Every finding on record at The Legacy Living and Rehabilitation Center

Based on medical record review and staff interview, the facility failed to ensure transfer and/or discharge notices included the reason for transfer or discharge for 4 of 5 sample residents (#1, #3, #77, #79) reviewed for transfer and discharge. The findings were: 1. Review of a progress note for resident #79 dated [DATE] and timed 2:19 PM showed .This nurse was notified of resident unwitnessed fall. Upon assessment, resident was found to be A&Ox1 [alert and oriented times 1] and slightly decreased LOC [level of consciousness], noted by increased response times. Resident was found to have an abnormal pulse on left wrist and clammy skin. Resident was incontinent at the time of fall, per staff report. Provider on call aware of clinical findings and transfer to ER [emergency room] obtained . The following concerns were identified: a. Review of a Notice of Transfer dated [DATE] showed the resident was provided a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility currently and their welfare is impacted. b. Review of a progress note dated [DATE] and timed 2:20 PM showed spoke with [name], POA regarding resident status. Resident has been out of facility greater than 30 days and is no longer on bed hold for facility. Discussed concerns with previous balance and Medicaid pending status. Resident has not been approved for Medicaid coverage for 2025. Being out over 30 days requires new admission per regulations. Legacy is not currently taking admissions. [POA name] requests to return call to Legacy to further conversation with Medicaid needs. c. Review of a progress note dated [DATE] and timed 2:46 PM showed Spoke with [name], VP care manager at [hospital name] regarding resident discharge from facility. Explained that resident received transfer notice [DATE] with bed-hold notice and appeal rights. Resident remained continuously inpatient beyond 30 days (current 60 days). Bed-hold has expired; resident has lost return rights. Facility is currently closed to admissions; readmission to facility declined at this time as resident is a new admission. d. Review of the medical record showed no evidence the resident was issued a discharge notice following the acute care transfer on [DATE]. e. Interview with the facility administrator on [DATE] at 2:27 PM confirmed the facility did not issue a discharge notice at anytime during the hospital stay. 2. Review of a progress note for resident #77 dated [DATE] and timed 2:21 AM showed Around 0100 [1 AM], resident pushed [his/her] call light and had [his/her] oxygen off. O2 sat [saturation] at 69% and slowly went up to 77%. Resident given a drink and started coughing. O2 sat was 77% pm 2 L, O2 increased to 4L and O2 sat rechecked and was 69% At 0117, received order from [nurse practitioner] to get permission from family to send to ER and she stated if unable to get a hold of family, we could still send to the ER. Call placed to [resident representative] at 0120 [1:20 AM]. [Resident representative] did not answer the phone. Left message that we would be sending resident to the ER if we did not hear otherwise from him. 0124 [1:24 AM], Call placed to 911. 0140 [1:40 AM], ambulance arrived at the facility. Resident's O2 did come up to 93 on 4 L but then went back down to 88 on 2 L. 0153 [1:53 AM], reports given to [name] RN ER nurse. Building charge nurse, [name] notified that resident went to the ER. No call received from resident's [representative] as of this time. The following concerns were identified: a. Review of a Notice of Transfer dated [DATE] showed the resident was provided a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility currently and their welfare is impacted. 3. Review of a progress note for resident #1 dated [DATE] and timed 9:01 PM showed Resident had had several episodes of emesis during the evening med pass, day shift reported to cna's [sic] that the resident had not eaten very much all day. Called to residents [sic] room as he/she had a third episode of emesis. Took resident's vitals: BP 147/74, P124, T100, RR 68, O2 was 77% on 2 and 4 liters of oxygen, resident denies any pain. Assessed resident as I suspected he/she may have aspirated, crackles to right lower lung. Building charge also assessed resident and we agreed resident was in respiratory distress, tachypneic and unable to slow his/her breathing. 9:09 PM Obtained an order from on call provider W.S. to the the [sic] resident to the ER. 21: 12 [9:12 PM] Called 911 to have an ambulance dispatched to the facility. 21:20 [9:20 PM] Notified residents POA, [POA Name], that I was sending his/her [parent] to the ER. [POA] thanked us for notifying him/her, said he/she would contact the co-POA, [co-POA Name], about [their parents] situation and stated, I will probably head to the hospital. 21:31 [9:31 PM] Ambulance service left the facility with the resident. 01:44 [1:44AM] Contacted CCH for an update on the resident, spoke with [Name] R.N. Nurse reported that the resident was awaiting a bed, and that he/she was being admitted for aspiration pneumonia, VS are stable, resident is tachypneic, and has a fever that is 100.4, down from 103.2 Resident was given lactated ringers, resident has a right sided block, and a prolonged QT interval, WBC [white blood cell] count is 20.9. 07:12 [7:12 AM] spoke with [name] R.N. Respiratory panel is negative, CT scan shows Bilateral aspiration. Nurse states that the resident is resting comfortably. The following concerns were identified: a. Review of Notice of Transfer dated [DATE] showed the resident was provided with a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility currently and their welfare is impacted. 4. Review of Notice of Transfer dated [DATE] for resident #3 showed the resident was provided with a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility currently and their welfare is impacted. 5. Interview with the facility administrator on [DATE] at 2:27 PM confirmed the transfer notices provided to the residents or representatives did not include a specific reason for the transfer to acute care.

Based on observation, medical record review, and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (#37, #63) reviewed for dementia care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] for resident #63 showed the resident had a BIMS score of 2 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-traumatic brain dysfunction, non-Alzheimer's dementia and anxiety. Review of the resident's care plan, initiated on 1/26/26 revealed the resident had behavioral symptoms which included wandering into other resident's rooms, taking others food and scavenging for food throughout the environment. Interventions were to reorient resident to her/his own food during mealtimes, redirect resident and intervene as appropriate. The following concerns were identified: a. Observation on 3/10/26 at 5:39 PM showed resident #63 took a dish out of the dirty dish bin and licked the plate, which also resulted in food dripping down the front of her/his shirt. There were two CNAs working on the unit who were assisting in a resident room and one dietary aid who was serving food, no other staff was in the area. b. Observation on 3/11/26 at 12:16 PM showed resident #63 took food chunks out of the dirty dish bin and ate them. No staff were in the area at the time of the incident. c. Observation on 3/12/26 at 5:52 PM showed resident #63 removed another resident's plate off of the table and put it in the dirty dish bin. An aid noticed and followed the resident to the bin and directed him/her to put the plate down. The resident followed directions and proceeded to lick his/her fingers clean after putting the dish down. Further observation showed the CNA did not implement interventions to prevent the resident from licking his/her hands or provide hand hygiene. d. Review of a progress note dated 2/25/26 at 3:24 PM showed the IDT team discussed resident #63's involvement in three resident-to-resident altercations during the month. The progress note showed .current care planning, supervision, environmental controls, and/or behavioral interventions may not be sufficient to prevent recurrence. Further review showed the corrective action was to implement more activities, such as catch with the blue ball, folding laundry, dish washing station, resident interaction with similar background, 1 to 1 activities with puzzles, reading, and trivia and the interdisciplinary team would follow up in two weeks and as needed for effectiveness. There was no evidence that the effectiveness was re-evaluated. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #37 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, and depression. Review of the resident's care plan, initiated on 1/13/26 showed the resident was an elopement risk and wandered due to impaired safety awareness and dementia. The care plan showed the resident displayed behaviors of wandering into other resident's rooms and exit seeking and had interventions which included identifying a pattern of wandering to adjust to resident's needs and intervene as appropriate, staff was to monitor the resident's location and document wandering behavior, and attempt diversional interventions. The following concerns were identified: a. Review of an Alert Note dated 10/21/25 at 7:25 AM showed on 10/20/25 at 6:26 PM, resident #37 wandered into another resident's room which upset the resident. The other resident responded by swatting at the air, in the direction of resident #37, with no physical contact. At that time, the CNA provided redirection, and de-escalated the situation; however, there was no evidence of evaluation of interventions or behavior triggers. b. Observation on 3/12/26 at 4:35 PM showed resident #37 was at the exit with his/her walker and attempted to open the door and four other residents were in the dining/living area. Further observation showed no staff were present at the time of the incident. 3. Interview with CNA #2 on 3/13/26 at 8:45 AM indicated that staff just know the residents' behavioral patterns and he always made loops around the unit. If there was a resident who needed two or more staff members at once they were not able to fully watch other residents. 4. Interview with LPN #2 on 3/13/26 at 8:53 AM indicated staff were generally familiar with the residents' behavioral flow, and there was no wander guard in use in the locked unit. She was unaware of specifics of documentation requirements when redirection or intervention was used, aside from putting in an alert chart note that is pushed as a behavior note. She was unaware of any specific rules of minimum staff supervision in common areas. 5.Interview with the NHA on 3/13/26 at 10:13 AM revealed the expectation for resident supervision on the locked unit was to have supervision in common areas at all possible times. She reported if residents left the locked unit with staff, they received continuous 1 to 1 supervision.

Based on observation, resident and staff interview, medical record review, and activity calendar review, the facility failed to ensure individual activities of preference were provided to 1 of 2 sample residents (#68) reviewed for activities. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #68 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and Review of an Activities-Initial Review dated 6/26/24 showed activities/interests/hobbies the resident participated in included team roping and cribbage. The assessment showed the resident wished to participate in activities while in the home, participate in group activities, participate in outings, participate in 1 to 1 activities with staff, and participate in independent activities. Further review showed activities should be modified to accommodate cognitive deficit and hearing deficit, and assistance should be provided to get the resident to activities. Review of the Activities care plan last revised on 2/16/26 showed the resident enjoyed listening to music while bathing, watching westerns and the news, reading mystery and action books, and playing cribbage. The following concerns were identified:a. Interview with the resident on 3/10/226 at 5:33 PM revealed s/he did not feel s/he was offered choices and s/he wanted to play cards; however, staff would not play with him/her. The resident stated s/he had to wait for family to visit so s/he could play cards. Further interview revealed the resident did not participate in other activities due to his/her decreased mobility. b. Review of the progress notes from 3/5/26 to 3/11/26 showed the resident participated in 1 to 1 activities three times, on 3/5, 3/8, and 3/11. Further review showed no evidence the activities included the resident's preferences, specifically, there was no evidence the facility offered or played cards with the resident.c. Review of the progress notes from 2/10/26 to 3/4/26 showed the resident did not participate in any 1 to 1 activities. d. Review of the progress notes from 1/28/26 to 2/9/26 showed the resident participated in 1 to 1 activities five times, on 1/28, 1/30, 2/1, 2/4, and 2/9. Further review showed no evidence the activities included the resident's preferences, specifically, there was no evidence the facility offered or played cards with the resident.e. Review of the medical record showed no evidence an activity assessment had been completed since 6/24/26.f. Review of the activity calendar for March 2028, February 2028, and January 2028 showed no card game activities were scheduled or provided by the facility.g. Review of the activity participation record from 1/13/26 through 3/12/26 showed no evidence the resident was offered, refused, or participated in any group activities during the time period. Further review showed no evidence the resident was offered, refused, or participated in activities identified as interests on the resident's activity assessment.2. Interview with the activity director on 3/12/26 at 5:36 PM confirmed the facility did not have card games on the activity calendar; however, she revealed there was a group of residents who played cards sometimes. She confirmed resident #68 was not assisted to play to cards with any of the groups. She revealed staff should document refusal of activity participation in the medical record.3. Interview with the activity director on 3/12/26 at 6:20 PM revealed the facility identified 1 to 1 activities were not being completed as they should be and the facility had limited documentation of resident refusals. 4. Interview with the facility administrator on 3/13/26 at 7:49 AM confirmed an activity assessment had not been completed since 6/26/24.5. Review of the policy titled Activity Schedule last revised 5/2025 showed .1. Activities will be designed to meet and support the participants physical, mental, intellectual, and psycho-social well-being. 2. Activities will create opportunities for each resident to have a meaningful life by supporting their domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning) .

