizophrenia. On 7/13/26, at 11:46 a.m. R46 was observed wheeling out of his room. R46 stated his bedsheet was wet with urine, and he was going to find staff to change his sheets. On 7/13/26, at 4:04 p.m. R46's room door was open and his bed was not made. A rumpled soiled top sheet was observed on top of R46's mattress. A strong urine odor was present in the room. On 7/15/26, at 11:23 a.m. nursing assistant (NA)-D was observed to wheel R46 to his room to change his soiled pants, provide peri care and change R46's soiled linen. When NA-D removed the soiled fitted sheet from R46's bed, the mattress had a 6-centimeter (cm) tear on the upper right side of the mattress. A large 12 x 12-inch-deep brown dry stain was covering the center of the mattress and various discoloration was scattered over the remaining areas of the mattress. NA-D stated R46's mattress was stained and the rip was in it for a while. NA-D stated he usually did a repair report on things like that. The staff used an online tells system to report broken equipment. NA-D was not sure if R46's mattress was reported or not but that he would be sure to fill one out when he was done with assisting with cares. During interview on 7/15/26, at 1:10 p.m. licensed practical nurse (LPN)-B stated staff put in request for repair to equipment in the facility tells system. That system notified maintenance at the facility, and they could see it right away. The maintenance person was really good about getting to staff request for repairs timely. LPN-B would put in a request to change R46's mattress right away. During interview on 7/15/26, at 3:45 p.m. the maintenance staff (maint)-A stated she had gotten a work order that day to replace the mattress for R46's bed. Maint-A stated they were not informed until that day about the mattress and would bring up a mattress and replace it. A policy was requested for equipment repair; however, none was received. Dining Room The undated facility list identified 27 residents resided on the unit. On 7/13/26, at 12:30 p.m. the noon meal was observed in the second-floor dining area. Ten residents were seated at various tables throughout the dining room. Each resident was eating their meal from a plastic tray which held their plate of food, silver ware and drinks. On 7/14/26, at 8:46 a.m. residents were observed in the second-floor dining area. Each resident was eating their meal from a plastic tray which held their plate of food, silver ware and drinks. On 7/14/26, at 12:10 p.m. residents were observed in the second-floor dining area. Each resident was eating their meal from a plastic tray which held their plate of food, silver ware and drinks. On 7/15/26, at 6:09 p.m. residents were observed in the second-floor dining area. Staff were removing the meal trays from the cart and placing them in front of the residents and did not remove the trays. Each resident ate their meal from a plastic tray which held their plate of food, silver ware and drinks. During interview on 7/15/26, at 6:41 p.m. NA-E stated they do try to serve each table and then go to the next table, that is how it was supposed to be done. He had also worked at other facility's where the plates and utensils were taken off the plastic serving trays and put on the table in front of each resident and it did look more home like when it was done that way, however they did not do that at this facility. When interviewed on 7/15/26, at 6:49 p.m. registered nurse (RN)-A stated the facility served the resident meals on the trays. She was not sure why. The staff used to take the plates off the trays and then put them on the tables in front of the residents, but they had stopped doing that for some reason. It would make the dining room more homelike; she had just never noticed it before. During interview on 7/16/26, at 10:14 a.m. the director of nursing (DON) stated the staff were using the steam cart and dished up the food correctly in the dining area, but when it broke they went to serving resident meals on trays. Resident's meals should not be placed in front of the residents.

Based on interview and document review, the facility failed to develop and revise comprehensive, person-centered care plans to address resident-specific interventions for leaves of absence (LOAs), including interventions to promote resident safety and staff direction when residents left the facility without notifying staff or signing out, for 2 of 2 residents (R10, R37) reviewed for supervision. Findings include: R10 R10's admission Minimum Data Set (MDS) dated [DATE], identified modified independence with no issues with short term memory and was independent with ambulation. Diagnoses include medically complex condition, diabetic ulcer on foot, and wound infection. Identified did not have a history of falls. R10's elopement risk assessment dated [DATE] identified R10 was a low risk for elopement. R10's dated 4/21/26, identified R10 was a vulnerable adult while residing in the facility. R10 was at risk for decreased cognitive and physical abilities related to diagnoses including diabetes, alcohol use disorder, chronic suicidal ideation. R10 was at risk for decreased cognitive and physical abilities. Interventions included: Staff were directed to: Monitor for signs of emotional distress or mood and behavior changes. Safety monitoring would be implemented as needed to ensure R37's safety (i.e. 15-minute checks, 1:1, etc.) Staff would continue to follow the facility vulnerable adult and abuse reporting policy. The local Ombudsman, Adult Protection, Police and/or state/financial agencies would be notified of any suspected abuse or financial exploitation as needed. R10's progress notes dated 6/1/26 through 7/12/26 identified R10 went on eleven leaves of absence during that period and on three occasions R10 did not sign out. The medical record did not reflect any interventions for when R10 left the facility and what the interventions were in place when R10 did not sign out per the facility policy. During an interview on 7/15/26 at 6:10 p.m., nursing assistant (NA)-N stated R10 frequently left the facility in the evenings. Prior to leaving, the resident was expected to notify the nurse where he was going, provide an approximate return time, and sign the resident sign-out book. During an interview on 7/16/26 at 11:31 a.m., NA-E stated R10 was expected to check with the nurse before leaving to receive any medications needed during the leave and for nursing to determine whether it was safe for the resident to leave. NA-E further stated R10 had previously left without signing out. When staff discovered the resident was gone, they searched the facility and surrounding grounds, and if unable to locate him, they notified the nurse. During an interview on 7/16/26 at 3:15 p.m., licensed practical nurse (LPN)-C stated R10 frequently left the facility and was expected to notify nursing before doing so. LPN-C stated they were unsure whether the resident's frequent leaves of absence were included in the care plan but believed they should have been. During an interview on 7/16/26 at 3:57 p.m., the director of nursing (DON) further stated staff should be able to review the care plan and report sheets to understand the resident's routine and acknowledged that, for a resident who frequently left the facility, those expectations should be reflected in the care plan so staff would know what actions were required. R37: R37's quarterly MDS dated [DATE], identified R37 had mild cognitive impairment and R37 required partial/moderate assistance with bathing/showering and was independent with all other care areas. R37 exhibited no behavior during the assessment period. R37's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 3/24/26, identified R37 had a family for financial and healthcare decisions as needed. Risk factors included: diagnoses of unspecified dementia, agitation, and anoxic brain damage. Other risk factors may include pain, hearing/visual deficits, use of psych medications, communication problems, sleep disturbances, difficulty with activities of daily living, poor decision making, increased risk of safety concerns, mood concerns, and social isolation. R37 had impaired short-term recall and didn't recall what some outside professionals were visiting with him and for what purpose. R37 was his own decision maker and had family to assist with healthcare and financial decisions as needed. R37's MHM Elopement Risk Evaluation V5 dated 6/17/26, identified a score of 1 placing R37 at low risk for elopement. R37's care plan revised 6/24/26, identified R37 was categorically a vulnerable adult while R37 resides in a Skilled Nursing Facility. R37 was at risk for decreased cognitive and physical abilities related to diagnosis including: (list dx of HIV, Anoxic Brain Damage, Mild Intermittent asthma, acute kidney failure, epilepsy, syphilis, sepsis, chronic obstructive pulmonary disease (COPD), and metabolic encephalopathy). Staff were directed to: Monitor for signs of emotional distress or mood and behavior changes. Safety monitoring would be implemented as needed to ensure R37's safety (i.e. 15-minute checks, 1:1, etc.) Staff would continue to follow the facility vulnerable adult and abuse reporting policy. The local Ombudsman, Adult Protection, Police and/or state/financial agencies would be notified of any suspected abuse or financial exploitation as needed. R37's nursing notes identified the following: On 12/12/25 at 2:47 p.m., R37 On 12/12/25 at 2:47 p.m., R37 On 12/12/25, at 2:47 p.m., R37 had not returned from leave of absence (LOA). Writer placed call to R37's telephone number several times with message left. Writer placed call to provider that R37 had not returned from LOA and had not received scheduled medications. Writer updated administrator resident had not returned. On 5/28/26 at 12:35 a.m., R37 stepped out to smoke in the smoking area on the afternoon shift. During rounds, writer discovered R37 was not in the building and was not outside in the smoking area. A voicemail was left to call the facility back, so they were able to confirm R37's whereabouts. The medical record lacked any updates to the care plan regarding safety plans in the community and interventions when R37 did not sign out per facility policy. During an interview on 7/16/26 at 10:55 a.m., registered nurse (RN)-B stated R37's elopement assessment placed R37 at low risk because R37 had always come back before the 24-hour deadline. It's not that he doesn't want to be here or he wanted to leave against medical advice. He just goes out and forgets to sign out. RN-B stated R37's care plan should have been updated with interventions to address R37's failure to sign out and to direct staff on what should occur when R37 did not let staff know when he was leaving and when he was returning. During an interview on 7/16/26 at 3:02 p.m., the DON stated R37 hadn't left the building for greater than 24 hours without notifying staff. It was generally because R37 had forgotten to sign out and staff re-educated R37 when he returned. R37's care plan should have been updated to address R37's failure to sign out and to direct staff on what should occur when R37 did not let staff know when he was leaving and when he was returning. During an interview on 7/16/26 at 3:55 p.m., the administrator stated he expected the resident care plans to be resident centered to ensure the resident's safety. The facility policy Care Planning – Interdisciplinary Team dated 7/21/23, identified the Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician. b. The Registered Nurse who has responsibility for the resident. c. The Dietary Manager/Dietician. d. The Social Services Worker/Social Services Designee responsible for the resident. e. The Activity/TR Director. f. Therapists (speech, occupational, physical ect. (as applicable). g. Consultants (as applicable). h. The Director of Nursing (as applicable). i. The Floor Nurse responsible for resident care (as applicable). j. Nursing Assistants responsible for the resident's care (as applicable0. k. Others as appropriate or necessary to meet the needs of the resident.

Based on observation, interview and document review, the facility failed to ensure licensed nursing staff followed manufacturers recommendations when preparing insulin via a NovoLog FlexPen for 1 of 2 residents (R63) reviewed for insulin administration.Findings include: The manufacturer's instructions for the NovoLog injection pen dated March 2023, identified when preparing to administer insulin using the pen clean the end where the needle attaches, install the needle and remove the cap. Dial pen to two units of insulin until you see a drop of insulin coming out of the needle and then dial up the correct dosage. Failure to do so could cause the resident to not receive the correct dosage of insulin. R63's quarterly Minimum Data Set (MDS) dated [DATE], identified R63 had moderate cognitive impairment and a diagnosis of diabetes mellitus (a condition where the body had difficulty regulating its blood sugars). R63's provider's orders dated 6/9/26, identified R63 received NovoLog injection pen (insulin) 100 units/1 milliliter (ml) on a sliding scale (dosage based on blood sugar level) three times a day. On 7/16/26 at 8:25 a.m., licensed practical nurse (LPN)-B reviewed the order for insulin in R63 chart and stated her blood sugar this morning was 183 and would require 4 units of insulin today. LPN-B obtained R63's NovoLog flex pen and supplies and entered the room. LPN-B dialed the pen to two units and depressed the injection button before attaching the needle. LPN-B then cleansed the rubber stopper, attached the needle, dialed four units, and administered the insulin without priming the pen after the needle was attached or verifying that insulin flowed from the needle. LPN-B stated that was the way she always primed the pen. During an interview on 7/16/26 at 11:20 a.m., the director of nursing (DON) stated the expected procedure to administer insulin using a flex pen was to take the cap off the pen, sanitized the top, attach the needle, prime the needle by dialing up two units and watch for a drop of insulin and then dial up the correct dosage and administer to the resident. The facility's Medication and Treatment Orders policy dated 2/2024, and the Medication Pass Checklist Tool dated 1/28/26, did not identify preparing and administering insulin using a NovoLog flex pen.