Based on staff interview, medical record review, and policy review, the facility failed to ensure adequate supervision was provided to prevent resident injuries for 1 of 8 sample residents (#21) reviewed for accident hazards. The findings were: 1. Review of the MDS assessment dated [DATE] showed resident #21 had a BIMS score of 0 which indicated severe cognitive impairment and had diagnoses of Alzheimer's Disease and Non-Alzheimer's Dementia. Review of resident #21's care plan dated 8/2025 and last revised on 4/28/25 identified that the resident was at risk for falls related to dementia, and poor safety awareness. The following concerns were identified:a. Interview with CNA #1 on 3/13/26 at 10 AM revealed the resident had been sitting at the end of long table in the dining room where his/her chair was pushed up to the table. The resident tried to push the chair out, was unable to get back far enough, the resident climbed over the arm of chair and fell on the floor. The CNA reported she was not close enough to assist.b. Interview with LPN #1 on 3/13/26 at 8:26 AM revealed that the resident was observed trying to step over the arm of the chair that was pushed up to the table, and the resident fell. Further interview revealed the resident could not get his/her leg up high enough to clear the chair.c. Review of a Risk Management Review Note dated 12/18/25 and timed 9:47 AM showed Resident was in the dining room and climbed up on a dining room chair falling. Root Cause: Poor impulse control, poor safety awareness. resident has desire to clean and tidy immediate areas. Treatment required: Transferred to ER for evaluation. Resulting in surgical hip repair with pinning. Interventions put into place: Clear pathways with mobility and exit from dining tables. Ensure that she/he is able to move chair at desire without obstacles behind her. Requires assist with ambulation upon return. Supervision in the dining room during meals.d. Review of a Post Fall Evaluation note dated 1/28/26 and timed 5:45 PM showed on 1/28/26 at 4:32 PM the resident had a witnessed fall in the living room while attempting to ambulate on his/her own with an untied shoelace. Further review showed there was no evidence of injury.e. Review of a Post Fall Evaluation note dated 3/3/26 and timed 5:55 PM showed the resident had an unwitnessed fall in the dining room while s/he attempted to ambulate on her/his own. Further review showed there was no evidence of injury.f. Review of facility policy titled Fall Management last revised 6/2025 showed . 2. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Resident and resident representative (if applicable) will be invited to all care plan meetings. Interventions are to be re-evaluated when a resident falls for efficacy. 4. Document the resident's response to interventions and revise interventions if they are not successful.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure a resident, whose hospitalization or therapeutic leave exceeded the bed-hold period under the State plan, was allowed to return to the facility for 1 of 4 sample residents (#79) reviewed for transfer and discharge. The findings were: 1. Review of a progress note for resident #79 dated [DATE] and timed 2:19 PM showed .This nurse was notified of resident unwitnessed fall. Upon assessment, resident was found to be A&Ox1 [alert and oriented times 1] and slightly decreased LOC [level of consciousness], noted by increased response times. Resident was found to have an abnormal pulse on left wrist and clammy skin. Resident was incontinent at the time of fall, per staff report. Provider on call aware of clinical findings and transfer to ER [emergency room] obtained . Review of a Notice of Transfer dated [DATE] showed the resident was provided a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility currently and their welfare is impacted. Further review showed Return to Facility . A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan or facility policy, return to the facility to their previous room if available or immediately upon the first availability of a bed in semi-private room if the resident- (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services . The following concerns were identified:a. Review of a progress note dated [DATE] and timed 2:20 PM showed spoke with [name], POA regarding resident status. Resident has been out of facility greater than 30 days and is no longer on bed hold for facility. Discussed concerns with previous balance and Medicaid pending status. Resident has not been approved for Medicaid coverage for 2025. Being out over 30 days requires new admission per regulations. Legacy is not currently taking admissions. [POA name] requests to return call to Legacy to further conversation with Medicaid needs.b. Review of a progress note dated [DATE] and timed 2:46 PM showed Spoke with [name], VP care manager at [hospital name] regarding resident discharge from facility. Explained that resident received transfer notice [DATE] with bed-hold notice and appeal rights. Resident remained continuously inpatient beyond 30 days (current 60 days). Bed-hold has expired; resident has lost return rights. Facility is currently closed to admissions; readmission to facility declined at this time as resident is a new admission.c. Review of the medical record showed no evidence the resident was issued a discharge notice following the acute care transfer on [DATE].d. Interview with the facility administrator on [DATE] at 2:27 PM revealed the resident was not allowed to return because s/he had been gone longer than the bed hold, the facility completed a discharge, they determined the resident would be a readmission, and the facility was not accepting admissions. She confirmed a transfer notice was provided to the resident on [DATE] when the resident required acute care services at a hospital and did not issue a discharge notice at anytime during the hospital stay. Further interview revealed the facility had available beds when the resident was ready to return to the facility. 2. Review of the policy titled Notice of Transfer last revised on 10/21 showed .Return to Facility . A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan or facility policy, return to the facility to their previous room if available or immediately upon the first availability of a bed in semi-private room if the resident- (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services .

Based on medical record review and staff interview, the facility failed to ensure pre-admission screening was performed after a new diagnosis of mental illness for 1 of 3 sample residents (#6) with qualifying diagnoses. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #6 had diagnoses which included depression and psychotic disorder (other than schizophrenia). The following concerns were identified:a. Review of the PASARR Level I assessment completed on 3/8/21 showed the resident did not have a psychiatric diagnosis and did not present evidence of mental illness which included a possible disturbance in orientation, affect or mood that was not attributable to dementia or other medical diagnosis.b. Review of the medical record showed the new diagnosis of psychotic disorders with hallucinations due to known physiological condition was created on 9/5/25.c. Interview with the NHA on 3/12/26 at 4:19 PM revealed the resident had a new diagnosis of psychosis that was related to the resident's urinary tract infections that did not trigger the initial PASARR. Further interview confirmed the PASARR II should have been completed.d. Interview with the NHA on 3/12/26 at 5:52 PM confirmed the facility had started a full-scale audit on PASARRs last week.

Based on observation, resident and staff interview, medical record review, facility incident investigation review, and policy and procedure review, the facility failed to protect the residents' right to be free from mental abuse by another resident for 2 of 6 sample residents (#28, #41) reviewed. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #36 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and diagnoses which included non-traumatic brain dysfunction, cerebral palsy, anxiety disorder, depression, and bipolar disorder. The following concerns were identified:a. Review of an incident report dated 5/30/25 showed resident #36 reported resident #9 had touched his/her genitalia, in front of resident #36, before lunch. Resident #36 reported s/he told resident #9 You're nasty, go away and resident #9 left. Further review showed resident #36 reported s/he did not feel safe to the unit manager.b. Interview with resident #36 on 9/11/25 at 8:45 AM revealed about a month ago s/he was doing something in the kitchen area and resident #9 asked resident #36 to play with resident #9's genitals. Resident #36 revealed s/he was mad when the incident happened. Further interview revealed s/he was afraid of resident #9 because resident #9 would playfully grab out toward resident #36 when s/he walked by and resident #36 did not feel it was playful; however, s/he revealed resident #9 had never grabbed resident #36. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #28 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact, and diagnoses which included medically complex conditions. The following concerns were identified:a. Review of a facility incident report dated 9/10/25 showed resident #28 reported resident #9 entered resident #28's doorway, grasped his/her own genitals which were in his/her pants, and asked resident #28 if s/he wanted to play house. The review showed resident #28 yelled for resident #9 to leave, which s/he did. Further review showed resident #28 reported the incident occurred on 9/6/25.b. Interview with resident #28 on 9/10/25 at 3:42 PM revealed on 9/6/25 s/he was in his/her room, s/he heard someone coming down the hall, and saw resident #9 at resident #28's doorway. The resident revealed resident #9 asked if s/he would play house with him/her. Resident #28 revealed resident #9 had his/her genitals out when resident #9 asked the question. Resident #28 revealed s/he told resident #9 to get the hell out of here. Resident #28 revealed a couple nurses were close and heard the incident and resident #28 felt it was an embarrassing situation. Further interview revealed resident #9 had asked if s/he would touch him/her and play with him/her before in the dining room, resident #9 had done similar things to other residents who were not willing to speak up, and s/he reported it on 9/9/25 during a care conference. S/he did not recall who the nurses were that heard the incident.3. Interview with the facility administrator on 9/11/25 at 11:01 AM revealed the facility was completing staff education, in regard to abuse, following the 9/10/25 incident involving resident #9 and resident #28. She revealed the facility implemented hourly checks on resident #9 and they had developed a performance improvement plan for previous incidents; however, they had not developed a PIP for incidents involving resident #9.4. Review of the facility policy titled Abuse Policy last revised 5/2025 showed .10. Mental abuse is defined as but not limited to humiliation, harassment, threats of punishment, or withholding of treatment or services .Abuse By Other Residents .If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and notifies the primary physician/NP. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization, can then be implemented .

Based on medical record review, staff interview, State Survey agency incident database review, facility incident review, and policy and procedure review, the facility failed to ensure allegations of abuse and investigation findings were reported for 3 of 6 sample residents (#9, #36, #41) reviewed for abuse allegations. The findings were:1. Review of a progress note for resident #9 dated 4/12/25 and timed 5:05 PM showed Note Text: 4/11/2025 09:12 CNA documentation: I was informed by another resident that [resident #9] was being inappropriate at breakfast. Resident told her that [s/he] wanted [him/her] to touch [his/her] [genitals] during breakfast. Informed other resident to alert staff if it occurs again. Receiver calm and required no interventions. 2. Review of a progress note for resident #41 dated 6/4/25 and timed 2:13 PM showed LATE ENTRY Note Text: Nursing staff communicated to leadership and social services resident stated a [male/female] resident exposed [his/her] genitals to [him/her]. SW [social worker] [name] and SW [name] met with resident who stated a [male/female] resident 'flashed' [him/her]. Resident stated [s/he] had 'heard' from other residents that [s/he] was making advances. SW asked where this occurred, and resident was uncertain. SW asked if it happened in the dining room and resident stated no. SW asked when it occurred, and resident did not recall [s/he] believed 'day time'. SW asked if others were around and may have also been exposed to this and [s/he] stated no, no one was around. Resident stated [s/he] confronted the [male/female] and [s/he] denied doing it. Resident stated multiple times [s/he] feels safe and is not afraid of [him/her] and is not fearful to leave [his/her] room. Following up on this incident SW interviewed nursing staff who stated this resident was told a negative story about the accused [male/female] resident the day prior. Nursing staff advised the day prior, this resident saw the [male/female] and stated 'are you the [resident] who asks people to play with [his/her] [genitals]?' Nursing staff stated the [male/female] resident did not respond and left the area and expressed to the nursing staff [s/he] was upset at this interaction. Nursing staff advised this resident did not come out for breakfast, only came out for lunch and was not alone with this [male/female] resident at any time. Due to the need for assistance [s/he] is pushed to and from the dining room by staff. Staff confirmed by the time this resident arrived in the dining room multiple other residents were in the dining room. Staff confirmed that today's lunch this resident was sat in the main dining room which is where nutrition staff as well as nursing staff work in order to serve lunch and no resident or staff witnessed any incident. Nursing staff also confirmed that the [male/female] resident who is being accused sits in a separate dining space and would not be in the visual path or vicinity of this resident during the only time in which [s/he] would have left her room. Discussion with administrator following interviews found that the events of the day negate the claim this resident made. No further follow up at this time needed as resident reports [s/he] has no concerns and nursing staff interviews dispute resident claim. It is believed this resident heard claims made by another resident the day prior which impacted [his/her] accusation.3. Review of an incident report dated 5/30/25 showed resident #36 reported resident #9 had touched his/her genitalia, in front of resident #36, before lunch. Resident #36 reported s/he told resident #9 You're nasty, go away and resident #9 left. Further review showed resident #36 reported s/he did not feel safe to the unit manager.4. Review of the State Survey Agency incident database showed no evidence the incidents involving resident #9, resident #36, or resident #41 were reported.5. Interview with the facility administrator and DON on 9/11/25 at 1:41 PM confirmed the allegations and investigation findings were not reported to the state survey agency. 6. Review of the facility policy titled Abuse Policy last revised on 5/2025 showed .The facility will ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury and reasonable suspicion of a crime, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken .

Based on medical record review, staff interview, state survey agency incident database review, facility incident review, and policy and procedure review, the facility failed to ensure allegations of abuse were thoroughly investigated for 2 of 6 sample residents (#9, #41) reviewed for abuse. The findings were: 1. Review of a progress note for resident #9 dated 4/12/25 and timed 5:05 PM showed Note Text: 4/11/2025 09:12 CNA documentation: I was informed by another resident that [resident #9] was being inappropriate at breakfast. Resident told her that [s/he] wanted [him/her] to touch [his/her] [genitals] during breakfast. Informed other resident to alert staff if it occurs again. Receiver calm and required no interventions.2. Review of a progress note for resident #41 dated 6/4/25 and timed 2:13 PM showed LATE ENTRY Note Text: Nursing staff communicated to leadership and social services resident stated a [male/female] resident exposed [his/her] genitals to [him/her]. SW [social worker] [name] and SW [name] met with resident who stated a [male/female] resident 'flashed' [him/her]. Resident stated [s/he] had 'heard' from other residents that [s/he] was making advances. SW asked where this occurred, and resident was uncertain. SW asked if it happened in the dining room and resident stated no. SW asked when it occurred, and resident did not recall [s/he] believed 'day time'. SW asked if others were around and may have also been exposed to this and [s/he] stated no, no one was around. Resident stated [s/he] confronted the [male/female] and [s/he] denied doing it. Resident stated multiple times [s/he] feels safe and is not afraid of [him/her] and is not fearful to leave [his/her] room. Following up on this incident SW interviewed nursing staff who stated this resident was told a negative story about the accused [male/female] resident the day prior. Nursing staff advised the day prior, this resident saw the [male/female] and stated 'are you the [resident] who asks people to play with [his/her] [genitals]?' Nursing staff stated the [male/female] resident did not respond and left the area and expressed to the nursing staff [s/he] was upset at this interaction. Nursing staff advised this resident did not come out for breakfast, only came out for lunch and was not alone with this [male/female] resident at any time. Due to the need for assistance [s/he] is pushed to and from the dining room by staff. Staff confirmed by the time this resident arrived in the dining room multiple other residents were in the dining room. Staff confirmed that today's lunch this resident was sat in the main dining room which is where nutrition staff as well as nursing staff work in order to serve lunch and no resident or staff witnessed any incident. Nursing staff also confirmed that the [male/female] resident who is being accused sits in a separate dining space and would not be in the visual path or vicinity of this resident during the only time in which [s/he] would have left her room. Discussion with administrator following interviews found that the events of the day negate the claim this resident made. No further follow up at this time needed as resident reports [s/he] has no concerns and nursing staff interviews dispute resident claim. It is believed this resident heard claims made by another resident the day prior which impacted [his/her] accusation.3. Review of the state survey agency incident database showed no evidence the incidents involving resident #9 or resident #41 were reported or investigated.4. Review of the facility incidents showed no evidence the 4/12/25 or 6/4/25 allegations were investigated.5. Interview with the facility administrator and DON on 9/11/25 at 1:41 PM confirmed the allegations were not investigated.6. Review of the facility policy titled Abuse Policy last revised on 5/2025 showed .The facility will conduct an internal investigation. That investigation includes interviewing any staff members, residents, or family members who may have knowledge of the incident. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken .

Based on medical record review, staff and resident interview, incident investigation review, and policy and procedure review, the facility failed to ensure residents with dementia received treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 sample residents (#9) reviewed for dementia care. The findings were:1. Review of the annual MDS assessment dated [DATE] showed resident #9 had a brief interview for mental status score of 5 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia and unspecified dementia with psychotic disturbance. Further review showed the resident had no behavior symptoms present and had a foley catheter in place. Review of the care plan last revised on 9/10/25 showed the resident had a risk behavior challenge r/t [related to] Specify Behavior: history of making sexually suggestive comments to other residents, often comments are associated with catheter. Interventions included the resident enjoys cutting paper as a job with scissors, anticipate and meet the resident's needs: If [resident name] is asking others to 'play with [his/her] [genitals]' [s/he may need catheter care, and Assist the resident to develop more appropriate methods of coping and interacting and asking for help. The following concerns were identified:a. Review of a progress note dated 11/24/24 and timed 7:08 PM showed Note Text: This was noted in previous documentation Resident was sitting by the nurse's medication cart, taking [his/her] morning medications. When resident was just about to leave, resident commented, I am going to go look for someone to play with my [genitals]. Resident was educated that this was not appropriate in this environment. Resident laughed at the education as [s/he] left the cart to go to breakfast. This was noted in previous documentation Later in the morning, a staff member had walked past this resident sitting at the breakfast table and had noted that the resident had [his/her] hand in [his/her] pants and was moving [his/her] hand. Staff member asked resident if [s/he] would remove [his/her] hand from [his/her] pants while [s/he] was in a public setting. Resident was educated on appropriate places to perform private matters. Resident laughed at the education, removed [his/her] hand from [his/her] pants, and verbalized understanding.b. Review of a progress note dated 12/25/24 and timed 8:19 AM showed .Resident initiated a verbal altercation with another resident after [s/he] accidentally pushed another resident into the table. Yelled at [him/her] to Shut the hell up. When questioned about the incident, [name] stated that [s/he] and the other resident were going to get the cows in. Attempted to reorient resident .c. Review of a progress note dated 1/4/25 and timed 8:15 AM showed Note Text: Activity aide was telling [resident name] what was happening today, after aide was done [resident name] stated [s/he] was looking for someone to play with [his/her] private parts. Aide explain to [resident name] that was not right. [S/He] stated ok and aide went on with her work.d. Review of a progress note dated 3/1/25 and timed 3:55 PM showed Note Text: CNA reported: 'Resident asked me if I wanted to lay on [his/her] groin, to which I replied 'No.' After that, [s/he] asked me if I knew somebody who would want to, and I replied, again, 'No.' Nurse educated resident.e. Review of a progress note dated 3/6/25 and timed 8:10 AM showed Note Text: [Resident name] was sitting in the Great Room and asked a staff member what time [name], who plays guitar, will be here today. [S/He] was told 10:45. [Resident name] responded Well I guess I will just have to find someone to play with my [genitals] until then. Staff member responded that we should not be speaking like that, [Resident name] was easily redirected.f. Review of a progress note dated 3/13/25 and timed 10:06 AM showed Note Text: 3/8/2025 09:50 CNA documentation: resident came over to CNA kiosk on Birch North and asked if CNA could help [him/her] when asked with what he pointed to [his/her] groin area.g. Review of a progress note dated 3/18/25 and timed 9 AM showed Note Text: [Resident name] was at the front of the building and when aide stopped to ask [him/her] what [s/he] is up to [Resident name] stated looking for someone to play with [his/her] private parts. I told [him/her] that it is not appropriate to say things like that.h. Review of a progress note dated 3/23/25 and timed 4:13 PM showed Note Text: [Resident name] was up by the great room and asked me if I could help [him/her] and I asked with what [s/he] needs help with and then [s/he] had a smirk on [his/her] face and out [sic] [his/her] hand in the slit of [his/her] Pj bottom and was pulling on [his/her] privete part. I told [him/her] sorry no I can't help you with that.i. Review of a progress note dated 4/12/25 and timed 5:05 PM showed Note Text: 4/11/2025 09:12 CNA documentation: I was informed by another resident that resident was being inappropriate at breakfast. Resident told [him/her] that [s/he] wanted [him/her] to touch [his/her] [genitals] during breakfast. Informed other resident to alert staff if it occurs again. Receiver calm and required no interventions.j. Review of a progress note dated 4/24/25 and timed 7:16 AM showed Note Text: 4/23/2025 15:47 CNA documentation: Resident used inappropriate sexual innuendos. [S/He] said come play with my [genitals]. [His/her] implication was to play with [his/her] [genitals]. [S/He] was disappointed that the [male/female] staff said no. HR [human resources], and two CNAs witnessed [his/her] behavior.k. Review of a progress note dated 5/16/25 and timed 11:59 AM showed Note Text: Resident made comment to SW [s/he] is in need of finding a [gender] to 'play with [his/her] [genitals]'. SW [social worker] encouraged resident to reach out to [his/her] [spouse] if in need of intimacy.l. Review of an incident report dated 5/30/25 showed resident #41 reported resident #9 had touched his/her genitalia, in front of resident #41, before lunch. Resident #41 reported s/he told resident #9 You're nasty, go away and resident #9 left. Further review showed resident #41 reported s/he did not feel safe to the unit manager. Interview with resident #41 on 9/11/25 at 8:45 AM revealed about a month ago s/he was doing something in the kitchen area and resident #9 asked resident #41 to play with resident #9's genitals. Resident #41 revealed s/he was mad when the incident happened. Further interview revealed s/he was afraid of resident #9 because resident #9 would playfully grab out toward resident #41 when s/he walked by and resident #41 did not feel it was playful; however, s/he revealed resident #9 had never grabbed resident #41. m. Review of a facility incident report dated 9/10/25 showed resident #28 reported resident #9 entered resident #28's doorway, grasped his/her own genitals which were in his/her pants, and asked resident #28 if s/he wanted to play house. The review showed resident #28 yelled for resident #9 to leave, which s/he did. Further review showed resident #28 reported the incident occurred on 9/6/25. Interview with resident #28 on 9/10/25 at 3:42 PM revealed on 9/6/25 s/he was in his/her room, s/he heard someone coming down the hall, and saw resident #9 at resident #28's doorway. The resident revealed resident #9 asked if s/he would play house with him/her. Resident #28 revealed resident #9 had his/her genitals out when resident #9 asked the question. Resident #28 revealed s/he told resident #9 to get the hell out of here. Resident #28 revealed a couple nurses were close and heard the incident and resident #28 felt it was an embarrassing situation. Further interview revealed resident #9 had asked if s/he would touch him/her and play with him/her before in the dining room, resident #9 had done similar things to other residents who were not willing to speak up, and s/he reported it on 9/9/25 during a care conference. S/he did not recall who the nurses were that heard the incident.2. Interview with the administrator and DON 9/11/25 at 11:43 AM revealed resident #9 spent a lot of time throughout the facility, liked to visit with people, and liked to watch activities. They revealed the resident was pretty nosey and was not well liked by other residents because s/he wants to know what they are doing, why they are doing it, and tell them why they are doing it wrong. The revealed the facility had offered resident #9 counseling, offered alone time in his/her room, offered magazines, worked with his/her spouse, set up weekly calls with his/her spouse because s/he won't come visit, and offered activities. They revealed the facility had completed staff education in response to comments and had identified issues happen more when s/he has been noted to have blood in his/her urine or pain with urinary obstruction. 3. Interview with the administrator and DON on 9/11/25 at 1:41 PM confirmed the resident's care plan was not fully developed for the resident's behaviors or facility interventions. 4. Review of the facility policy titled Abuse Policy last revised 5/2025 showed .Abuse By Other Residents .If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and notifies the primary physician/NP. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization, can then be implemented .