Based on observation, interview, and document review, the facility failed to provide assistance with toileting and elimination by ensuring a resident's urinal was emptied and removed before the resident entered common areas for 1 of 4 residents (R33) reviewed for activities of daily living (ADL).Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], identified R33 had moderately impaired cognition. R33 was independent with toilet transfers, required supervision with toilet hygiene and maximum assistance with grooming. R33 was occasional incontinent of bladder. Diagnoses included hemiplegia (paralysis on one side) anxiety, psychotic disorder, unspecified intracranial injury with loss of consciousness, restlessness and agitation. R33's care plan revised 3/30/26, directed staff to assist R33 with toileting every two to three hours and as needed. Staff were to keep the urinal within reach of the bed and offer to bring the resident to the bathroom after meals to prevent voiding on himself. On 7/14/26, at 3:41 p.m. R33 was seated in his wheelchair in the dining room playing bingo with activity staff and other residents. R33 had an uncovered urinal hanging off the left side of his wheelchair arm rest that was a quarter full of yellow liquid. The urinal was open without a lid over the top. During interview on 7/14/26, at 3:55 p.m. registered nurse (RN)-A stated she had not noticed R33 had a urinal hanging off his wheelchair and now noticed that he did and it did have urine in it. RN-A stated the urinal should not be hanging there and should remain in R33's room. There would be a potential for infection if the urinal splashed or spilled. On 7/15/26, at 5:51 p.m. R33 was observed seated in his wheelchair in the dining room eating supper with a number of other residents. A urinal was hanging off the left side of his wheelchair arm rest that was half full of yellow liquid. The urinal was open to the air with no cap to cover it. Nursing assistant (NA)-J approached R33 and asked if he was finished eating. NA-J removed R33's supper tray, urinal was visible hanging off the left side of R33's wheelchair; however, never acknowledged the urinal. During interview on 7/15/26, at 6:51 p.m. RN-A stated she just now noticed R33 had an open urinal with urine in it that was hanging off his wheelchair arm rest. RN-A stated R33 should not have an open urinal with urine in it in the dining room; however, made no attempt to remove the urinal or the resident from the dining room. On 7/15/26, at 6:54 p.m. licensed practical nurse (LPN)-E approached R33 in the dining room, put on gloves and took the half full urinal off of the wheelchair. R33 became very angry and was hollering and attempting to grab the urinal back. The director of nursing (DON) entered the dining room and attempted to reassure and soothe R33. LPN-E was able to remove the urinal from the dining room area. During interview on 7/16/26, at 10:14 a.m. the DON stated R33 should not have a urinal in a common area. Staff should have assisted him to the bathroom and removed the urinal from his wheelchair before he exited his room to go to the dining area. The facility policy Activities of Daily Living (ADLs)/Maintain Abilities Policy updated 3/31/23, identified the facility would provide care and services for hygiene, mobility, elimination, dining, and communication. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview and document review, the facility failed to provide assistance with dressing and personal hygiene, including offering a clean gown and morning grooming, for 1 of 4 residents (R3) reviewed for activities of daily living (ADLs). Findings include:R3 R3's annual Minimum Data Set (MDS) dated [DATE], identified R3 was rarely/never understood and R3 had a severe cognitive impairment. R3 had diagnoses that included ichthyosis vulgaris (a common inherited skin disorder characterized by dry, thick, and scaly skin resembling fish scales. It is primarily caused by a mutation in the FLG gene, which is responsible for producing filaggrin (a protein that helps your skin retain moisture and forms a healthy protective barrier)), major depressive disorder, mixed obsessional thoughts and acts, bipolar disorder, candidiasis of skin and nails (a yeast infection) and anxiety. R3 was always continent of bowel, used an indwelling catheter and partial to moderate assistance with personal hygiene, lower and upper dressing and putting on and taking off footwear.R3's care plan revised 6/8/26, identified R3 was continent of bowel, required assistance of one staff member for dressing and personal hygiene. Staff were directed to provide assistance with peri-cares every morning, at bedtime and as needed. Staff were directed to offer assistance with clothing. R3 often preferred to wear a hospital gown.During an observation on 7/15/26 at 5:52 p.m., R3 was lying in bed on his right side wearing a hospital gown with another hospital gown as a robe and red gripper socks. During an observation on 7/16/26 at 7:20 a.m., R3 was lying in bed wearing the same hospital gown observed the previous evening. The gown and red gripper socks were visibly soiled. R3 was unshaven with approximately one-quarter inch of beard growth, his hair was disheveled, and his room smelled strongly of urine. The catheter leg straps remained attached to R3's left leg while the catheter drainage bag was lying on the floor beside the bed. At 7:24 a.m., nursing assistant (NA)-F entered R3's room and asked R3 if he wanted to put on clothes. R3 responded nightgown. NA-F put on a disposable gown and gloves and stated he was going to change R3's catheter bed bag to a leg bag.At 7:27 a.m., NA-F exchanged R3's catheter bed bag for a leg bag. After cleaning the catheter bed bag, NA-F removed his gown and gloves and told R3 he would see him later. NA-F did not offer to change R3's gown or to provide morning cares for R3. During an interview on 7/16/26 at 7:39 a.m., NA-F stated R3 was already provided morning cares earlier that morning but R3 did not want to shave. NA-F stated he did not know why the catheter leg bag had not been connected during morning cares.During an interview on 7/16/26 at 11:27 a.m., registered nurse (RN)-B stated she was the nurse manager for R3. R3 liked things the same and would become very upset if staff took his things. RN-B stated she believed R3 refused morning cares and that was why R3 was wearing the same gown as the day prior. RN-B stated staff should have offered a clean gown and cares when the catheter leg bag was connected but would speak with staff to determine why it was not done.During an interview on 7/16/26 at 3:50 p.m., the director of nursing (DON) stated staff were expected to offer cares to residents and, if refused, to continue to offer and document. The facility policy Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 3/31/23, identified the facility would provide care and services for the following activities of daily living: bathing, dressing, grooming, and oral care.

Based on observation, interview, and document review, the facility failed to ensure urinary drainage bags were maintained in a manner that reduced the risk of contamination during catheter care for 1 of 2 residents (R3) reviewed for indwelling catheter care.Findings include:R3's annual Minimum Data Set (MDS) dated [DATE], identified R3 was rarely/never understood and R3 had a severe cognitive impairment. R3 had diagnoses that included ichthyosis vulgaris (a common inherited skin disorder characterized by dry, thick, and scaly skin resembling fish scales. It is primarily caused by a mutation in the FLG gene, which is responsible for producing filaggrin (a protein that helps your skin retain moisture and forms a healthy protective barrier)), major depressive disorder, mixed obsessional thoughts and acts, bipolar disorder, candidiasis of skin and nails (a yeast infection) and anxiety. R3 used an indwelling catheter.R3's care plan revised 6/8/26, identified R3 had an alteration in elimination due to has indwelling catheter 16 French (F) 10 milliliter (mL) related to bladder neck obstruction. Staff were directed with the following:Ensure catheter bag is hung on the bed frame and not placed directly on the floor.Use of privacy bag at all times.R3 wears leg bag during day and night bag at night. R3 notifies staff when he wishes staff to switch them from leg bag to night bag and vice versa.During an observation on 7/15/26 at 5:35 p.m., registered nurse (RN)-D entered R3's room with R3's meal tray and stated he was going to empty R3's catheter leg bag. RN-D put on a gown and gloves, then got R3's urine graduate from the bathroom.At 5:37 p.m., RN-D placed the urine graduate directly on the floor prior to draining the catheter bag into the graduate. RN-D opened the drainage port, emptied the urine, and closed the outlet without cleansing the outlet with an alcohol swab. RN-D took the graduate into the bathroom, poured the urine into the toilet then rinsed the graduate with water from the sink.During an observation on 7/16/26 at 7:20 a.m., R3 was lying in bed on his right side. R3 was wearing a catheter leg bag secured to his left leg, while the catheter drainage bag was lying directly on the floor beside the bed. At 7:24 a.m., nursing assistant (NA)-F put on a disposable gown and gloves and stated he was going to change R3's catheter bed bag to a leg bag.At 7:27 a.m., NA-F exchanged R3's catheter bed bag for a leg bag. After cleaning the catheter bed bag, NA-F removed his gown and gloves and told R3 he would see him later.During an interview on 7/16/26 at 7:39 a.m., NA-F stated R3 catheter bed bag should not have been lying on the floor but R3 could have put the catheter bed bag on the floor himself. R3 did not know why the catheter bed bag was not in a privacy bag to act as a barrier.During an interview on 7/16/26 at 3:50 p.m., the director of nursing (DON) stated staff were expected to put R3's catheter bag into a privacy bag to prevent the bag from lying on the floor. The DON stated the catheter kits even came with a privacy bag so one was always available. The facility policy Indwelling Catheter Care Procedure revised 5/2025, identified when emptying the catheter bag, put on new gloves, uncap bottom outlet of bag, drain urine into measuring container, cleanse outlet with alcohol swab and recap the outlet. Measure urine and dispose of it in toilet. Remove gloves and wash hands.