Based on observation, staff interview, medical record review, facility incident investigation review, and performance improvement plan review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 3 of 4 sample residents (#1, #3, #5) involved in a resident-to-resident altercation. This failure resulted in actual harm to resident #1 who suffered a hematoma above his/her left eyebrow and an abrasion under his/her left eye. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 4/8/25. The findings were: 1. Review of the 1/10/25 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE] and had diagnoses which included non-traumatic brain injury, Alzheimer's disease, and non-Alzheimer's dementia. The resident had a BIMS score of 0 out of 15 which indicated severe cognitive impairment and signs and symptoms of delirium including inattention and disorganized thinking which fluctuated. Review of the resident's care plan showed a focus area, revised on 11/4/24, in which s/he was at risk for harm from other residents due to cognition of self and others related to his/her interest in being close to others. Interventions included to direct the resident away from others who may be showing agitation, encourage him/her to participate in activities, be aware of the resident's surroundings to ensure s/he was not placing him/herself in a dangerous situation; observe resident in the common areas to ensure safety; and to redirect to activities or a snack when s/he was in other people's personal space. The following concerns were identified: a. Review of the Legacy Abuse or Neglect Investigation form showed on 3/24/25 at 1 PM resident #4 and resident #6 were observed by EVS technician #1 walking back to their room and resident #1 was following them. Resident #1 was heard stating Don't follow me [resident #1] you bitch. Resident #1 continued to follow resident #4 and resident #6 into their shared suite. EVS technician #1 followed the residents into the suite and witnessed resident #4 put [his/her] hands out forward and push [resident #1] in the chest and shoulder area b. Review of nursing description, dated 3/24/25 and timed 1:50 PM, showed This RN Arrived (sic) to the door entry way into the suite. Resident was found sitting up against the wall with CNA present. Resident was surrounded by two other residents. Abrasion under left eye and small hematoma above left eyebrow .no further injury. Resident denies any pain and then grabbed eye and stated this hurts asked resident about pain again, [s/he] states no. EVS states resident was walking while another resident was holding the door for his/her roommate to come in which s/he stated Do not come this way, you bitch resident proceeded to walk through the entry way when [s/he ] was pushed to the floor. c. Interview with EVS technician #1 on 4/15/25 at 12:13 PM revealed he had witnessed resident #4 push resident #1 to the ground; however, because of the angle of the hallway he was unable to see the resident fall to the ground. d. Review of the care plan for resident #4 had a focus area, initiated on 9/20/24, which showed The resident has a mood challenge r/t (related to) mood fluctuations r/t dementia, depression, DM (diabetes mellitus) with fluctuating blood sugars, frequent hallucinations and delusions. History of aggressive behaviors directed at others. Staff were directed to monitor/record/report to MD prn (as needed) risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. 2. Review of the 3/26/25 quarterly MDS assessment for resident #3 showed the resident was admitted to the facility on [DATE] and had diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, and non-Alzheimer's dementia. The resident had a BIMS score of 4 out of 15 which indicated severe cognitive impairment and had signs and symptoms of delirium including inattention and disorganized thinking which fluctuated. In addition, the resident was coded as wandering 1-to-3 days of the 7-day look-back period. Review of the resident's care plan, initiated on 10/9/24, showed the resident had a behavior challenge related to wandering frequently into other residents' rooms, crying, and exit seeking. Interventions included to encourage the resident to spend time in the common areas to deter him/her from attempting to enter the rooms of other residents and to interfere as necessary to protect the rights and safety of others. 3. Review of the 2/7/25 quarterly MDS assessment for resident #5 showed the resident was admitted to the facility on [DATE] and had diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, Parkinson's disease, anxiety disorder, and depression. The resident had a BIMS score of 3 out of 15 which indicated severe cognitive impairment and had signs and symptoms of delirium including inattention and disorganized thinking which fluctuated. Review of the physician's orders showed the resident was prescribed 10 milligrams of escitalopram (antidepressant) daily for anxiety with target behaviors identified as anxiousness, restlessness, and fixating. The following concerns were identified. a. Review of the Legacy Abuse or Neglect Investigation report showed camera footage of the Cottonwood unit resident hallway revealed resident #3 entered the room of resident #5 on 3/30/25 at 8:06 PM and a staff member entered the room at 8:09 PM. The staff emergency light was activated at 8:10 PM. According to CNA #1 she heard yelling coming from resident #5's room and resident #5 yelling get out. The CNA stated she found both residents on the floor kicking at each other; however, she did not witness contact being made. Review of the nursing assessment, completed following the incident, showed resident #3 had a small skin tear to his/her left outer wrist and resident #5 had a small bruise and a small scratch noted to his/her outer left wrist. Interventions included to make larger name signs for residents' doors which were contrasted with a bright background color. b. Review of a 3/31/25 nursing assessment showed resident #5 was reporting severe left arm pain and showed a decreased range of motion in the left wrist and left elbow, and scattered bruising was noted. The resident was sent for imaging with no acute fracture or dislocation identified. Further review of the facility's investigation showed resident #5 had an unwitnessed fall approximately 30 minutes to an hour after the resident-to-resident incident. The facility determined the injury to resident #5's wrist was most likely from the fall and not the resident-to-resident altercation. c. Review of resident #5's care plan. revised 3/31/25, showed [the resident] experiences a great amount of anxiety in regard to other (sic) entering [his/her] room without permission. Staff will continue encourage (sic) other wandering residents to not enter [the resident's] room. [The resident] prefers to have [his/her] door open to [his/her] room. But [s/he] is also extremely protective of [his/her] personal items .Staff are to assist with re-directing other residents out of [his/her] room. 4. Interview with the social worker on 4/15/25 at 8:34 AM revealed the facility was transitioning from two secure units to one and there had been a lot of activity which had upset some of the residents and had resulted in an increase in resident-to-resident incidents during March. Further the social worker stated if staff would have been in the resident hallway, heard resident #4 shout at resident #1, and intervened at that time, perhaps the incident could have been avoided. The social worker stated the root cause of many of the incidents was determined to be insufficient supervision throughout the unit and changes had been made to correct the issue as well as education provided to the staff on both dementia and abuse. Further, the facility had moved the social worker's office into the secure unit, and increased supervision and activities. 5. Interview with the NHA and DON on 4/15/25 at 1:30 PM revealed the facility's quality improvement committee had been restructuring the Cottonwood unit which included increased staffing, a full-time activities aide, ensuring staff were located in all locations of the unit, moving the social worker's office into the unit, and ensuring a unit manager was available at all times. In addition, the Cottonwood unit staff were provided an all day dementia care training course through the college and also an in-person 4-hour class on abuse. Further the DON stated the interdisciplinary team performed a daily incident review and written updates and interventions were provided to the unit nurses each day. 6. Review of the staffing schedule from 3/24/25 through 4/14/25 showed the Cottonwood unit was staffed with an additional CNA starting on 3/28/25. In addition, beginning on 4/8/25 the Cottonwood unit had a dedicated licensed nurse. 7. Review of the quality assurance committee's behavior management performance improvement plan (PIP) included a projected schedule with duties and assignments broken down into time blocks for each CNA working on the Cottonwood unit, the dietary aide duties, a dining room seating chart, activities expectations, and risk management duties. The next review of the PIP was scheduled for 4/19/25. 8. Review of the educational documentation provided by the facility showed the Cottonwood unit staff had completed the Dementia Capable Care training on 4/3/25 and the abuse training on 3/19/25. 9. Observation on 4/14/25 starting at 1:59 PM of the Cottonwood unit showed the doors of the residents' rooms had 8 by 10-inch laminated name signs in different bright colors attached to them. Ten residents were observed to be able to ambulate independently with 3 residents observed to wander throughout the unit. Staff were observed providing activities, intervening, and redirecting residents. The CNAs were observed using the charting kiosk in the resident hallway.

Based on observation, staff interview, medical record review, facility incident investigation review, and facility performance improvement plan review, the facility failed to ensure a safe environment for 4 of 6 sample residents (#1, #2, #3, #5) involved in 2 of 3 unwitnessed resident-to-resident altercations reviewed from 3/8/25 to 3/30/25. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 4/8/25. The findings were: 1. Review of the 3/30/25 resident-to-resident altercation involving resident #3 and #5 showed the following: a. Review of the 3/26/25 quarterly MDS assessment for resident #3 showed the resident was admitted to the facility on [DATE] and had diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, and non-Alzheimer's dementia. The resident had a BIMS score of 4 out of 15 which indicated severe cognitive impairment and had signs and symptoms of delirium including inattention and disorganized thinking which fluctuated. In addition, the resident was coded as wandering 1-to-3 days of the 7-day look-back period. Review of the resident's care plan, initiated on 10/9/24, showed the resident had a behavior challenge related to wandering frequently into other residents' rooms, crying, and exit seeking. Interventions included to encourage the resident to spend time in the common areas to deter him/her from attempting to enter the rooms of other residents and to interfere as necessary to protect the rights and safety of others. b. Review of the 2/7/25 quarterly MDS assessment for resident #5 showed the resident was admitted to the facility on [DATE] and had diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, Parkinson's disease, anxiety disorder, and depression. The resident had a BIMS score of 3 out of 15 which indicated severe cognitive impairment and had signs and symptoms of delirium including inattention and disorganized thinking which fluctuated. Review of the physician's orders showed the resident was prescribed 10 milligrams of escitalopram (antidepressant) daily for anxiety with target behaviors identified as anxiousness, restlessness, and fixating. c. Review of the Legacy Abuse or Neglect Investigation report showed camera footage of the Cottonwood unit resident hallway revealed resident #3 entered the room of resident #5 on 3/30/25 at 8:06 PM and a staff member entered the room at 8:09 PM. The staff emergency light was activated at 8:10 PM. According to CNA #1 she heard yelling coming from resident #5's room and resident #5 yelling get out. The CNA stated she found both residents on the floor kicking at each other; however, she did not witness contact being made. Review of the nursing assessment, completed following the incident, showed resident #3 had a small skin tear to his/her left outer wrist and resident #5 had a small bruise and a small scratch noted to his/her outer left wrist. Interventions included to make larger name signs for residents' doors which were contrasted with a bright background color. d. Review of a 3/31/25 nursing assessment showed resident #5 was reporting severe left arm pain and showed a decreased range of motion in the left wrist and left elbow, and scattered bruising was noted. The resident was sent for imaging with no acute fracture or dislocation identified. Further review of the facility's investigation showed resident #5 had an unwitnessed fall approximately 30 minutes to an hour after the resident-to-resident incident. The facility determined the injury to resident #5's wrist was most likely from the fall and not the resident-to-resident altercation. e. Review of resident #5's care plan. revised 3/31/25, showed [the resident] experiences a great amount of anxiety in regard to other (sic) entering [his/her] room without permission. Staff will continue encourage (sic) other wandering residents to not enter [the resident's] room. [The resident] prefers to have [his/her] door open to [his/her] room. But [s/he] is also extremely protective of [his/her] personal items .Staff are to assist with re-directing other residents out of [his/her] room. 2. Review of the 3/8/25 resident-to-resident incident involving resident #1 and #2 showed the following: a. Review of the 1/10/25 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE] and had diagnoses which included non-traumatic brain injury, Alzheimer's disease, and non-Alzheimer's dementia. The resident had a BIMS score of 0 out of 15 which indicated severe cognitive impairment and signs and symptoms of delirium including inattention and disorganized thinking which fluctuated. Review of the resident's care plan showed a focus area, revised on 11/4/24, in which s/he was at risk for harm from other residents due to cognition of self and others related to his/her interest in being close to others. Interventions included to direct the resident away from others who may be showing agitation, encourage him/her to participate in activities, be aware of the resident's surroundings to ensure s/he was not placing him/herself in a dangerous situation; observe resident in the common areas to ensure safety; and to redirect to activities or a snack when s/he was in other people's personal space. b. Review of the 3/18/25 quarterly MDS assessment showed resident #2 was admitted to the facility on [DATE] with diagnoses which included non-traumatic brain dysfunction, and non-Alzheimer's dementia. The resident had a BIMS score of 5 out of 10 which indicated severe cognitive impairment; was coded for having hallucinations and delusions; and exhibited verbal and physical behaviors towards others 1-to-3 days of the 7-day look-back period. Review of the resident's care plan showed s/he had a focus area, revised on 12/18/24, of having a behavioral issue which had a potential to be physically aggressive. The care plan identified a trigger for physical aggression being others in close proximity to residents. Interventions included independent time in room, participation in meals/activities in the main areas and removed for downtime, conversation, and television. In addition, if the resident became agitated staff were to intervene before the agitation escalated and guide the resident away from the source of distress. c. Review of a 3/8/25 alert note for resident #2 showed Resident pushed another resident to the floor, when asked why, the resident said resident #1 deserved it and had been annoying [his/her] whole life. The residents were immediately separated and redirected to opposite sides of the dining area. Review of a 3/10/25 risk management note showed Type of incident: Aggression towards another resident. [The resident] initiated physical aggression towards other resident in the main hallway in front of his/her room. Incident was not witnessed. Resident (referring to resident #1) was found on the floor with indication that [resident #2] had pushed [resident #1] out of the way. d. Review of the Legacy Abuse or Neglect Investigation report showed staff did not witness the incident; however, found resident #1 near resident #2's room on his/her knees attempting to get up. The resident showed no signs or symptoms of injury. Resident #2 stated I pushed [him/her] Further review showed due to lack of injury and unwitnessed incident this investigation will conclude unverified. Despite unverified, interventions have been put in place to provide space and time away from each other through structured activities. 3. Interview with the social worker on 4/15/25 at 8:34 AM revealed the facility was transitioning from two secure units to one and there had been a lot of activity which had upset some of the residents and had resulted in an increase in resident-to-resident incidents during March. The social worker stated the root cause of many of the incidents was determined to be insufficient supervision throughout the unit and changes had been made to correct the issue as well as education provided to the staff on both dementia and abuse. Further, the facility had moved the social worker's office into the secure unit, and increased supervision and activities. 4. Interview with the NHA and DON on 4/15/25 at 1:30 PM revealed the facility's quality improvement committee had been restructuring the Cottonwood unit which included increased staffing, a full-time activities aide, ensuring staff were located in all locations of the unit, moving the social worker's office into the unit, and ensuring a unit manager was available at all times. In addition, the Cottonwood unit staff were provided an all day dementia care training course through the college and also an in-person 4-hour class on abuse. Further the DON stated the interdisciplinary team does a daily incident review and written updates and interventions were provided to the unit nurses each day. 5. Review of the staffing schedule from 3/24/25 through 4/14/25 showed the Cottonwood unit was staffed with an additional CNA starting on 3/28/25. In addition, beginning on 4/8/25 the Cottonwood unit had a dedicated licensed nurse. 6. Review of the quality assurance committee's behavior management performance improvement plan (PIP) included a projected schedule with duties and assignments broken down into time blocks for each CNA working on the Cottonwood unit, the dietary aide duties, a dining room seating chart, activities expectations, and risk management duties. The next review of the PIP was scheduled for 4/19/25. 7. Review of the educational documentation provided by the facility showed the Cottonwood unit staff had completed the Dementia Capable Care training on 4/3/25 and the abuse training on 3/19/25. 8. Observation on 4/14/25 starting at 1:59 PM of the Cottonwood unit showed the doors of the residents' rooms had 8 by 10-inch laminated name signs in different bright colors attached to them. Ten residents were observed to be able to ambulate independently with 3 residents observed to wander throughout the unit. Staff were observed providing activities, intervening, and redirecting residents. The CNAs were observed using the charting kiosk in the resident hallway.