Based on observation, interview and document review, the facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for 1 of 1 resident (R46) reviewed for accident hazards; and the facility failed to ensure fall interventions were followed for 1 of 4 residents (R13) reviewed for accidents. Findings include: R46 R46's quarterly Minimum Data Set (MDS) dated [DATE], identified R46 had moderate cognitive impairment and required maximum assistance with dressing, grooming and toileting hygiene. R46 required moderate assistance with transfers and used a wheelchair for mobility. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety and schizophrenia. During observation on 7/13/26, at 11:50 a.m. R46 was in his wheelchair in his room. R46 rummaged through his bedside dresser, looking for items. R46's television was mounted on a wall between the bathroom and his closet. The power cord of the television ran across the closet doors and across the upper drawer of the fixed dresser to plug into a surge protector on the top of the dresser. R46 attempted to open the closet doors in his room to pick out a pair of pants. The television power cord was stretched tightly across the closet doors, preventing the closet door from opening fully unless the cord was lifted away from the doorway. During observation on 7/15/26, at 11:32 a.m. nursing assistant (NA)-D was assisting R46 change his clothes and bedding. NA-D attempted to open R46's closet door to obtain clothing. NA-D had to lift the television power cord up above the closet door in order to open it and pull out the needed clothes. NA-D stated the cord had been positioned that way for approximately one year and could be dangerous because if R46 pulled on the cord in an attempt to open the closet, the television or electrical cord could be damaged or create an injury hazard. NA-D did not know if it had been reported to maintenance or not, but he had never reported it. During interview on 7/15/26, at 1:10 p.m. licensed practical nurse (LPN)-B stated staff were supposed to put a request for repairs in the facility Tells system and that notified maintenance. LPN-B did not know if maintenance was aware of the power cord and she would put in a request right away for it to be fixed. During interview on 7/15/26, at 3:45 p.m. the maintenance staff (maint)-A stated staff put in a work order in the computer in the facility's Tells system. and also kept track by writing the work orders in a notebook. Maint-A stated she had just been notified that day the television for R46 needed to be fixed. Maint-A stated R46 previously had a longer power strip that allowed the television cord to reach the outlet without obstructing the closet doors, and someone had replaced it with a shorter power strip, causing the television cord to be stretched tightly across the closet doorway. The undated facility policy Awair Policy/Procedure identified supervisors would make impromptu inspection tours and effective corrective action and do hazard analysis of their work areas. Employees would report all safety hazards, make safety suggestions and take care of their equipment. R13 R13's quarterly MDS dated [DATE], identified R13 had severe cognitive impairment with disorganized thinking and inattention. R13 had verbal behaviors directed towards others 1 to 3 day per week. R13 was dependent on staff for putting on footwear and partial to moderate assist with dressing. It identified R10 as independent with bed mobility and ambulation. Diagnoses included Huntington's disease (an inherited, progressive neurodegenerative disorder that causes nerve cells in the brain to break down over time), psychotic disorder, restlessness and agitation. R13 did not have any falls since the last quarter. R13's care plan dated 6/26/26, identified was at risk for falls and included interventions of ambulating with resident, encourage resident to gripper sock, obtain slip-on shoes, reduce noise, offer snacks with observed running in the hallway and assist her back to her room, offer wheelchair when observed running in the hallway, and redirect resident to slow down when running in the hallway. The undated nurse's aide care sheet identified interventions to try with R10 included to ensure wearing gripper socks. During observation on 7/13/26 at 5:11 p.m., R13 repeatedly exited her room barefoot and ran through the hallway. Staff observed the behavior but did not provide gripper socks or shoes, walk with the resident, redirect her to slow down, or offer other care-planned interventions. During observations on 7/14/26, over approximately 11/2 hours, R13 repeatedly ran in and out of her room fourteen times while barefoot. Staff did not provide footwear, redirect her to slow down. During an interview on 7/14/26 at 4:30 p.m., NA-I stated R13 was difficult to redirect when she was out walking, when staff got closer to her, she would become more agitated. Staff usually step back because we did not want to agitate her and cause a fall. During an interview on 7/15/26 at 4:28 p.m., NA-E and NA-M stated they attempted to get her to wear gripper socks, but R13 became agitated, and would step back and try to reapproach. During an interview on 7/16/26 at 8:03 a.m., The DON stated R10's care plan should be followed to ensure safety.

Based on interview and document review, the facility failed to assess pain, and failed to offer or attempt non-pharmacological pain interventions (interventions other than medications), prior to the administration of as-needed (PRN) pain medications for 3 of 4 residents (R1, R2, R4) reviewed for pain. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated no cognitive deficits. R1 had pain that frequently affected sleep, the ability to participate in therapy, and activities of daily living (ADLs). R2 received scheduled pain medication, PRN pain medication, and non-medication interventions for pain.R1's alteration in comfort care plan dated 5/29/26, instructed to provide non-medicinal forms of pain relief such as positioning, rest, massage, pain medication as ordered by medical doctor, and to document on effectiveness of pain medication.A pain evaluation/assessment was requested for R1; however, none was provided. R1's provider order dated 5/21/26, instructed oxycodone-acetaminophen (opioid/narcotic pain medication) 10-325 milligrams (mg) to be given every four hours as needed for severe pain.R1's June 2026 Medication Administration Record (MAR) indicated oxycodone-acetaminophen PRN was administered at the following times: -6/7/26 at 3:26 a.m., for a pain level of 7/10 (moderate pain) which was recorded as E [effective for pain relief/reduction]. A corresponding progress note dated 6/7/26 identified the medication was administered, but lacked what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, or R1's pain location.-6/7/26 at 3:32 p.m., for a pain level of 8/10 (severe pain) which was recorded as E. A corresponding progress note dated 6/7/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R1's pain location.-6/7/26 at 7:36 p.m., for a pain level of 6/10 (moderate pain) which was recorded as E. A corresponding progress note dated 6/7/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R1's pain location.-6/7/26 at 11:38 p.m., for a pain level of 6/10 which was recorded as E. A corresponding progress note dated 6/7/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration nor R1's pain location.-6/8/26 at 6:22 a.m., for a pain level of 4/10 (mild pain) which was recorded as I [ineffective]. A corresponding progress note dated 6/8/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R1's pain location.-6/8/26 at 2:39 p.m., for a pain level of 8/10. A corresponding progress note dated 6/8/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R1's pain location.During an interview on 6/10/2026 at 9:37 a.m., R1 stated she had pain in her back but sometimes the pain was in her legs. PRN oxycodone-acetaminophen helped her pain as well as repositioning and rest, which she did herself. R1 identified she set an alarm to track when she could next have pain medication. R2's quarterly MDS dated [DATE] indicated no cognitive deficits. R2's Pain Evaluation form dated 4/21/26 indicated R2 had mild pain that frequently affected sleep and the ability to participate in therapy. R2 was on a scheduled pain medication regimen and did not receive PRN pain medication nor non-medication interventions for pain. R2 was not experiencing pain at the time the form was completed. R2's comprehensive care plan dated 4/27/26, lacked a focus, goal, or interventions related to pain management and the associated sleep issues or ability to participate in therapy. R2's provider order dated 4/20/26, instructed Methocarbamol (muscle relaxant), 500 mg, to be given every six hours as needed for muscle pain.R2's June 2026 MAR indicated Methocarbamol PRN was administered at the following times:-6/2/26 at 9:03 p.m., which was recorded as E [effective]. A corresponding progress note dated 6/2/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R2's pain level or pain location.-6/5/26 at 11:10 a.m., which was recorded as E. A corresponding progress note dated 6/5/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R2's pain level or pain location.-6/8/26 at 1:23 p.m., which was recorded as E. A corresponding progress note dated 6/8/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R2's pain level or pain location.During an interview on 6/9/2026 at 12:21 p.m., R2 stated she laid down to rest when she started to experience pain, which primarily was in her legs, as this helped to relieve it. If that did not work, she updated staff and requested a pain pill. She could not recall the name of this medication, but stated it relieved the pain R4's quarterly MDS dated [DATE], indicated moderately impaired cognition. R4 had received scheduled PRN pain medication and non-pharmaceutical pain interventions.P4's Pain Evaluation form dated 5/20/26, indicated R4 did not have pain in the five days prior to 5/20/26. R4 had mild pain that rarely or never interfered with sleep, therapy or day to day activities. R4's alteration in comfort due to generalized pain care plan focus, dated 2/23/26, included interventions, but not limited to, pain medication as ordered by medical doctor and to document the effectiveness of pain medication. R4's comprehensive care plan lacked indication of non-pharm interventions for pain. R4's provider order dated 5/7/26, instructed oxycodone-acetaminophen, 10 mg, to be given every four hours as needed for cancer-related pain.R4's June 2026 MAR indicated PRN oxycodone-acetaminophen was administered at the following times:-6/8/26 at 1:41 a.m., for a pain level of 6/10 which was recorded as E. A corresponding progress note dated 6/8/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R4's pain location.-6/8/26 at 9:30 a.m., for a pain level of 6/10 which was recorded as E. A corresponding progress note dated 6/8/26 identified the medication was administered for right rib pain but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration.-6/8/26 at 4:24 p.m., for a pain level of 8/10 which was recorded as E. A corresponding progress note dated 6/8/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R4's pain location.-6/8/26 at 8:38 p.m., for a pain level of 8/10 which was recorded as E. A corresponding progress note dated 6/8/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R4's pain location.-6/9/26 at 4:59 p.m., for a pain level of 8/10 (severe pain) which was recorded as E. A corresponding progress note dated 6/9/26 identified the medication was administered but did not include what, if any, non-pharmacological interventions had been attempted or offered prior to the medication administration, nor R4's pain location.During an interview on 6/9/2026 at 4:30 p.m., R4 stated he had pain in his mouth, head and whole body. He did not know if there was anything that helped with his pain and he could not. recall staff ever offering something other than medication(s) for the pain. During an interview on 6/9/2026 at 2:07 p.m., licensed practical nurse (LPN)-A stated when a resident complained of pain, the nurse should ask the resident where their pain was and to rate their pain on a scale of 0 (no pain) to 10 (worst pain ever), and the nurse should offer non- pharmacological (non-pharm) interventions like food, fluids, repositioning and a quiet space. If the non-[NAME] are ineffective, the nurse should offer a PRN pain medication if available. LPN-A explained the nurse should document the non-[NAME] attempted and the effectiveness, pain scale, and pain location when administering a PRN pain medication.During an interview on 6/9/2026 at 3:39 p.m., LPN-B stated when a resident complained of pain the nurse should ask the resident where the pain was located, rate the pain on a scale of 0-10, and what helped with the pain. LPN-B identified most residents knew what worked to relieve their pain and what did not. LPN-B explained when the nurse clicked on a pain medication to document administration; the computer would prompt to document pain level and open a note where the nurse should indicate where the pain was located. Non-pharm interventions were documented once a shift with any interventions attempted that shift. There was nowhere to document if the non-pharm intervention was effective or not.On 6/9/2026 at 4:11 p.m., a message was left for the facility's nurse practitioner with no return phone call.During an interview on 6/9/2026 at 4:37 p.m., director of nursing (DON) stated when a resident had pain, the nurse should complete a pain assessment that included pain location and pain severity, should attempt non-pharm interventions prior to administering a PRN pain medication, and should document pain location, rating and non-[NAME] attempted with effectiveness in a nursing note with the PRN medication administration. DON confirmed pain location and non-[NAME] attempted were not documented with the PRN pain medication administration for R1, R2, and R4. DON stated non-[NAME] were documented in the TAR once per shift. DON stated pain location was important so the nurse could assess if the pain was in a new location. The Medication Administration policy, dated 4/2018, instructed when PRN medications are administered the following should be documented:a. Date and time of administration, dose, route of administration (if other than oral), and ifapplicable, the injection site.b. Complaints or symptoms for which the medication was given.c. Results achieved from giving the dose and the time results were noted.d. Signature or initials of person recording administration and signature or initials of personrecording effects.The Pain Management Protocol dated 3/23/23, instructed nursing to evaluate for appropriate non-pharmacologic interventions to address the resident's pain.

Based on interview and document review, the facility failed to provide a pureed diet in accordance with residents needs for 1 of 3 residents (R1), reviewed for diet modifications. This resulted in an immediate jeopardy (IJ) when R1 received a regular textured meal on [DATE], which caused R1 to choke, lose consciousness, require the Heimlich maneuver and cardiopulmonary resuscitation (CPR). The facility immediately implemented corrective action so the deficient practice was issued at past noncompliance. The IJ began on [DATE], when R1 received a regular textured meal on [DATE], which caused R1 to choke, lose consciousness, require the Heimlich maneuver and cardiopulmonary resuscitation (CPR) and was identified on [DATE]. The administrator was notified of the past noncompliance IJ on [DATE], at 4:40 p.m. The facility implemented immediate corrective action on [DATE], prior to the start of the survey and was issued as past non-compliance. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired, required one-person physical assistance with eating and a mechanically altered diet. R1's diagnosis included vascular dementia. R1's nutrition care plan revised [DATE], indicated R1 was on a mechanically altered diet with pureed textures and required 1 person assistance with meals and to be seated at 90 degrees. R1's nutritional status care area assessment (CAA) dated [DATE], indicated R1 was on a pureed diet due to difficulty chewing. The CAA further indicated, Noncompliance with the diet is a risk to the resident as it could lead to choking, inability to consume adequate food and fluids, and/or aspiration. R1's physician orders dated [DATE], indicated, Regular diet, pureed texture, regular (thin) consistency. R1's undated nurse aide care sheet indicated R1 required a regular diet with pureed texture, thin liquids and assistance of one with meals. R1's progress note by administrator per license practical nurse (LPN)-A dated [DATE], at 19:20 (7:20 p.m.) indicated, At 18:10 [6:10 p.m.] CNA [NA-nursing assistant] staff called writer [LPN-A] to dining room to check on [R1]. [LPN-A] noted [R1] is choking, having difficulty breathing, her face turning blue and using breathing accessory muscles. [R1] is on a pureed diet. [LPN-A] noted pureed diet on [R1's] table but one of the [NA] states [R1] had a piece of chicken. [LPN-A] immediately started heimlic [sic] maneuver, looked for any food particles in her mouth and found nothing. Staff then assisted [R1] back to her room. [LPN-A] called 911 at around 18:15 [6:15 p.m.]. [R1] became unresponsive, unable to obtain pulse, her skin blue. Staff lowered [R1] to the floor on hard board and [LPN-A] started CPR. [LPN-A] continued performing CPR on [R1], with thirty compressions and two breaths for five minutes. [R1] became responsive and began breathing on her own. EMS [emergency medical services] personnel arrived facility, around 18:35 [6:35 p.m.], transported [R1] to ER [emergency room ] for evaluation. R1's provider encounter note by medical doctor (MD) dated [DATE], indicated, Call received from nursing staff, patient had a choking episode at dinner. Patient was having difficulty breathing she then became nonresponsive. CPR was initiated 911 was called able to revive patient at facility but was taken emergency room for further evaluation. During interview on [DATE], at 11:57 a.m. LPN-A stated when called to the dining room after staff reported R1 was choking a pureed diet was on the table by R1. LPN-A further stated she provided the Heimlich maneuver without success and R1 became unconscious and required CPR. LPN-A further stated that any staff that takes a meal off the cart was supposed to compare the meal ticket to the actual meal to confirm it was the right meal being served. During interview on [DATE], at 12:17 p.m. NA-A stated they were supposed to double check that the meal ticket matched the actual meal. NA-A stated on [DATE], NA-B handed him a tray and instructed him to assist R1 with the meal. NA-A further stated he looked at the meal ticket but did not realize it was the wrong meal on the tray. NA-A cut up the chicken and gave R1 a bite and then NA-B noticed it was the wrong meal and provided the correct one. NA-A told NA-B that R1 had already had a bite of chicken, so NA-B instructed him to watch R1 closely. R1 began choking right away so they notified the nurse (LPN-A). During interview on [DATE], at 12:59 p.m. NA-B stated they were supposed to look at the meal ticket and make sure that the ticket matched the meal. With [R1], I don't know how she got the wrong food. NA-B further stated he thought R1 had the correct meal, a pureed diet on the day she choked. During interview on [DATE], at 12:49 p.m. administrator stated R1's meal ticket was on another resident's tray who had a similar name and was on a regular textured diet. Administrator further stated the meal card did not match the meal that was on the tray and that neither NA-A nor NA-B performed the required second check to ensure the meal ticket matched the actual meal and therefore did not notice R1 had the wrong meal. During interview on [DATE], at 1:33 p.m. culinary director (CD) stated kitchen staff dished up the meal according to the meal ticket and placed both the meal and the ticket on the tray. CD further stated kitchen staff completed the first check to ensure the meal ticket matched the meal and that the NA or whoever was serving it was supposed to double check the accuracy of the meal when they removed the tray from the meal cart. CD could not explain why R1's meal was not accurate on [DATE]. The facility education Texture and Thickened Liquid diet dated [DATE], indicated, Kitchen Staff: MUST follow the Diet Extensions that lay out what therapeutic and texture modified diets can and cannot have. Nursing Staff: Should assist with '2nd check' to ensure the food is delivered to the correct person and the correct diet is being served per the tray card. The undated facility policy Diet Manual and Diet Orders indicated diet orders were written as a prescription by the physician and may include altered textures. The policy further indicated if a pureed diet was ordered the dietary department would puree the food. The past noncompliance IJ began on [DATE]. The IJ was removed, and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: -The facility immediately reviewed all meals and meal tickets to ensure they matched and that all residents had the correct meal. -The facility completed a full house audit on diet orders in point click care (PCC) and ensured the nursing care sheets and care plans matched the order and the meal ticket for all residents. Any discrepancies were immediately corrected, and the meal ticket reprinted if necessary. -A section was added to the facility's Morning Meeting Stand Up Form about new admits, diets, and meal tickets to ensure each new admit is getting the correct meal ticket created and the diet in PCC matches the meal ticket. -All staff were educated on diet textures and liquids, signs and symptoms of chewing and swallowing difficulties, meal tickets, and their roles. Education was completed [DATE] through [DATE]. The staff were then given a knowledge quiz and educated further if necessary. -Audits were initiated right away on [DATE] with all meals for all residents to ensure accuracy until all staff were trained. Ongoing audits continue with the five residents per floor per meal daily for one week and then five residents per floor per meal weekly for four more weeks. Additional audits include pick five residents weekly to ensure PCC order, nursing care sheet, meal ticket, and care plan match for four more weeks. Audit all new admits ensuring matching PCC order, NAR guide, and meal ticket match for four weeks. Verification of corrective action was confirmed by observation, interview, and document review on [DATE], from 9:35 a.m. to 4:50 p.m. Nursing staff were observed during meal service to verify the meal tickets matched the meals on the trays prior to removing the trays from the meal cart. Nursing and kitchen staff interviewed confirmed education was provided regarding textured diets and first and second check process to confirm correct meals were being provided. Sign-in sheets for Texture and Thickened Liquid diet education confirmed education began on [DATE]. Meal ticket and tray audits reviewed and confirmed appropriate interventions initiated and deficient practice corrected on [DATE], therefore this was cited at past noncompliance.

Based on interview and document review, the facility failed to complete outbreak COVID-19 testing of all staff according to Center for Disease Control (CDC) guidelines for outbreak testing. As a result the facility was in outbreak status on 1/08/22. This practice resulted in an immediate jeopardy (IJ) situation related to the high likelihood of serious illness, harm or death that had the potential to affect all 51 residents, staff, family and visitors in the facility. The immediate jeopardy began on 1/8/22, when the facility failed to test all staff during a COVID-19 outbreak which began on 1/8/22. The administrator and the director of nursing (DON) were notified of the immediate jeopardy at 6:48 p.m. on 1/24/22. The immediate jeopardy was removed on 1/25/22, at 4:50 p.m. when the facility implemented interventions to ensure all staff were tested for COVID-19 was completed however, noncompliance remained at the lower pattern scope and severity level F, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings Include: The CDC: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, directed healthcare facilities to develop and implement a testing plan for testing residents and healthcare professionals [CONDITION(S)]-CoV-2. The CDC guidance recommended any new COVID-19 infection in any staff or any nursing home-onset COVID-19 resident infection triggered an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases was critical in stopping further [CONDITION(S)] transmission. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. On 1/20/22, at 2:53 p.m. director of nursing (DON) indicated the facility staff were being tested two times a week, on Monday and Thursday due to their outbreak status. On 1/20/22, at 5:09 p.m. Administrator sent an e-mail, which identified the facility outbreak testing was initiated on 1/10/2022. On 1/24/22, at 9:20 a.m. the infection preventionist confirmed at current, 11 residents and three staff were positive with COVID-19. Review of the facility untitled list undated, identified the facility currently had 53 employees. Review of facility forms titled Staff COVID-19 Outbreak Testing, from 1/10/22, to 1/17/22, revealed the following: -1/10/22, identified 26 of 53 staff members were tested . -1/13/22, identified 16 of 53 staff members were tested . -1/17/22, identified 17 of 53 staff members were tested . No further testing results were provided. On 1/24/22, at 12:34 p.m. IP-A indicated the facility was currently in COVID-19 outbreak status, and began testing all staff and residents, regardless of their vaccination status on 1/10/22, and every Monday and Thursday. The IP indicated residents and staff were currently being tested with a combination of antigen and PCR tests and provided the list of the staff she had tested to the administrator and DON. IP-A indicated she had instructed the DON and administrator to have staff complete an antigen test prior to their next shift if they missed the PCR COVID-19 testing. IP-A stated she expected the DON or administrator to keep track of which staff had completed the COVID-19 tests, and assumed it was the administrator who had kept track of the testing. On 1/24/22, at 2:22 p.m. DON stated the facility process to assure all employees had been tested for COVID-19 began with the facility sending out text messages to all employees informing them when the testing was scheduled. DON indicated the process to assure all staff had their testing completed relied on the employees informing the facility if they had testing completed at another facility. DON confirmed IP-A kept track of the staff tested and sent the information to her. DON indicated the facility has been attempting to put a better process in place to assure all staff were tested . DON stated the associate administrator kept a checklist too. On 1/24/22, at 2:28 p.m. during a joint interview with associate administrator and administrator, the administrator indicated the facility tracking process they had in place was not accurate in keeping track of which staff had been tested . Associate administrator confirmed she used a staff listing of all employees to check off those staff who completed the testing. She did not keep the list when they completed testing and they were unable to determine which staff still had to complete the testing. Associate administrator stated she assumed IP-A kept track of the staff who had antigen testing done between their regular testing's completed on Mondays and Thursdays. Administrator confirmed the testing logs they had provided were the only documentation the facility had during their outbreak testing. Administrator confirmed outbreak testing had not been completed on all staff per CDC recommendations. On 1/24/22, at 2:39 p.m. during a follow up interview IP-A confirmed she had not been tracking COVID-19 testing of staff during the outbreak and was not certain who was responsible to assure all staff were being tested . IP-A stated she was not able to confirm if all staff had been tested . IP-A verified she was not aware of any staff receiving antigen testing prior to working their shifts if they had missed the testing, and stated she had not been notified of any antigen testing being completed in the facility. On 1/24/22, at 3:16 p.m. nursing assistant (NA)-B indicated he got tested in the facility last week, however, was not tested the week before. On 1/24/22, at 4:14 p.m. director of infection control (DIC)-A confirmed the facility had not been conducting COVID-19 outbreak testing of staff per CDC recommendations. DIC-A verified the facility did not have a system in place to assure all staff were tested . On 1/24/22, at 4:24 p.m. during a follow-up interview DON confirmed the facility did not have a tracking system in place to determine all staff had been tested during the outbreak. The DON indicated there had been no contact tracing in place to compare residents and staff who had tested positive for COVID-19. The DON confirmed she was not aware how many staff had been tested since the outbreak was identified on 1/8/22. The DON indicated it was important to complete outbreak COVID-19 testing of staff to control the spread of COVID-19 during the outbreak. The facility lacked any documentation of staff and resident contact tracing or any evidence of a process for testing staff and residents during an outbreak. On 1/24/22, at 5:53 p.m. administrator confirmed the facility outbreak began on 1/8/22, when licensed practical nurse (LPN)-E was found COVID-19 positive on 1/8/22. The facility policy titled COVID-19 Testing Policy revised 10/5/21, identified any new COVID-19 in any staff or any nursing home-onset COVID-19 infection in a resident triggered an outbreak investigation. In an outbreak investigation rapid identification and isolation of new cases was critical in stopping further [CONDITION(S)] transmission. The policy identified all health care workers, regardless of vaccination status, would be tested for [CONDITION(S)]-CoV-2 when working in a facility experiencing an outbreak. The policy identified the facility would conduct testing of all residents and staff every 3 to 7 days, until 14 days had passed since the last positive case. The policy identified upon identification of a new COVID-19 case in the facility, they would document the date the case was identified, the date the other residents and staff were tested , the dates the residents and staff who tested negative were retested , and the results of all tests. The IJ, which began on 1/24/22, was removed on 1/25/22, at 4:50 p.m. when it could be verified through observation, interview and document review the facility implemented testing for COVID-19 for all current residents and staff per CDC guidance. The facility started a process to review the community transmission rate every other week on Monday and determine frequency of testing of unvaccinated staff per CDC COVID Data Tracker. All unvaccinated employees would be contacted every Monday by the facility human resources director or designee to ensure staff are tested per CDC frequency. If an unvaccinated employee failed to test per frequency they would be removed from the schedule until corrected and correction action was completed. The facility human resources director or designee would maintain all testing records to include testing day attendance, follow up with employees who did not test and test results. Employee schedules would be audited daily to ensure all employees were tested . Staff received the above education prior to the start of their next shift. Staff that were on leave, on-call and/or not frequently in the facility were mailed an education packet or verbal education would be completed on the phone. Lastly, staff competency testing was initiated for COVID-19 antigen self testing if the facility ends up deeming this necessary due to staff shortages.