Based on medical record review, staff interview, media article review, and state survey incident database review, the facility failed to ensure allegations which resulted in a reasonable suspicion of a crime were reported for 1 of 4 sample resident (#1) reviewed for allegation reporting. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #1 had a brief interview for mental status score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included heart failure, hypertension, peripheral vascular disease, diabetes mellitus, cerebrovascular accident, anxiety disorder, depression, and asthma. Further review showed the resident required supervision or touching assistance with transfer and toileting hygiene. Review of a progress note dated [DATE] and timed 5:50 AM showed the resident was found unresponsive and cardiopulmonary resuscitation, which included chest compressions, was implemented. Emergency Medical Services arrived and pronounced the resident deceased at 5:02 AM. The following concerns were identified: a. Review of a newspaper article dated [DATE] showed .Police Department have been investigating the death of [AGE] year-old [resident #1], who died Nov. 29 last year .[resident #1]'s cause of death was determined to be toxicity or overdose of a known prescription medication . b. Interview with the resident's physician and nurse practitioner #1 on [DATE] at 9 AM revealed they were aware of the allegation of prescription drug toxicity or overdose from a prescription medication. c. Review of the state survey agency incident report database showed no evidence the allegation of drug toxicity or overdose was reported. d. Interview with the DON and administrator on [DATE] at 3:45 PM revealed the facility was aware of the allegation of drug toxicity or overdose from a prescription medication and a facility investigation was initiated. They revealed the allegation was not reported due to the facility reporting a previous allegation surrounding the resident's death; however, they confirmed the previous allegation did not include an allegation of drug toxicity or overdose for the resident.

Based on observation, medical record review, staff interview, closed-circuit camera review, and policy and procedure review, the facility failed to protect the resident's right to be free from neglect for 1 of 3 sample residents (#6) reviewed for abuse and neglect. This failure resulted in the death of resident #6 who exited the facility without being noticed and was outside in winter weather conditions for 9 hours and 17 minutes. This failure resulted in the determination of immediate jeopardy due to the lack of necessary services to ensure residents' safety. On [DATE] there were 19 residents on the Cottonwood and Pine units who were identified as high-risk for wandering/elopement. Corrective measures were implemented prior to the survey and compliance was determined to be met on [DATE]. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #6 had a brief interview for mental status score of 3 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease. Further review showed the resident was dependent on staff for toileting hygiene, personal hygiene, bathing, and required substantial/maximal assistance with oral hygiene, upper and lower body dressing, putting on/taking off footwear, and toilet transfer. Review of the resident's activities of daily living care plan last revised on [DATE] showed the resident was able to walk independently. Review of the resident's elopement risk/wandering care plan initiated on [DATE] showed the resident had a history of exit seeking and wandering behaviors and interventions included Resident has had successful elopements from the courtyard and [s/he] needs close supervision when [s/he] is outside .Monitor location per nursing head count procedure. Document wandering behavior and attempted diversional interventions in behavioral log .The resident's triggers for exit seeking are restlessness and delusional thoughts [s/he] has to go somewhere . The following concerns were identified: a. Review of an Abuse or Neglect Investigation dated [DATE] showed staff on the Cottonwood unit were unable to locate resident #6 at approximately 4 AM. A search for the resident was initiated and the resident was located lying on the ground outside in the courtyard, without signs of life. The investigation indicated the closed-circuit television cameras showed the resident exit a door to the courtyard at 7:10 PM on [DATE], 9 hours and 15 minutes prior to being found. The facility immediately suspended RN #1, CNA #1, and CNA #2 pending investigation. b. Review of a closed circuit-camera video dated [DATE] and beginning at 6:59 PM showed 2 residents on the Cottonwood unit were seated inside the door. The video camera was outside, pointed toward the door, and there was snow visible on the grass and sidewalk. At 7:08:13 PM, resident #6 stood up and ambulated toward the door. The resident exited the Cottonwood unit into the courtyard at 7:08:32 PM and proceeded to walk toward the camera, away from the door, until s/he was no longer visible on the camera, at 7:09:09 PM. At that time, the resident was wearing a long-sleeved shirt, blue jeans or slacks, slippers, and s/he was walking with a shuffled gait. Continued review showed the other resident remained seated in a chair inside the Cottonwood unit. At 7:21:47 PM, 12 minutes after resident #6 exited the Cottonwood unit, a staff member, who was inside the building, walked toward the exit door. The staff member reached toward something on the right-hand side of the door, then walk away without exiting the door or observing the courtyard outside the Cottonwood unit. Review of a second closed-circuit camera video dated [DATE] and beginning at 7:06:34 PM, showed a broad view of the courtyard areas of the Pine and Cottonwood units, where snow was visible throughout the courtyards, including on the walkways. On [DATE] at 7:09:32, resident #6 was observed entering the camera's view and ambulating toward the facility. The resident continued to ambulate with his/her arms out to the side until the resident falls to the ground, into the snow, at 7:10:51 PM. Resident #6 continued to move around, in what appeared to be efforts to get up, until his/her movement is not discernable at 7:20 PM. The resident continued to lay in the outside courtyard, in the snow, until the end of the video at 9 PM. Review of a closed-circuit camera video of the Cottonwood and Pine courtyards dated [DATE] and beginning at 8:59:33 PM showed resident #6 remained lying in the outside courtyard, in the snow, until the end of the video on [DATE] at 12:00:12 AM. Review of a closed-circuit video of the Cottonwood and Pine courtyards dated [DATE] and beginning at 12 AM showed resident #6 lying in the outside courtyard, in the snow. On [DATE] at 4:25:22 AM, an individual is observed exiting the facility into the courtyard. The individual was holding a flashlight and walked toward where the resident was lying on the ground. At 4:25:34 AM, the individual observed the resident on the ground, turns, and runs back into the facility, then returns to the resident. Another individual is observed exiting the facility and walking toward the resident at 4:25:47 AM, 9 hours and 17 minutes after resident #6 exited the Cottonwood unit. c. Review of climate-data.org showed the high temperature in the facility's location on [DATE] was 36 degrees Fahrenheit and the low temperature was 15 degrees Fahrenheit. Further review showed the high temperature on [DATE] was 33 degrees Fahrenheit and the low temperature was 15 degrees Fahrenheit. 2. Interview with CNA #3 on [DATE] at 3:20 PM revealed on [DATE] she was assigned to work the night shift on the Pine unit. The CNA revealed at approximately 4:30 AM on [DATE], CNA #1 came to the Pine unit to tell her they were unable to find resident #6. The CNA revealed around that same time, CNA #2 notified her that the resident had been found outside, deceased . The CNA revealed she was unsure how long the resident had been outside. CNA #3 stated the facility protocol was to go outside, prior to turning off the alarm, and visually check the area anytime an alarm sounded. The CNA further stated resident #6 was an exit seeking person. The CNA revealed on the night of the incident there were 3 CNAs and 1 nurse for the Pine and Cottonwood units. She revealed 1 CNA and the nurse floated between the units to assist with cares. The CNA revealed she did not see resident #6 during the shift. Further interview revealed staff on the Pine and Cottonwood units were expected to perform rounds on each resident every two hours to provide water, verify call light placement, and assist residents to the bathroom. She further revealed resident #6 needed assistance to toilet. 3. Interview with RN #1 on [DATE] at 8:19 PM revealed she was the charge nurse on the Pine and Cottonwood units for the night shift (6 PM to 6 AM) on [DATE]. She stated CNA #1 reported resident #6 was missing when he was performing 4 AM rounds. At that time the staff initiated a search, checked the rooms in the Cottonwood unit, and were unable to locate the resident. The RN revealed she told the CNA to check outside and she headed to the Pine unit to look for the resident. The RN revealed the CNA notified her resident #6 was outside before she made it to the Pine unit. The RN revealed the door alarms were supposed to go off and the CNA said he only heard an alarm at midnight. The RN revealed the CNA told her he did not go outside at that time because the doors would lock and he would not be able to get back into the facility. The RN stated she observed resident #6 around 11:30 PM or 12 AM when she administered medications to the resident and CNA #1 also reported seeing the resident around that time. 4. Interview with CNA #1 on [DATE] at 8:25 PM revealed he was the float CNA on the Pine and Cottonwood units during the night shift on [DATE]. The CNA revealed he found the resident outside between 4 AM and 4:30 AM. The CNA revealed he thought he observed resident #6 between 8 PM and 10 PM and did not see him/her during the 12 AM rounds as he was assisting on the Pine unit. The CNA revealed the door alarms went off twice during the shift, once between 8 PM and 10 PM and once around 11 PM. The CNA revealed he did not go outside and check for residents when the door alarms went off because there were other residents at the doors when the alarms sounded. 5. Attempts to interview CNA #2 were unsuccessful on [DATE] and [DATE]. The CNA's phone number indicated there were restrictions preventing the completion of the call. 6. Interview with nurse supervisor #1 on [DATE] at 5:25 PM revealed she was notified by CNA #3 that resident #6 was found outside, deceased , at approximately 4 AM. The nurse supervisor arrived at the facility around 4:30 AM or 4:45 AM and the administrator and law enforcement were already on the Cottonwood unit. At that time, she and the other nurse supervisor removed and replaced all staff assigned to the Cottonwood unit. 7. Interview with nurse supervisor #2 on [DATE] at 5:50 PM revealed she was the nurse on call the day of the incident involving resident #6. The nurse supervisor revealed she received a call about the incident from a CNA and she went to the building as a result. The nurse supervisor revealed upon arrival, the administrator, law enforcement, and the other nurse supervisor were already on the Cottonwood unit. She revealed at that time, she and the other nurse supervisor removed and replaced all staff assigned to the Cottonwood unit. 8. Interview with the DON and ADON on [DATE] at 1:40 PM confirmed the closed-circuit camera video showed resident #6 exit the facility at 7:08 PM, walk through the courtyard, and fall to the ground. The DON revealed the staff member observed on the video at 7:21 PM was CNA #2, and on the video the CNA performed actions that appeared to be silencing the alarm. She revealed when exit door alarms sounded, staff were expected to look outside for residents and confirmed that did not occur on [DATE] at 7:21 PM. Further interview verified the video showed the resident remained on the ground, in the same location until s/he was found by CNA #1 at 4:25 AM, 9 hours and 17 minutes after s/he exited the building. 9. Review of a facility policy titled Code W (Elopement/Exit Seeking) Wandering Resident or Patient last revised on ,d+[DATE] showed .1. Mitigation: Activities and interventions will be planned to reduce or eliminate wandering or escape risks to patients or residents. Every effort will be made to eliminate the risk of wandering residents or patients. Including: locked units, wander guard, staff rounding, door alarms, and/or one to one observation if a patient has altered mental status and requires close observation . 10. Based on the facility's failure to provide services that were necessary to prevent resident harm, it was determined there was an immediate jeopardy situation on [DATE] at 7:08 PM when resident #6 exited the Cottonwood unit without implementation of staff interventions. 11. Review of an Abatement Plan dated [DATE] showed the following interventions were implemented as a result of the incident: a. All staff on shift at the time of the incident were removed and replaced. b. Assessment of residents for high-risk wandering behaviors was initiated on [DATE]. c. Implementation of visual checks on wandering residents and spot checks for verification of visual checks was implemented on [DATE] at 3:57 PM. d. Door alarm function and maintenance audits were implemented immediately on [DATE]. Maintenance inspected and tested all doors to ensure functionality. Door alarm audits were initiated on [DATE]. e. Staff training was conducted to perform visual rounds on residents every two hours, identifying and managing high-risk wandering behaviors, proper response protocols when door alarm sounds, and documentation of reporting requirements for at-risk residents. In addition, resident education/training was performed to notify the nurse if they leave the facility. Staff Training was initiated on [DATE] at 4:11 PM and was ongoing prior to next scheduled shift for staff. f. AD HOC (when necessary or needed) Quality Assurance and Performance Improvement (QAPI) meeting was performed to discuss the incident and interventions. g. Ongoing preventive measures included regular reassessment of all residents for wandering risk during care plan reviews, QAPI monitoring and evaluation for effectiveness of interventions monthly, and emergency drills for elopement. h. Facility compliance was determined to be met on [DATE] when staff training was performed, per the education sign-in sheet. 12. The implementation of the Abatement Plan was verified during the survey and the immediate jeopardy was determined to have been removed on [DATE]; however, deficient practice remained at scope and severity of G.