Based on observation, interview and document review, the facility failed to implement appropriate isolation and transmission based precautions on the second floor secured unit for 2 of 2 residents (R11 and R14) who were positive for COVID-19. In addition, the facility failed to implement proper use of personal protective equipment (PPE) per Centers for Disease Control and Prevention (CDC) CDC to prevent and/or minimize further spread of COVID-19. Further, the facility failed to provide appropriative cleaning of bathrooms between resident use during a COVID-19 outbreak. This deficient practice resulted in an immediate jeopardy (IJ) which had the potential to affect all 51 residents, staff, family, and visitors in the facility. The immediate jeopardy began on 1/20/22, when appropriate infection control practices to isolate/quarantine residents and proper use of personal protective equipment (PPE) were not implemented to reduce the spread of COVID-19 in the facility The administrator, associate administrator(AA), director of nursing (DON), regional director of operations (RDO), regional nurse consultant (RNC) were notified of the immediate jeopardy at 5:10 p.m. on 1/21/22. The immediate jeopardy was removed on 1/25/22, at 1:00 p.m. when the facility implemented interventions to ensure residents and all staff were educated on proper isolation precautions and proper use of PPE. However, noncompliance remained at the lower pattern scope and severity level F, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: Review of R11, R14, R6, R24, R22, R17, R18, R19, R20, R21, R23, R18 and R4's COVID-19 lab results revealed the following: R11's Simple Laboratories test resulted dated 1/19/22, indicated R11 was positive for COVID 19. R14's Simple Laboratories test resulted dated 1/15/22, indicated R14 was positive for COVID 19. R6's Simple Laboratories test resulted dated 1/12/22, indicated R6 was positive for COVID 19. R24's Simple Laboratories test resulted dated 1/15/22, indicated R24 was positive for COVID 19. R22's Simple Laboratories test resulted dated 1/19/22, indicated R22 was positive for COVID 19. R17's Simple Laboratories test resulted dated 1/19/22, indicated R17 was positive for COVID 19. R19's Simple Laboratories test resulted dated 1/19/22, indicated R19 was positive for COVID 19. R20's Simple Laboratories test resulted dated 1/19/22, indicated R20 was positive for COVID 19. R21's Simple Laboratories test resulted dated 1/19/22, indicated R21 was positive for COVID 19. R13's Simple Laboratories test resulted dated 1/12/22, indicated R13 was positive for COVID 19. R23's Simple Laboratories test resulted dated 1/19/22, indicated R23 was positive for COVID 19. R18's Simple Laboratories test resulted dated 1/12/22, indicated R18 was positive for COVID 19. R4's Simple Laboratories test resulted dated 1/15/22, indicated R4 was positive for COVID 19. CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, identified the facility must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and healthcare professionals in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death, which included: Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection, identified the following guidelines: -residents with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for Transmission-Based Precautions (quarantine) based on close contact with someone with [CONDITION(S)]-CoV-2 infection. -residents should NOT be cohorted with patients with confirmed [CONDITION(S)]-CoV-2 infection unless they are confirmed to have [CONDITION(S)]-CoV-2 infection through testing. Ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. - healthcare personnel (HCP) who enter the room of a resident with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). On 1/20/22, at 10:44 a.m. during an observation, several residents on the secured unit were seated out in the dining room area with two staff members completing activities on the secured unit. R11, who had tested positive for COVID-19 on 1/19/22, was seated at the end of the dining room area sitting alone wearing a surgical mask over his face and was sleeping. R15 who was COVID-19 negative entered the dining room area without a facemask on and sat down in a chair to watch TV. The two activity staff that were in the area were not observed directing R15 to place a mask on his face or redirecting R11 back to his room. - at 10:54 a.m., R17 who had tested positive for COVID-19 on 1/19//22, had a sign on his door which indicated R17 was in droplet isolation precautions (used for diseases or pathogens including COVID-19 that can spread in tiny droplets caused by coughing or sneezing). Nursing assistant (NA)-E was observed to have a N95 mask on, with a surgical mask over it and a face shield covering his face. NA-E donned a disposable gown, gloves and entered R17's room while licensed practical nurse (LPN)-F who was in the hallway closed the door behind him. NA-E opened R17's door, had removed his gown and gloves. NA-E stood in the door way, removed his surgical mask, disposed of it in in the room, sanitized his hands while exiting the room into the hallway and left his N95 mask on. - at 10:56 a.m., LPN-F obtained a disposable gown out of a plastic bin in the hallway, walked down to the nurses station, obtained a N95 mask, removed her eye protection and surgical mask. LPN-F proceeded to donn her N95 mask over her nose and mouth, applied a surgical mask over her N95 mask, placed her eye protection back on and walked down the hallway to R14's room. R14 who had tested positive for COVID-19 on 1/15/22, had a sign present on her doorway which indicated R14 was in droplet isolation precautions. R14 came out of her room with a surgical mask on her face while LPN-F donned a disposable gown and directed R14 her back to her room. LPN-F proceeded to glove her hands and entered R14's room. - at 11:13 a.m., R14 exited her room wearing her surgical mask below her nose, walked down the hallway past NA-E and NA-E directed R14 to adjust her mask up. R14 complied and proceeded to walk by several residents and staff in the hallway. NA-E did not re-direct R14 back to her room. LPN-F exited R14's room wearing her eye protection and N95 mask, walked up to the nurses station, placed paper towels on nursing station counter and gloved her hands. LPN-F and NA-E removed their N95 masks, cleaned their eye protection and donned new N95 masks. R14 walked by LPN-F wearing a surgical mask below her nose, LPN-F directed her to adjust her mask up due to R14 pulling it down, R14 complied while walking down the hallway back towards her room. - at 11:29 a.m., R11 remained sleeping in the dining room and several residents continued to participate in activities while two staff members were present. No staff were observed to redirect R11 back to his room even though he was COVID 19 positive. - at 11:34 a.m., LPN-A was observed wearing a N95 mask with a surgical mask donned over the N95 mask and had eye protection on. LPN-A proceeded to donn a gown, gloves prior to entering R6 and R22's room with medications. R6 who had tested positive for COVID-19 on 1/12/22, and R22 who had tested positive for COVID-19 on 1/19/22, had a sign present on their doorway which indicated R6 and R22 were in droplet isolation precautions. - at 11:47 a.m., LPN-A exited R6's and R22's room, had removed her gown and gloves and continued to wear her surgical mask over her N95 mask with her eye protection in place. LPN-A entered the bathroom down the hallway, removed her surgical mask and was not observed to removed her N95 mask. LPN-A walked over to her medication cart wearing the same N95 mask, when R7 who was negative for COVID-19 wheeled up to her in his wheel chair and requested a glass of water. LPN-A handed R7 a glass of water and R7 proceeded to pull down his mask and drank the water. LPN-A continued to wear the same N95 mask while she was working COVID-19 positive residents. - at 12:00 p.m., LPN-A continued to stand by her medication cart reviewing the computer, when R8 who was negative for COVID-19 approached her and began to visit with her. LPN-A continued to wear the same N95 mask. - at 12:04 p.m., R9 who was negative for COVID-19 wheeled out of his room up to LPN-A's medication cart and requested a pain pill. LPN-A dispensed pain medication, handed R9 the medication and he took it independently with water. LPN-A continued to wear the same N95 mask. - at 12:12 p.m., LPN-A delivered meals to R9's and R10's room who was negative for COVID-19, while continuing to wear the same N95 mask. - at 12:14 p.m., LPN-A set up medications at her cart, walked down the hallway and entered R26's and R27's room with medications in hand, who were known to be negative for COVID-19. LPN-A continued to wear the same N95 mask. -at 12:16 p.m., NA-E had a face shield on, N95 mask and donned a surgical mask over his N95 mask. NA-E proceeded to donn a disposable gown, gloves, while registered nurse (RN)-A had eye protection on, a N95 mask on and surgical mask over her N95 mask and began to donn a disposable gown and gloves. R11, who had tested positive for COVID-19 on 1/19/22, and R12 who was negative for COVID-19 had a sign present on their doorway which indicated R11 and R12 were in droplet isolation precautions. NA-E entered the room with a food tray, delivered it to R12 and the DON handed NA-E another room tray to R11. NA-E removed his gown, gloves, sanitized his hands, removed surgical mask, sanitized his hands and exited the room and continued to have the same N95 mask on and face shield. - at 12:21 p.m., R14 who had tested positive for COVID-19 on 1/15/22, and R24 who had tested positive for COVID-19 on 1/15/22, had a sign present on their doorway which indicated R14 and R24 were in droplet isolation precautions. RN-A entered R14's and R24's room with a room tray, delivered it and the DON handed RN-A another room tray and she delivered it. NA-E donned a surgical mask over the same N95 mask, a disposable gown, gloves and entered R17's room who had tested positive for COVID-19 on 1/19/22, and R2's room who was negative for COVID-19 while carrying a room tray. NA-E delivered the tray to R17 and the DON handed another room tray for R2. NA-E set the room tray on R2's bed side table and closed the door. - at 12:26 p.m. NA-E exited R17's and R2's room wearing the same N95 mask, walked down the hallway to the bathroom next to the nurse station and washed his hands. NA-E donned a surgical mask over his N95 mask, donned a disposable gown, gloves and walked down the hallway to assist other staff to deliver more room trays to COVID-19 residents. - at 2:05 p.m., contracted agency staff (CAS)-A was in the hallway with a supply cart, completing COVID-19 testing for residents. CAS-A was wearing a disposable gown, gloves, eye protection and a N95 mask over a surgical mask. R11 who had tested positive for COVID-19 on 1/19/22, wheeled himself out of his room into the hallway. CAS-A performed a nasal swab COVID-19 test on R11 while in the hallway. There were no other residents or staff in the vicinity. CAS-A removed her gloves, filled out the paperwork, used a wipe to sanitize her hands and applied a new pair of gloves. CAS-A entered R11's room, asked R11's roommate R12 to complete a COVID-19 test and R12 refused. CAS-A did not remove her gown and N95 after completing COVID-19 testing on R11, who was known to be positive for COVID-19, prior to attempting the test on R12 who was COVID-19 negative. CAS-A indicated she completed testing for the facility two times a week for residents and staff. - at 2:52 p.m., CAS-A was observed while wearing a disposable gown, gloves, a N95 mask over her surgical surgical mask and had eye protection, to enter R16's room, CAS-A was wearing the same PPE she wore while testing R11. CAS-A attempted to swab R16, and she refused who was negative for COVID-19. CAS-A stated she had been fit tested years ago for proper N95 mask use, however had not been recently. CAS-A said she had entered the facility with the surgical mask and just placed her N95 mask over it. CAS-A confirmed she mistakenly tested R11, who was known to be COVID-19 positive, and stated she should have changed her PPE after testing R11. CAS-A verified she continued to test other residents while wearing the same gown, surgical mask and N95 mask. CAS-A indicated she had not received any training on infection control practices and was not fit tested for her N95 mask. CAS-A verified other residents were at risk of transmitting the virus to non COVID-19 patients