Based on medical record review, staff interview, closed-circuit camera review, and policy and procedure review, the facility failed ensure residents received adequate supervision to prevent accidents for 1 of 3 sample residents (#6) reviewed for accident hazards. This failure resulted in the death of resident #6 who exited the facility without being noticed and was outside in winter weather conditions for 9 hours and 17 minutes. This failure resulted in the determination of immediate jeopardy due to a lack of implementation of interventions, including adequate resident supervision. On [DATE] there were 19 residents on the Cottonwood and Pine units who were identified as high-risk for wandering/elopement. Corrective measures were implemented prior to the survey and compliance was determined to be met on [DATE]. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #6 had a brief interview for mental status score of 3 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease. Further review showed the resident was dependent on staff for toileting hygiene, personal hygiene, bathing, and required substantial/maximal assistance with oral hygiene, upper and lower body dressing, putting on/taking off footwear, and toilet transfer. Review of the resident's activities of daily living care plan last revised on [DATE] showed the resident was able to walk independently. Review of the resident's elopement risk/wandering care plan initiated on [DATE] showed the resident had a history of exit seeking and wandering behaviors and interventions included Resident has had successful elopements from the courtyard and [s/he] needs close supervision when [s/he] is outside .Monitor location per nursing head count procedure. Document wandering behavior and attempted diversional interventions in behavioral log .The resident's triggers for exit seeking are restlessness and delusional thoughts [s/he] has to go somewhere . The following concerns were identified: a. Review of an Abuse or Neglect Investigation dated [DATE] showed staff on the Cottonwood unit were unable to locate resident #6 at approximately 4 AM. A search for the resident was initiated and the resident was located lying on the ground outside in the courtyard, without signs of life. The investigation indicated the closed-circuit television cameras showed the resident exit a door to the courtyard at 7:10 PM on [DATE], 9 hours and 15 minutes prior to being found. The facility immediately suspended RN #1, CNA #1, and CNA #2 pending investigation. b. Review of a closed circuit-camera video dated [DATE] and beginning at 6:59 PM showed 2 residents on the Cottonwood unit were seated inside the door. The video camera was outside, pointed toward the door, and there was snow visible on the grass and sidewalk. At 7:08:13 PM, resident #6 stood up and ambulated toward the door. The resident exited the Cottonwood unit into the courtyard at 7:08:32 PM and proceeded to walk toward the camera, away from the door, until s/he was no longer visible on the camera, at 7:09:09 PM. At that time, the resident was wearing a long-sleeved shirt, blue jeans or slacks, slippers, and s/he was walking with a shuffled gait. Continued review showed the other resident remained seated in a chair inside the Cottonwood unit. At 7:21:47 PM, 12 minutes after resident #6 exited the Cottonwood unit, a staff member, who was inside the building, walked toward the exit door. The staff member reached toward something on the right-hand side of the door, then walk away without exiting the door or observing the courtyard outside the Cottonwood unit. Review of a second closed-circuit camera video dated [DATE] and beginning at 7:06:34 PM, showed a broad view of the courtyard areas of the Pine and Cottonwood units, where snow was visible throughout the courtyards, including on the walkways. On [DATE] at 7:09:32, resident #6 was observed entering the camera's view and ambulating toward the facility. The resident continued to ambulate with his/her arms out to the side until the resident falls to the ground, into the snow, at 7:10:51 PM. Resident #6 continued to move around, in what appeared to be efforts to get up, until his/her movement is not discernable at 7:20 PM. The resident continued to lay in the outside courtyard, in the snow, until the end of the video at 9 PM. Review of a closed-circuit camera video of the Cottonwood and Pine courtyards dated [DATE] and beginning at 8:59:33 PM showed resident #6 remained lying in the outside courtyard, in the snow, until the end of the video on [DATE] at 12:00:12 AM. Review of a closed-circuit video of the Cottonwood and Pine courtyards dated [DATE] and beginning at 12 AM showed resident #6 lying in the outside courtyard, in the snow. On [DATE] at 4:25:22 AM, an individual is observed exiting the facility into the courtyard. The individual was holding a flashlight and walked toward where the resident was lying on the ground. At 4:25:34 AM, the individual observed the resident on the ground, turns, and runs back into the facility, then returns to the resident. Another individual is observed exiting the facility and walking toward the resident at 4:25:47 AM, 9 hours and 17 minutes after resident #6 exited the Cottonwood unit. c. Review of climate-data.org showed the high temperature in the facility's location on [DATE] was 36 degrees Fahrenheit and the low temperature was 15 degrees Fahrenheit. Further review showed the high temperature on [DATE] was 33 degrees Fahrenheit and the low temperature was 15 degrees Fahrenheit. 2. Interview with CNA #3 on [DATE] at 3:20 PM revealed on [DATE] she was assigned to work the night shift on the Pine unit. The CNA revealed at approximately 4:30 AM on [DATE], CNA #1 came to the Pine unit to tell her they were unable to find resident #6. The CNA revealed around that same time, CNA #2 notified her that the resident had been found outside, deceased . The CNA revealed she was unsure how long the resident had been outside. CNA #3 stated the facility protocol was to go outside, prior to turning off the alarm, and visually check the area anytime an alarm sounded. The CNA further stated resident #6 was an exit seeking person. The CNA revealed on the night of the incident there were 3 CNAs and 1 nurse for the Pine and Cottonwood units. She revealed 1 CNA and the nurse floated between the units to assist with cares. The CNA revealed she did not see resident #6 during the shift. Further interview revealed staff on the Pine and Cottonwood units were expected to perform rounds on each resident every two hours to provide water, verify call light placement, and assist residents to the bathroom. She further revealed resident #6 needed assistance to toilet. 3. Interview with RN #1 on [DATE] at 8:19 PM revealed she was the charge nurse on the Pine and Cottonwood units for the night shift (6 PM to 6 AM) on [DATE]. She stated CNA #1 reported resident #6 was missing when he was performing 4 AM rounds. At that time the staff initiated a search, checked the rooms in the Cottonwood unit, and were unable to locate the resident. The RN revealed she told the CNA to check outside and she headed to the Pine unit to look for the resident. The RN revealed the CNA notified her resident #6 was outside before she made it to the Pine unit. The RN revealed the door alarms were supposed to go off and the CNA said he only heard an alarm at midnight. The RN revealed the CNA told her he did not go outside at that time because the doors would lock and he would not be able to get back into the facility. The RN stated she observed resident #6 around 11:30 PM or 12 AM when she administered medications to the resident and CNA #1 also reported seeing the resident around that time. 4. Interview with CNA #1 on [DATE] at 8:25 PM revealed he was the float CNA on the Pine and Cottonwood units during the night shift on [DATE]. The CNA revealed he found the resident outside between 4 AM and 4:30 AM. The CNA revealed he thought he observed resident #6 between 8 PM and 10 PM and did not see him/her during the 12 AM rounds as he was assisting on the Pine unit. The CNA revealed the door alarms went off twice during the shift, once between 8 PM and 10 PM and once around 11 PM. The CNA revealed he did not go outside and check for residents when the door alarms went off because there were other residents at the doors when the alarms sounded. 5. Attempts to interview CNA #2 were unsuccessful on [DATE] and [DATE]. The CNA's phone number indicated there were restrictions preventing the completion of the call. 6. Interview with nurse supervisor #1 on [DATE] at 5:25 PM revealed she was notified by CNA #3 that resident #6 was found outside, deceased , at approximately 4 AM. The nurse supervisor arrived at the facility around 4:30 AM or 4:45 AM and the administrator and law enforcement were already on the Cottonwood unit. At that time, she and the other nurse supervisor removed and replaced all staff assigned to the Cottonwood unit. 7. Interview with nurse supervisor #2 on [DATE] at 5:50 PM revealed she was the nurse on call the day of the incident involving resident #6. The nurse supervisor revealed she received a call about the incident from a CNA and she went to the building as a result. The nurse supervisor revealed upon arrival, the administrator, law enforcement, and the other nurse supervisor were already on the Cottonwood unit. She revealed at that time, she and the other nurse supervisor removed and replaced all staff assigned to the Cottonwood unit. 8. Interview with the DON and ADON on [DATE] at 1:40 PM confirmed the closed-circuit camera video showed resident #6 exit the facility at 7:08 PM, walk through the courtyard, and fall to the ground. The DON revealed the staff member observed on the video at 7:21 PM was CNA #2, and on the video the CNA performed actions that appeared to be silencing the alarm. She revealed when exit door alarms sounded, staff were expected to look outside for residents and confirmed that did not occur on [DATE] at 7:21 PM. Further interview verified the video showed the resident remained on the ground, in the same location until s/he was found by CNA #1 at 4:25 AM, 9 hours and 17 minutes after s/he exited the building. 9. Review of a facility policy titled Code W (Elopement/Exit Seeking) Wandering Resident or Patient last revised on ,d+[DATE] showed .1. Mitigation: Activities and interventions will be planned to reduce or eliminate wandering or escape risks to patients or residents. Every effort will be made to eliminate the risk of wandering residents or patients. Including: locked units, wander guard, staff rounding, door alarms, and/or one to one observation if a patient has altered mental status and requires close observation . 10. Based on the facility's failure to provide services that were necessary to prevent resident harm, it was determined there was an immediate jeopardy situation on [DATE] at 7:08 PM when resident #6 exited the Cottonwood unit without implementation of staff interventions. 11. Review of an Abatement Plan dated [DATE] showed the following interventions were implemented as a result of the incident: a. All staff on shift at the time of the incident were removed and replaced. b. Assessment of residents for high-risk wandering behaviors was initiated on [DATE]. c. Implementation of visual checks on wandering residents and spot checks for verification of visual checks was implemented on [DATE] at 3:57 PM. d. Door alarm function and maintenance audits were implemented immediately on [DATE]. Maintenance inspected and tested all doors to ensure functionality. Door alarm audits were initiated on [DATE]. e. Staff training was conducted to perform visual rounds on residents every two hours, identifying and managing high-risk wandering behaviors, proper response protocols when door alarm sounds, and documentation of reporting requirements for at-risk residents. In addition, resident education/training was performed to notify the nurse if they leave the facility. Staff Training was initiated on [DATE] at 4:11 PM and was ongoing prior to next scheduled shift for staff. f. AD HOC (when necessary or needed) Quality Assurance and Performance Improvement (QAPI) meeting was performed to discuss the incident and interventions. g. Ongoing preventive measures included regular reassessment of all residents for wandering risk during care plan reviews, QAPI monitoring and evaluation for effectiveness of interventions monthly, and emergency drills for elopement. h. Facility compliance was determined to be met on [DATE] when staff training was performed, per the education sign-in sheet. 12. The implementation of the Abatement Plan was verified during the survey and the immediate jeopardy was determined to have been removed on [DATE]; however, deficient practice remained at scope and severity of G.