when proper infection control measures were not followed. On 1/21/22, at 7:39 a.m., R11 tested positive for COVID-19 on 1/19/22, R12 and R15's were negative for COVID-19 shared bathroom was observed. After the toilet was heard being flushed, R11 was observed to be pulling up his incontinent brief from around his thighs. - at 8:03 a.m., R11 exited his room independently in his wheelchair, DON attempted to redirect R11 back to his room and he refused. DON assisted R11 by placing a mask on his face and walked away. R11 pulled his surgical mask down below his chin and wheeled passed LPN-A and RN-B towards the dining room area and they did not redirect R11 back to his room. R11 wheeled himself further down the hallway and while passing RN-A who did not redirect him back to his room however, did ask him to readjust his mask up and R11 complied. - at 8:10 a.m. R11 entered the dining room where several other residents were seated and DON directed R11 to go to the other side of the dining room. - at 8:12 a.m. R11's mask was again noted to be positioned below his nose and noted only over his mouth, and DON asked R11 to readjust his mask however did not attempt to redirect him back to his room. RN-A brought R11 a cup of coffee to drink, while other residents remained in the dining room area. RN-A did not attempt to redirect R11 back to his room. - at 8:18 a.m. R15 who was negative for COVID-19 without a facemask on, walked independently out of his room and down the entire length of the hallway passing by several staff who did not re-direct him to put a facemask on or return to his room. R15 entered the dining room area where the DON asked R15 to eat in his room. R15 refused and proceeded to sit down in a chair in the dining room area and drank coffee while R11 was eating his breakfast. Regional nurse consultant (RNC) asked R15 to wear a mask and R15 refused saying I never wore a mask in my life. - at 8:24 a.m. R15 continued to sit in the dining room area while drinking his coffee approximately 20 feet from R11 as he continued to eat his breakfast independently. - at 8:25 a.m. R15 stood up from his chair in the dining room, walked independently down the hallway to the nurses station where RN-A asked R15 to go back to his room and R15 complied. R11 continued to eat independently in the dining room area. - at 8:43 a.m., R15 with no facemask on walked independently to the dining room area and sat down in a chair, while R11 continued to be in the dining room area with his mask positioned below his chin. RNC asked R15 to put a mask on and he refused. - at 8:48 a.m. RNC asked R11 to adjust his mask up, he complied and she wheeled him out of the dining room area back to his room. - at 9:28 a.m. the shared bathroom for R11, R12 and R15 was not observed to had been cleaned by nursing staff or housekeeping staff after R11 used it earlier. On 1/20/22, at 1:57 p.m. LPN-F indicated staff were expected to wear full PPE and N95 masks when entering a COVID-19 positive room. LPN-F stated staff were expected to remove PPE when exiting the room including the N95 mask. LPN-F indicated staff were expected to sanitize their hands and place a new surgical mask on after having contact with COVID-19 positive residents. LPN-F indicated she had never been fit tested for her N95 mask and confirmed she was not wearing her N95 mask correctly LPN-F stated she only wore a surgical mask over her N95 mask to provide extra protection from COVID-19. On 1/20/22, at 2:11 p.m. LPN-A indicated when staff entered a COVID-19 positive room, they were expected to wear a gown, goggles, gloves and a N95 mask. LPN-A confirmed her usual practice was to keep the same N95 mask on during the shift and confirmed she had not removed the N95 mask she wore in R6's and R22's positive COVID-19 room. LPN-A indicated sometimes she wore a surgical mask over her N95 mask for extra protection. LPN-A stated she had not been trained to change her N95 mask with every COVID-19 resident and indicated by not changing it the possibility existed of transmitting COVID-19 to other residents. LPN-A indicated she had not been fit tested for her N95 mask either. On 1/21/22, at 9:14 a.m. NA-A verified R11 was positive for COVID-19 and was independent with his activities of daily living (ADL's) which included using the bathroom. NA-A indicated R12 was not positive for COVID-19 and the facility had tried to move R12, however he refused. NA- A stated R12 was independent with ADL's and used the bathroom independently. NA-A indicated R15 was independent with ADL's and used the bathroom independently. NA-A stated the usual practice was for staff to clean a shared bathroom after each resident use for COVID-19 positive residents. NA-A indicated he had cleaned R11, R12's and R15's bathroom earlier that morning before 7:00 a.m. and verified R11 had used the bathroom after that. NA-A confirmed he had not cleaned it since due to being busy on the floor. R12 was aware of the risk and benefits which was discussed with his family. On 1/20/22, at 9:18 a.m., nursing assistant (NA)-D was observed to have eye protection and a surgical mask on which covered his nose and mouth area. NA-D donned gloves, hairnet and proceeded to enter R4's room who had tested positive for COVID-19 on 1/15/22, to empty R4's commode. NA- D was not observed wearing a gown or an N95 mask when entering R4's room. After a few minutes NA-D exited R4's room wearing his eye protection and surgical mask, discarded a bag of garbage in the soiled utility room and sanitized his hands. NA- D while wearing the same surgical mask, walked into R5's who was COVID-19 negative to check on the him and then immediately exited the room. NA-D walked down the hallway to R28 and R29's room, who were COVID-19 negative, entered the room to check on them and immediately exited the room. NA-D was not observed to change his surgical mask after exiting R4's COVID-19 positive room. -at 10:57 a.m., NA-C wore eye protection, a surgical mask which covered her nose and mouth area and a hairnet on her head. NA-C proceeded to donn a disposable gown and entered R19's room, who tested positive for COVID-19 on 1/19/22. NA-C began making R19's bed when R20 walked out of the bathroom and sat down on his bed. NA-C removed her gown, washed her hands and immediately walked out of R19's room. NA-C was not observed to wear gloves or a N95 mask and had not removed her surgical mask after exiting R19's room. - at 11:51 a.m., administrator-B was observed wearing a gown, gloves. eye protection, a N95 mask over her surgical mask and a face shield. Administrator-B proceeded to enter R13's room, who had tested positive for COVID-19 on 1/12/22, and delivered a meal tray. Administrator-B proceeded to remove her gown, gloves and sanitized her hands while leaving R13's room. Administrator-B wore her N95 mask on her chin and her surgical mask was covering her nose and mouth area. Administrator- B walked into the bathroom down the hall, removed her N95 mask and surgical mask, and sanitized her hands. Administrator-B applied a clean surgical mask and stated she should have been wearing her surgical mask over her N95 mask when going into a COVID-19 positive room. -at at 2:55 p.m , hospice registered nurse (HRN)-A walked out of R6's room wearing eye protection, a N95 mask and sanitized her hands. R6 had tested positive for COVID-19 on 1/12/22. HRN-A proceeded to apply a face shield and sat down behind the nurses desk. At 3:13 p.m., HRN-A continued to be seated behind the nurses desk wearing the same N95 mask. HRN-A stated she was taught through the Hospice agency to apply a surgical mask over her N95 mask and when leaving a resident's room to only remove the surgical mask and to keep the N95 mask on. On 1/21/22, at 7:58 a.m., R14 who tested positive for COVID-19 on 1/15/22, was observed exiting her room while wearing a surgical mask covering her mouth and exposing her nose. R14 walked down the hallway past registered nurse (RN)-A and RN-B who had not redirected R14 to adjust her mask or return to her room. R14 continued to walk down the hallway, entered the dining room area where other COVID negative residents were present and sat down in a chair. -at 8:03 a.m., R14 stood up, walked down the hallway past RN-A who instructed her to adjust her mask and R14 did not comply. RN-A was not observed to redirect R14 back to her room and R14 continued to walk independently down the hallway with her surgical mask placed below her nose and not covering her mouth. -at 8:06 a.m., R14 returned into the hallway with her mask remaining below her nose and only covering her mouth area. R14 walked to the dining room past RN-B who was not observed to redirect her back to her room or remind her to adjust her mask. R14 sat down in a chair in the middle of the dining room area with multiple residents seated around her. RN-A entered the dining room and began to handout surgical mask to the other residents in the dining room. -at 8:12 a.m., R14 stood up, walked down the hallway with her surgical mask positioned below her nose. R14 walked past the DON who asked to R14 to adjust her mask. R14 did not comply and was not asked or redirected back to her room. -at-9:36 a.m., R14 exited her room wearing a surgical mask in the same position, walked down the hallway past RN -B who asked her to adjust her mask and she refused. RN-B was not observed to redirect R14 back to her room. R14 continued to walk further down the hallway into the dining room area and sat down. R14's mask continued to be positioned below her chin exposing her nose and mouth. LPN A approached R14 and talked to her however was not observed to redirect R14 back to her room or to re-position her mask. - at-9:51 a.m., R14 continued to be seated in the dining room area with her mask positioned below her chin seated next to R15. R14 stood up, walked over to the smoking room area, when LPN-A approached R14 however was not observed to redirect R14 back to her room or ask her to re-position her mask. -at 10:01 a.m , R11's (who tested positive for COVID-19 on 1/19/22), shared bathroom call light was noted to be on. The toilet was heard flushing and R11 was observed coming out of his bathroom in his wheelchair. RN- B walked up to R11's doorway, stood in the hallway and asked R11 if he needed anything. R11 shook his head no and RN- B instructed R11 to turn off his bathroom call light. R11 proceeded to wheel himself into the bathroom and shut off the bathroom call light. RN -B was not observed to clean or disinfect the bathroom after R11 was done using it. -at 10:33 a.m., R11's bathroom call light was on and the toilet was heard to be flushing. NA-A was observed to be wearing eye protection, donning a gown, gloves and a N95 mask. NA-A entered R11's room, asked R11 if he had used the bathroom and R11 responded to NA-A by shaking his head up and down indicating he had used the shared bathroom. NA-A proceeded to remove his gown, gloves in the room and sanitized his hands while exiting the room. NA-A walked out into the hallway, removed his N95 mask, threw it away and sanitized his hands. NA- A was not observed cleaning or disinfecting the shared bathroom after R11 used it. - at 10:44 a.m., R15 was observed going into his room to use the bathroom. OTA-A entered R15's room, verified R15 was using the bathroom and the toilet was heard to be flushing. No nursing staff or housekeeping staff were observed cleaning or disinfecting the bathroom before or after R15 had used it. On 1/20/22, at 9:25 a.m. NA-D confirmed he had not worn a gown or a N95 when entering R4's room as he was only emptying his commode. NA-D indicated he should have worn a gown and N95 before entering R4's room however did not do so since he had not completed direct cares with R4. On 1/20/22, at 11:06 a.m. NA-C verified R19 was positive for COVID-19 and her usual practice was to wear full PPE which included: a N95 mask, gown, gloves and eye protection. NA-C indicated she only wore her N95 mask and gloves when doing direct cares with a resident known to be positive with COVID-19. NA-C confirmed she did not have a N95 mask and gloves on before she entered R19's room. 1/20/22 at 12:00 p.m., administrator-B confirmed R13 was positive for COVID-19-19 and indicated when entering a positive COVID-19 room staff were expected to wear a gown, gloves, eyewear and a surgical mask covering the N95 mask. Administrator-B indicated her usual practice was if she pulled her surgical mask down three times then she needed to change it. Administrator-B confirmed she had worn her N95 mask over her surgical mask when she entered R13's room and verified she was wearing her N95 mask incorrectly. 1/20/22 at 1:54 p.m NA-E indicated when a resident was positive for COVID-19 staff were expected to place a sign on the door and were to encourage the resident to remain in their room. NA-E indicated residents did not always listen to staff and continued to come out of their rooms when they have COVID-19. NA-E stated staff should have been wearing a gown, a N95 mask, face shield, and gloves before entering a COVID-19 room and before exiting the room they should have removed their gown and gloves and sanitized their hands. NA-E indicated nursing staff received education weekly on COVID-19 by text messages from the administration. 1/20/22 at 2:07 p.m RN-A confirmed R14 was positive for COVID-19 and indicated when a resident tested positive for COVID-19 staff were expected to place a sign on the door and isolate them to their room. RN-A stated staff should have been wearing a gown, gloves and a N95 mask before entering a COVID-19 room and staff should have removed the gown and sanitized hands before exiting the room. RN-A indicated staff were expected to remove their N95 mask in the hallway, sanitize their hands and place a clean surgical mask on. RN-A stated staff should have encouraged all residents that are positive with COVID-19 to remain in their rooms and staff should have been redirecting them back to their rooms if they are coming out of their rooms. RN-A confirmed she had not redirected R14 back to her room when she came out into the hallway. R4 On 1/20/22, at 8:33 a.m. nursing assistant (NA)-C who was only wearing a surgical mask and eye protection came out of R4's (who had tested positive for COVID-19 on 1/15/22) room while carrying a meal tray and put in on the serving cart. R4's door had a sign on his door which identified R4 was in droplet isolation precautions. NA-C verified she did not wear PPE when picking up the meal trays and only wore PPE while providing direct cares to residents who had COVID-19. NA-C verified she was not wearing a N95 mask, a gown and gloves while picking up meal trays. R11 On 1/20/22, at 8:47 a.m. facility scheduler (FS)-A who wore a surgical mask and eye goggles left R11's (who had tested positive for COVID-19 on 1/19/22) room carrying a meal tray to serving cart, then walked down the hallway. FS-A was noted to not have a gown or gloves on. R11's door had a sign present on his door which indicated R11 was in droplet isolation precautions. R17 On 1/21/22, at 7:57 a.m. NA-A was observed in the shared bathroom of R2, R25, and R17 (who tested positive for COVID-19 on 1/19/22) and filled a basin with water. R2 (who was COVID-19 negative) was seated on the edge of his bed by the door and a curtain divided the two residents. NA-A proceeded to provide morning cares for R17, while he sat on the edge of his bed. After NA-A was done completing morning cares for R17, NA-A went to the shared bathroom, emptied the basin water into the toilet, turned on the water faucet, rinsed the basin, emptied it again and filled the basin with soap and water. NA-A proceeded to assist R17 to complete the rest of his morning cares. At 8:14 a.m. NA-A again returned to the shared bathroom, emptied the basin, turned on the faucets, rinsed the basin and emptied the water into the toilet. At 8:15 a.m. while NA-A was still in the bathroom, R25 (who was COVID-19 negative) opened the door from the adjoining room and informed NA-A he needed to use the bathroom. NA-A left the shared bathroom into R17's room without cleaning or disinfecting the bathroom before R25 used the bathroom. 1/20/22, at 11:10 a.m. during a follow up interview with NA-C stated she had sanitized her hands after she picked up breakfast trays that morning. NA-C indicated she wore eye protection and a surgical mask for source control, and wore other PPE when providing cares in rooms of residents who had COVID-19. NA-C indicated she had not worn N95 masks, gowns or gloves when picking up trays from COVID positive residents that morning. On 1/20/22, at 11:56 a.m. NA-D indicated he had assisted R4 by emptying his commode earlier and was not able to remember if he had applied a gown prior to entering R4's room. NA-D stated his usual practice was to apply full PPE, including gown, gloves, N95 mask and eye protection when entering any COVID-19 positive residents' rooms and to dispose of his N95 when he exited the room. On 1/21/22, at 8:24 a.m. NA-A indicated R17 did not use the bathroom, however R2 and R25 used the bathroom independently. NA-A confirmed R25 had used the bathroom right after he had emptied R17's basin and verified he had not disinfected the bathroom prior to R25 using it. NA-A stated at times R17 would leave his room at times to go out to smoke. NA-A indicated it was difficult to redirect residents to their rooms who were positive with COVID-19 and to remind them to wear their masks. On 1/20/22, at 2:53 p.m. director of nursing (DON) indicated infection preventionist (IP)-A currently had COVID-19 and DON was responsible for the infection prevention program while IP-A was out of the facility. The DON stated the last time the facility had completed fit testing for N95 masks was last year, and confirmed not all staff had been fit tested at that time. DON verified she expected staff to wear full PPE (gown, gloves, eye protection) for any reason when entering a resident's room who was known to be positive with COVID-19, which included wearing a N95 mask and to remove the N95 when leaving the room. The DON indicated this was important to prevent the spread of COVID-19 to other residents. The DON stated the facility isolated residents who were COVID-19 positive for 14 days. The DON verified staff were allowed to wear a surgical mask over their N95 mask, if they were going from one resident COVID-19 room to another resident's room who had COVID-19. The DON indicated the staff were expected to remove the surgical mask covering their N95 mask before entering a different resident's room who was positive for COVID-19 to save time. The DON stated staff were expected to remove their N95 mask and dispose of it after leaving a COVID-19 room. The D [TRUNCATED]

Based on interview and document review, the facility failed to ensure the safety interventions for elopement were implemented for 1 of 3 residents (R1) reviewed for elopement. This failure resulted in an immediate jeopardy (IJ) when R1 followed an outside provider from the secured unit down an elevator and eloped out the front door. The facility had implemented corrective action so the deficient practice is being issued at past non-compliance. The IJ began on 6/4/21, at 5:45 p.m. when R1 left the facility after following an outside provider from the secured unit down the elevator and out the front door of the building. The administrator and director of nursing (DON) were notified of the IJ on 6/10/21, at 12:30 p.m. The facility implemented immediate corrective action on 6/9/21, prior to the start of the survey and was issued as past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], included cognitively intact with a diagnosis of traumatic subdural hemorrhage (bleeding between the brain and its covering) and was independent with activities of daily living (ADLs). R1's elopement risk evaluation with an effective date of 5/17/21, identified, R1 voiced intentions for elopement and appeared to be at risk for elopement and was placed on the secured unit. R1's care plan dated 6/7/21, identified, Resident is at risk for elopement due to cognitive impairment and discontentment with placement. R1's goal was, Resident will not leave the building alone. Interventions included, Staff will be aware of residents whereabouts in the building, door alarms will be answered promptly, in the event of a hospitalization facility will send a disclaimer card along with paperwork to inform hospital of elopement risk and decision maker status, elopement assessment completed per facility protocol, follow facility elopement protocol, notify administrator and police department for missing person as indicated, and notify family and responsible parties. R1's incident review and analysis dated 6/5/21, at 9:27 a.m. included, Resident was last seen around 1700 [5:00 p.m.] using the phone at the nurses' station, then went missing since. Writer noticed resident was not in the area around 1745 [5:45 p.m.] and called an all staff search throughout the building, but the resident was nowhere to be found. Per staff report, resident went in his wheelchair in front of an outside provider in the elevator downstairs around 1730. Social service designee was notified by floor staff around 6:00 p.m. the resident had left the building via the elevator when an outside provider left the building. Further included, Staff searched thoroughly and could not locate resident. Writer called 911 and reported around 1800 [6:00 p.m.]. The officer arrived and got information from the writer, which included information of what the resident looked like and a facesheet. The guardian, administrator, DON, medical director, and social service notified. A missing persons report was filed with the police. Additionally included, Resident had expressed his past desire to discharge from the facility. Resident has a history of homelessness and so resident does have street smarts in regard to safety in the community. R1's progress note dated 6/4/21, at 6:49 p.m. included, R1 was last seen around 5:00 p.m. around the nurses' station using the phone and then went missing. When interviewed on 6/10/21, at 11:02 a.m. nursing assistant (NA)-A stated, she had seen R1 go out the door with a lady and had reported this to the nurse. NA-A had found out later that R1 was missing. When interviewed on 6/10/21, at 11:40 a.m. licensed practical nurse (LPN)-A stated, I saw the resident in his wheelchair follow a lady out the door but I didn't know either of them. I just thought they were visiting. The elopement guideline dated 11/2017, included, The facility will identify such environmental hazards such as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior. Further included, The facility will implement interventions to minimize these risks and hazards as appropriate. The past noncompliance immediate jeopardy began on 6/4/21. The immediate jeopardy was removed, and the deficient practice corrected by 6/9/21, after the facility implemented a systemic plan that included the following actions: On 6/4/21, at 6:00 p.m. the nurse on duty called 911 and reported R1 missing. On 6/4/21 an audit of residents at risk for elopement was completed and care plans updated accordingly by the DON. A Visitors For Secure Unit All Staff Education sign in sheet identified, on 6/4/21 through 6/9/21 all facility staff, outside providers, and hospice agencies were educated on the elopement guideline dated 11/2017. All staff were educated on all guests, visitors, hospice agencies, etc. will be escorted up to second floor and will always be escorted back down to first floor by a staff member. All staff were educated on at no point will a guest go up to the secured unit by themselves to ensure that residents that aren't supposed to leave the secured unit, do not leave the secured unit. A report entitled The Estates at Lynnhurst, Ad hoc, dated 6/7/21, identified the administrator, DON, registered nurse manager, social service director (SSD), social service worker, assistant director of nursing (ADON), and the health information/admissions director performed an adhoc Quality Assessment and Performance Improvement (QAPI) meeting to discuss root cause analysis and the plan of correction. During observation of the doors and inside the elevator on 6/10/21, at 10:20 a.m. signs were posted stating, VISITORS, GUESTS AND PROVIDERS PLEASE READ: Effective 6/4/21 all guests, visitors and providers must be escorted on and off second floor. Please ask a staff member to bring you upstairs, and when you are ready to leave please ask a staff member to bring you back down. This is for the safety of all of our residents. LPN-B, LPN-C, NA-A, NA-B, HSKP-A, and ADON were interviewed on 6/10/21, between 10:00 a.m. and 11:08 a.m. and stated they had received education on the elopement guideline, not allowing visitors or any outside providers in the elevator to the secured unit without a staff escort, and the elopement binders. In addition, elopement binders were available to determine which residents are at risk for elopement in which they could reference.