Based on medical record review and physician and staff interview, the facility failed to respond to a change of condition for 1 of 4 sample residents (#3) who experienced a change of condition. This failure resulted in actual harm to resident #3 who reported health concerns and passed away. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #3 had a brief interview for mental status score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included heart failure, hypertension, peripheral vascular disease, diabetes mellitus, cerebrovascular accident, anxiety disorder, depression, and asthma. Further review showed the resident required supervision or touching assistance with transfer and toileting hygiene. The following concerns were identified: a. Review of a progress note dated [DATE] and timed 7:30 AM showed .Nurse called to room per staff with resident c/o [complaints of] feeling like [s/he] has Pneumonia and wants an ambulance to the hospital. Vital signs WNL [within normal limits]. No distress noted. Lungs clear to auscultation all fields. O2 sats [oxygen saturation] 91% on 3 L [liters] O2 via NC [nasal cannula]. Resident states [s/he] coughed all night and wanted to go to hospital. No cough noted. Duoneb treatment given. Resident has no more complaints and is in bed asleep . b. Review of a progress note dated [DATE] and timed 2:56 PM showed .Write [sic] in resident's room to evaluate for c/o heart attack. Vital signs ,d+[DATE], 97, 20, 98.7, 91% on 3 L O2 via NC. Resident states that [s/he] has been having chest pain since last night but is unable to rate pain. [S/he] says that [s/he] did not sleep well last night and just wants to lay back in [his/her] bed. Resident assisted to bathroom and back to bed. Denies any chest pain at this time . c. Review of a progress note dated [DATE] and timed 5:50 AM showed the resident was found unresponsive and cardiopulmonary resuscitation, which included chest compressions, was implemented. EMS arrived and pronounced the resident deceased at 5:02 AM. d. Interview with housekeeper #1 on [DATE] at 2:52 PM revealed on [DATE] around 2:30 PM she entered the resident's room and the resident told the housekeeper s/he had a F-ing heart attack last night and the nurse didn't give a shit. The housekeeper reported the concerns to the CNAs on the floor and they said they had reported it to the nurse; however, she had not done anything. The housekeeper revealed when the she returned to the resident's room, she said a prayer with the resident and then the resident fell asleep. Further interview revealed the housekeeper also reported the resident's concerns to her supervisor and her supervisor reported it to the building charge nurse. e. Interview with MA-C #1 on [DATE] at 3:30 PM revealed she worked with the resident on [DATE], the day before s/he passed away. The MA-C revealed the resident reported not feeling well and s/he just wanted to sleep. The MA-C revealed she reported the resident's condition to LPN #3; however, she was unsure what the LPN had done. f. Interview with CNA #4 on [DATE] at 3:33 PM revealed she had received report on [DATE] that resident #3 was not feeling well. The CNA stated at 6:30 AM the resident felt s/he needed to go to the hospital and s/he thought s/he had pneumonia. The CNA reported the concerns to the nurse; however, the resident remained at the facility. The CNA revealed the resident continued to have concerns throughout the day which included needing assistance with transfers, incontinence, and seizure-like shaking during toileting, which were not normal for the resident. Further interview revealed LPN #3 did not respond to the resident's concerns and stated oh well [his/her] vitals are fine. g. Interview with RN #3 on [DATE] at 4:26 PM revealed she was the building charge nurse on [DATE]. The RN revealed she was notified by environmental services about concerns made by the resident. The RN revealed she called down and talked to LPN #3 who reported the resident's vital signs were normal; however, RN #3 asked her to check on the resident. The RN revealed when she contacted LPN #3 later to follow-up on the concerns, LPN #3 told her the resident said s/he didn't have any chest pain. h. Interview with CNA #5 on [DATE] at 4:30 PM revealed on [DATE] the resident was having a difficult time getting out of bed and needed to use the mechanical lift. The CNA stated the resident was not his/her normal self and she reported the concerns to LPN #3 multiple times. The CNA revealed she felt like she was ignored by the nurse and the resident passed away the following day. i. Interview with the resident's physician and nurse practitioner #1 on [DATE] at 8:02 AM confirmed they were not notified of any concerns or change in condition for the resident on [DATE]. They revealed regardless of complaints, if a resident verbalized a desire to go to the hospital, they would expect the nurse to contact them and then send the resident for evaluation. In addition, the physician indicated with all the reported complaints she would expect the nurse to contact her to notify her of a possible change in condition. 2. Interview with LPN #1 on [DATE] at 5:59 PM revealed she took over care of the resident on the night shift (6 PM to 6 AM) on [DATE]. She revealed when RN #2 had given her report at shift change, she reported the resident had not been feeling well; however, she did not indicate she had contacted the physician. The LPN revealed she interacted with the resident during the shift when she provided scheduled medications and the resident did not report any concerns at that time. The LPN revealed the CNA found the resident unresponsive around 4 AM on [DATE] and staff began a lifesaving intervention. 3. Interview with LPN #3 on [DATE] at 8:08 PM revealed on [DATE] the CNA reported the resident thought s/he had pneumonia and s/he wanted to go to the bathroom around 7 AM. At that time, LPN #3 went to the resident's room and listened to the resident's lungs which were clear. The LPN revealed she offered the resident Mucinex and a breathing treatment and the resident accepted the breathing treatment. The LPN revealed when she returned to the resident's room, the resident was sleeping. The LPN stated the CNA reported the resident had verbalized concerns about having a heart attack, to the housekeeper, around noon. The LPN revealed when she checked the resident, s/he did not report any concerns and told the LPN s/he wanted to go to bed. The LPN revealed she obtained vital signs which were within normal limits. The LPN confirmed she did not notify the resident's physician and she was suspended, then terminated, after the resident passed away. 4. Interview with the DON and ADON on [DATE] at 1:40 PM revealed they expected the nurses to notify the provider of all resident changes in condition and resident requests for hospitalization . The DON confirmed LPN #3 did not work after [DATE] and she was terminated from the facility as a result of not responding to the resident's change of condition. Further interview confirmed the nurse did provide the resident with an as needed medication related to his/her complaints.

Based on medical record review, resident representative and staff interview, facility investigation review, and policy and procedure review, the facility failed to ensure a resident's right to be free from physical abuse, verbal abuse, and neglect for 1 of 6 sample residents (#1). The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 6/18/24. 1. Review of a quarterly MDS assessment dated [DATE] showed resident #1 had brief interview for mental status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. The resident had behaviors which included inattention, disorganized thinking, delusions and wandering and s/he was totally dependent on staff for toileting, showering, dressing and personal hygiene. Further review showed the resident had diagnoses which included dementia with other behavioral disturbance, anxiety, transient alteration of awareness, muscle weakness, and need for assistance with personal care. The following concern was identified: a. Review of the facility investigation showed an incident reported on 5/23/24. The investigation showed CNA #2 was observed, via audio/video surveillance, to have several nights without rounding on resident #1 despite claiming she rounded every two hours. The CNA was observed leaving the resident unattended in the bathroom, and the CNA was observed entering the resident's room, at times, without providing resident care. The investigation showed the resident was found attempting to dress and self-propel his/herself out of the bathroom, causing the resident to fall, and showed the resident had gone 13 hours without being checked during the CNA's shift. Further review showed other staff had voiced concerns with the CNA related to the conditions of residents found upon change of shift and what was reported to them, such as saturated briefs and beds, clothing, dentures still in residents' mouths, dried feces, and dried urine left on beds under clean incontinence pads. b. Review of an incident report dated 5/26/27 showed the resident's daughter had provided video footage, with audio, of CNA #1 verbally and physically abusing resident #1. The incident report showed the footage had evidence of the CNA physically pushing the resident in bed and pulling the resident up by one arm, the CNA telling the resident she hated entering the room, and asking the resident what s/he needed. The incident report showed the CNA entered the resident's room several times stating I just took you to the bathroom, you just hit your call light, returning to the room [ROOM NUMBER] minutes later and turning the call light off, slapping his/her hands to his/her hips, and stating you keep turning the call light on. Further review showed the CNA used verbal tone with body language that was aggressive and threatening, and refused to take the resident to the bathroom. The resident made comments following the incident which included you sure I won't get in trouble if I call for help? c. Review of a progress note dated 5/27/24 and timed 10:30 AM showed .COMMUNICATION - with Physician .SBAR Summary: Situation: Resident's (dtr) daughter came into the facility (@) at 945 wanting to speak to the nurse over the unit with some concerns with Saturday and Sunday night shift CNA that worked the unit. Resident's dtr proceeded to show various incidents that were caught on the video camera in the room throughout the night that showed verbal frustration towards resident and an incident that showed potential physical roughness towards the resident when placing resident into the bed. Nurse told dtr that management would be notified promptly to address her concerns. Nurse left resident's room and placed call to the on-call Nursing Management @ 1008 with information received. Assessment (RN)/Appearance (LPN): Resident's skin is clean, dry, and intact with appropriate bruising to R hand from prior day's lab draw from this nurse. ROM is WNL with no s/s of discomfort or injury. Resident's VS WNL for resident. d. Review of a progress note dated 5/27/24 and timed 2:03 PM showed .COMMUNICATION - with Physician .Situation: When laying resident down for rest periods in bed when resident is shown the call light and instructed to call for help resident follows up with statement; Are you sure I can call for help? I won't get in trouble. Assessment (RN)/Appearance (LPN): After resident's incident has had a change in behavior when transferring to bed noted by staff and nurse. Resident appears fearful and making statements as above. The behavior and statements are new to resident. Resident during other cares and periods appears at ease and not in distress with baseline interactions. e. Interview with CNA #1 on 6/19/24 at 11:53 AM revealed she had complained to the administration for months about being overwhelmed and needing help. She stated the resident would call and she didn't know what the resident wanted. The CNA revealed she went to the nurse trying to figure out what the resident wanted. The CNA revealed she had no intention of hurting the resident. She revealed the resident was going to sit on the floor and she had pushed the resident toward the bed to keep him/her from falling. The CNA stated she was crying and frustrated and she had asked for help prior to the shift. f. CNA #2 was not available for an interview. 2. Interview with the resident representative on 6/19/24 at 1 PM revealed the resident felt safe since the doors were closed between the 2 units and she stated staff were treating the resident ok. 3. Review of a policy titled Abuse provided by the administrator on 6/18/24 at 1:50 PM showed . Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion . 4. The following plan of correction was implemented by the facility by 6/18/24: a. Corrective actions included resident assessment, CNA suspension during the investigation, facility reported to adult protection agency, state survey agency, and state board of nursing, and disciplinary action for the perpetrators. b. System changes included coaching and education, CNA monitoring, training on rounding requirements and expectations, staff reassignment, and staff education on abuse and neglect b. Identification of others included staff and resident interviews. c. Monitoring included review of CNA audits.