Based on observation, interview and document review, the facility failed to comprehensively reassess and implement interventions to promote the healing of current pressure ulcers, and prevent new pressure ulcers from developing for 2 of 2 residents (R27and R32) reviewed for pressure ulcers. This resulted in actual harm for R27 who was not repositioned per protocol and developed a new pressure ulcer. Findings include: R27 was not repositioned on 7/11/18, for three hours and twenty-four minutes (3 hrs 24 min). When repositioned, it was observed R27 had acquired a new Stage 2 open area (Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow opening). The ulcer was recorded as measuring 1.7 centimeter (cm) length by 0.5 cm width to the right of the coccyx. Review of R27's progress notes indicated the resident had previously had an open area identified 6/28/18. A progress note documented by licensed practical nurse (LPN)-C, dated 6/28/18 at 10:34 a.m. included: NA (nursing assistant) reported res (resident) has an open area between buttocks' crease measuring 2.0 x 0.5 cm. Area cleaned and a dry dressing applied. Left message for NP (nurse practitioner) waiting on call back. When interviewed on 7/12/18, at 2:30 p.m. LPN-C verified there had been an open area to R27's buttock crease at the end of June. LPN-C verified that area was not the same as the new open area discovered 7/11/18, at 10:14 a.m. to the right of R27's coccyx. LPN-C stated registered nurse (RN)-K had observed the open area to R27's buttock crease on 6/28/18. LPN-C stated RN-K could confirm the open area in (MONTH) was in the crease of the buttock and not on the coccyx. RN-K was interviewed by phone on 7/12/18, at 2:35 p.m RN-K verified R27 had an open area to the buttock crease on 6/28/18. Document review of the form titled, Reporting Reminders, dated 6/28/18 included: open area on buttock crease 2.0 x 0.5 cm (centimeter). Furthermore the report sheet indicated LPN-C was the day shift nurse and RN-C was the relieving evening shift nurse. RN-C was interviewed by phone on 7/13/18, at 2:42 p.m. RN-C could not recall receiving information in report regarding the open area to the buttock crease for R27 on 6/28/18. RN-C could verify the physician had not returned a phone call regardinng the area, and stated information pertaining to an open area on the buttock crease for R28 was not passed on to the night shift through report. Continuous observations were made of R27 on 7/11/18, from 6:50 a.m. until 10:14 a.m. and R27 was not offered any position change or assistance with any other care. At 6:50 a.m. R27 was lying in bed positioned on her back with the head of the bed elevated twenty degrees. At 8:42 a.m. NA-A brought R27 a breakfast tray. At 8:50 a.m. RN-B elevated the head of R27's bed to approximately thirty degrees in order to feed R27. At 9:12 a.m. RN-B adjusted the bed to lower the head of the bed to about twenty degrees. R27 was not offered any position change or other cares during the observation. At 10:03 a.m. the surveyor asked LPN-A, who was responsible for R27's care, if there were any treatments for R27 that neeed to be completed. LPN-A went to the nursing desk to check. At 10:05 a.m. LPN-A returned to the room with NA-A to perform care. At 10:14 a.m., R27 was turned to the left side to remove an incontinence brief and to visualize the buttocks and posterior thighs. There were multiple red creases and wrinkling of the skin to the buttocks and posterior thigh areas observed. Furthermore, there was an open area to the right of the coccyx measuring approximately 1.7 cm in length by 0.5 cm size in width. When interviewed on 7/11/18, at 10:20 a.m. LPN-A confirmed not having been aware of any current open areas. LPN-A also stated the new open area looked like a Stage 2 pressure area to the right of the coccyx. There were no open areas visualized to the crease of the buttocks at that time. When interviewed on 7/11/18, at 10:30 a.m. NA-A stated she was not aware of when the night shift staff had last completed repositioning for R27. NA-A stated R27 had not had any repositioning since NA-A had come on duty at 7:00 a.m. NA-A also aknowledged not being aware of any open areas to R27's buttocks or coccyx. Furthermore, NA-A verified R27 required assistance with position changes every two hours according to the nursing assistant assignment sheet. R27's Resident Face Sheet, indicated her [DIAGNOSES REDACTED]. A facility form titled, Brief Interview for Mental Status (BIMS) revealed R27 had moderately impaired cognition. A Skin Assessment, Skin Risk and Braden dated 5/22/18, indicated R27 was at moderate risk to develop pressure ulcers: Resident is at risk for pressure ulcers and tissue breakdown r/t (related to) diabetes, intellectual disabilities, and incontinence. Nurses to monitor blood glucose and inspect skin weekly. Staff are to anticipate needs and provide brief changes and repositioning q2h (every 2 hours). R27's record lacked any evidence of weekly skin checks and lacked any bath or body audits. When interviewed on 7/12/18, at 1:52 p.m. the director of nursing (DON) verified there was no follow up to the 6/28/18, documented progress note indicating R27 had an open area to the crease of the buttocks. The DON stated, The staff should have charted whether the area healed or resolved. Furthermore, the DON verified the nursing staff should have attempted to contact the physician again when the physician did not respond to the call made on 6/28/18, at 10:34 a.m. The DON verified the facility did not have a good system for documentation and follow through with skin checks, but stated the facility was in the process of implementing weekly skin checks on all residents. Furthermore, the DON verified R27 had a new open area that was assessed as a Stage 2 pressure area to the right of the coccyx. Document review of the nurse practitioner (NP) notes verified the last medical provider visit had been made on 6/19/18, and there were no new physician orders [REDACTED]. Facility policies for Wound Documentation, Off-loading, Positioning, Care Planning, Weekly skin checks, and Notificaiton of the Physician were requested, but none were provided. When interviewed on 7/12/18, at 1:52 p.m. the DON verified there were no specific policies, but stated the facility expectation was staff would provide care per care plan and assessment, in accordance with Federal and State regulations. R27's care plan dated 7/11/18, indicated R27 had Risk for skin breakdown related to impaired mobility. Open area to coccyx. Date initiated: 7/11/18. A Care Area Assessment (CAA) dated 9/20/17, triggered pressure ulcer and included: CAA triggered related to resident's need for extensive assistance with bed mobility, incontinence of bowel and bladder, being at risk for alterations in skin integrity, suspected deep tissue injury, and a stage 1 pressure area. Pressure areas were noted on admission. She is at risk for further alterations in skin integrity, rashes, and infection. No referral needed at this time. When interviewed on 7/12/18, at 2:50 p.m. the DON verified the facility expectation would be to evaluate the wounds weekly ensuring the physician was well informed and to follow the interventions for repositioning. The DON confirmed R27 should have been repositioned at least every two hours. R32's skin was not assessed per facilty policy, and R32 developed a pressure ulcer. On 7/10/18, at 9:43 a.m., R32 was observed to be seated in a wheelchair. R32 stated she had a wound from the wheelchair rubbing the side of her left leg. R32 also stated staff had removed the left side piece from the wheelchair to prevent it from rubbing again. F32's face sheet undated, identified [DIAGNOSES REDACTED]. R32's Minimum Data Set (MDS) assessment dated [DATE], indicated R32 required extensive two person assistance with bed mobility, dressing, and toileting, and extensive one person assistance with locomotion on and off the unit with two person total assistance with transfers. The MDS further indicated R32 had an unstageable pressure ulcer. R32's care plan indicated potential for impaired skin integrity, and identified risk factors for pressure ulcers including: extensive assist with bed mobility, incontinence of bowel and bladder, dependence on staff for changing and pericare, Braden score of 13, and an unstageable pressure ulcer to left outer thigh. The care plan goal was for the pressure ulcer to heal without complication. Care plan interventions included: extra protein for wound healing, wound vac placed 6/25, and to change treatment per MD orders. R32's orders included house supplement in the evening for wound healing, provide house supplement QD for wound healing. During an interview on 7/12/18, at 9:40 a.m. LPN-D stated R32 had no feeling on the left side, which was where the wheelchair was rubbing on the resident's left leg. LPN-D stated that's why R32 had not known there was a wound. LPN-D further stated skin assessments should be done weekly for R32 with her bath. During an interview on 7/12/18, at 11:59 a.m. the director of nursing (DON) verified skin inspections should be completed weekly, but verified they were not being completed. The DON said an order was entered, so they would now be done. The (MONTH) treatment administration record (TAR) indicated weekly skin evaluations were to be completed. The TAR skin evaluations were checked as having been completed 5/5/18, 5/12/18 and 5/19/18. Review of a skin assessment dated [DATE], indicated R32's skin was intact. A skin assessment dated [DATE], indicated a wound had been identified 5/21/18. Although the (MONTH) TAR had been checked to indicate assessments had been completed, no skin evaluations were documented for 5/5, 5/12 or 5/19/18. The skin assessment documentation for 5/24/18 indicated R32 had a wound measuring 5 cm length, 3.5 cm width, which was unstageable with 25% granulation, 0% slough, 75% eschar (an unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed). Wound documentation for 5/31, 6/6, 6/14, 6/21, 6/28 and 7/5/18, indicated R32's wound continued to be unstageable. The facility wound process checklist dated 9/2011 indicated: start weekly wound documentation form (pressure only). In addition, the facility's weekly charting/wound ulcer documentation protocol dated 9/2011 included: Once charted on weekly Wound/Skin Data Sheet, nurse's notes should reflect the progress of the wound and any changes in plan of care . Always measure length, width, and depth and document it in that order . Describe the wound bed appearance. If the wound base has a mixture of these, use the percentage of its extent (i.e., the wound base is 75% granulation tissue with 25% slough tissue.