Based on medical record review, staff interview, policy and procedure review, and review of the state licensing division incident report form, the facility failed to protect the resident's right to be free from abuse by another resident for 3 of 10 residents reviewed for abuse (#26, #63, #106). This failure resulted in harm to resident #106 who experienced sexual abuse. The findings were: 1. Review of the [DATE] admission MDS assessment for resident #106 showed s/he was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. The resident had a BIMS score of ,d+[DATE] (severe cognitive impairment), did not exhibit any behaviors, and require supervision or touching for walking up to 50 feet. The following concerns were identified: a. Review of a [DATE] alert note showed CNA notified writer that another resident was found with [his/her] hand up this residents shirt touching [resident's upper chest]. CNA immediately separated residents and notified writer. Writer assessed receiving resident and initiating resident for skin concerns and found nothing to report. Resident accepted being moved away from initiating resident without issue. b. Review of a [DATE] Risk Management Review Note showed a physical interaction occurred where a resident, [identified as resident #28], had [his/her] hand up a resident's shirt. The residents were immediately separated and monitored for distress. The root cause was determined to be poor impulse control of other resident [resident #28] and impaired cognition of both residents. c. Interview with the resident's representative on [DATE] at 1:49 PM confirmed the resident had been involved in an incident where another resident had placed his/her hands up the resident's shirt. The resident's representative stated it was very upsetting and the resident would have been horrified if s/he was cognitively intact. d. Review of a [DATE] progress note showed resident #28 had his/her hand down another resident's pants. Interview on [DATE] at 3:27 PM with medication aide #1 revealed she had observed resident #28 with his/her hands positioned in the waistband of another resident's pants. The medication aide revealed the resident's hand was not far into the waistband and away from the perineal area of the other resident. The medication aide revealed the other resident did not react to the placement of resident #28's hand and neither resident was concerned with the interaction; however, she separated the residents, placed them on increased monitoring, and assisted resident #28 to activities. Further interview revealed resident #28 had not had any previous sexual incidents prior to [DATE]. e. Interview with the DON and ADON on [DATE] at 2:16 PM revealed the facility had not followed up on the incident which occurred on [DATE] and were unable to identify the resident involved at the time of the interview. 2. Review of the [DATE] quarterly MDS assessment showed resident #63 was admitted to the facility on [DATE]. The resident had a BIMS score of ,d+[DATE] (severe cognitive impairment), did not exhibit any behaviors, and had diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, dementia, and anxiety disorder. The following concerns were identified: a. Review of a [DATE] physician communication note showed Resident involved in a resident to resident with the other resident being the aggressor. Other resident grabbed [resident name] left forearm and attempted to twist it. This caused bruising and broke the skin is (sic) in three areas. Wound was cleansed well and dressed per protocol. The resident causing the injury was identified as resident #62. b. Review of the Summary of Investigation report concluded that physical abuse did occur to resident #63 as inflicted by resident #62. It was determined resident #62 had become overstimulated during the day which led to the altercation. c. Interview with the ADON and the DON on [DATE] at 3 PM confirmed the injury to resident #63 did occur; however, documentation of the extent of the skin tears and post-event monitoring of the injuries could not be located. 3. Review of a Summary of Investigation report showed a resident-to-resident altercation took place on [DATE] at 1:40 PM which involved resident #26 and resident #114. Resident #114 pushed resident #26 which resulted in resident #26 falling and hitting his/her head on the floor. Both residents were transported by ambulance to the emergency department. Resident #26 did not require stitches and the CT scan performed was negative. Interventions included one-to-one staff supervision for resident #114 for behaviors and resident safety following return from the hospital. Interview with LPN #1 on [DATE] at 8:24 AM revealed resident #114 was very difficult as s/he refused medications and had aggressive behaviors. Resident #114 expired on [DATE]. 4. Review of the [NAME] County Memorial Hospital Long Term Care Abuse Policy, last reviewed on [DATE], showed INTENT: Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. STANDARDS: 1. Providing a safe environment for the resident is one of the most basic and essential duties of our facility .3. This facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals .ABUSE BY OTHER RESIDENTS .If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening.

Based on observation, medical record review, and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (#98) reviewed for dementia care. This failure resulted in actual harm to resident #98. The findings were: 1. Review of the 2/9/24 significant change MDS assessment for resident #98 showed the resident was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, traumatic brain injury, and depression. The resident had a staff assessment which determined the resident to have severe cognitive impairment. Further review showed the resident had not been prescribed any high-risk medications. Review of the resident's care plan, initiated on 10/20/23, showed the resident was at risk for elopement and wandering related to dementia. The staff were to intervene as appropriate. The following concerns were identified: a. Review of the resident's pain care plan, last revised 5/10/24, showed Administer pain medications per order, if non-medication interventions are ineffective. The care plan failed to include what the non-medication interventions were. b. Review of the care plan, initiated on 4/18/24, showed the resident had the potential to be physically aggressive related to dementia, poor impulse control, and neurological deficits. The interventions included a directive to Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. There was no evidence the facility had completed the analysis and developed a resident-centered comprehensive care plan. c. Review of the care plan for fall prevention, dated 12/26/23, showed Resident frequently chooses to urinate on the floor, [in his/her] room and also in other residents restroom. Monitory (sic) for wet floors often. d. Review of the neurological care plan, initiated on 1/19/24, showed the resident had an alteration in neurological status related to a head injury. The interventions included cueing, reorientation as needed, reposition or ambulation as tolerated. There was no evidence the facility had developed or implemented interventions to address the resident's neurological deficits. e. Review of the 2/9/24 significant change MDS assessment showed the resident did not exhibit physical or verbal behaviors towards self or towards others, did not wander, and rejected care 4 to 6 days of the look-back period. The resident was coded as having improved behavior since the prior assessment. f. Review of the 5/21/24 Regulatory Progress Note showed the resident was resistant to participate in review of systems. [S/he] does not allow for assessment and dismisses this provider .[s/he] does have behavioral disturbances of pushing, cursing or name-calling, grabbing, yelling and screaming, kicking and hitting toward staff. [S/he] does not have any behaviors directed at other residents. [S/he] does have an occasion of refusing care as well as self-neglect and throwing or smearing bodily waste .Staff report resident is compliant with medications but generally does not allow for cares or assessment. There are otherwise no additional concerns per staff. Further review of the progress note showed no assessment or behavioral care plan had been developed. g. Review of the 5/22/24 Multidisciplinary Care Conference note showed the resident was incontinent of bowel and bladder; resistive to cares being physical and verbally abuse towards staff. The resident was able to ambulate independently and can be found walking amongst the neighborhood and checking in on other residents. Currently, there is a barrier with having incontinent episodes and the behaviors that come when [s/he] offered to be cleaned. The most recent provider visit was unsuccessful, as resident denied participation. Further review of the care conference note showed no indication of an assessment to address the resident's behaviors and wandering. The care plan summary showed it had been reviewed with the patient and family; however, it had not been updated. h. Review of a behavior note, dated 3/9/24 and timed 9:36 AM, showed resident intruding into Pine [male/female] residents room, removing cue entry/name signs from the door and belongings from inside room. [Male/female] resident's [spouse] expressed anger that resident intrudes into [the resident's] room, stating it is an invasion of [the resident's] privacy and [s/he] requested something to be done about it immediately. This nurse and nursing staff increase rounding on resident to keep watch on [his/her] wandering throughout unit. i. Review of CNA documentation, dated 3/13/24 and timed 11:14 PM, showed Resident has been going into other residents rooms continuously. Try to redirect [him/her] to [his/her] own room and then goes back into others rooms. Continue to redirect. j. Review of CNA documentation, dated 3/14/24 and timed 12:04 AM, showed Resident entered another residents room while I was in the middle of changing the resident and asked [him/her] to leave numerous times before [s/he] finally left. k. Review of CNA documentation, dated 3/14/24 and timed 4:01 AM, showed Resident used call button in bathroom, went in to help [him/her] get out of feces brief and resident started pushing me away while trying to clean [his/her] bottom resident was hitting and punching me and almost fell due to [his/her] behaviors got resident stable in [his/her] step and let [him/her] walk to [his/her] bed. l. Review of a behavior note, dated 3/14/24 and timed 7:30 PM, showed Resident pacing and wandering unit throughout the day. [S/he] wanders into nurses/CNA stations and grabs staff belongings and tries to drink out of staff water bottles. [S/he] tries to go through papers/forms and desk items as well. Resident becomes agitated and belligerent when attempting to redirect, striking out at staff at times. Resident also observed going into other residents rooms and taking clothes and belongings. [S/he] requires constant supervision. m. Review of a behavior note, dated 3/17/24, showed Resident has had an incontinent episode of bowel. Took resident to room to be changed. Resident combative with staff, stepping on staff's feet and kicking at them while staff is trying to clean resident. Was not able to get resident cleaned up all the way D/T (due to) the resident kept being combative. Gave resident [his/her] clothes to get dressed and left the room. n. Review of a 3/18/24 behavior note showed While trying to shower [resident name] due to have BM (bowel movement) all over [his/her] legs and hands, [resident name] became very combative with CNAs by trying to hit and scratch them. CNA tried talking to [resident name] and explaining what they are doing and the reason for [his/her] shower but were unable to redirect [his/her] behavior during [his/her] shower. o. Review of an alert note, dated 3/26/24, showed Resident observed sitting on the floor in hallway; Unable to recall what happened; Was incontinent of BM and had BM all over [him/her] Resident is combative, kicking and hitting at staff the whole time we are trying to assist up and to the shower. Stayed combative the whole time while showering. Noted a small abrasion to right knee, and bruising to right great toe; Unsure if resident hit [his/her] head so neuro's where (sic) were initiated. p. Review of a behavior note, dated 3/27/24 and timed 1:42 AM, showed Resident found in room [ROOM NUMBER] (Pine unit) and was eating a snack. [S/he] told resident of that room I'm gonna eat you CNA removed resident from room. q. Review of an alert note, dated 4/8/24 and timed 5:25 AM, showed Resident paced the hallways for the entirety of the shift. [Resident] spent long periods of time at the end of the hallway. [Resident] found to have urinated all over the floor. Floors cleaned. [Resident] also spent the shift switching shoes back and forth with another resident . r. Review of a 5/12/24 incident report showed resident #98 was involved in an unwitnessed resident-to-resident altercation involving resident #28. Resident #98 resided in the Cottonwood unit and walked over to the Pine unit on 5/12/24 when at 6 PM CNAs heard yelling and responded to find resident #98 with a scratched earlobe. Resident #98 stated s/he had been hit by resident #28. Resident #28 responded with damn straight I did, [s/he] stole from me. The facility finalized the incident as inconclusive because it was not witnessed. s. Review of a behavior note, dated 5/15/24, showed Resident is at the end of the hall, going to the corner and peeing on the floors. Is trying to take [his/her] brief off and digging feces out of [his/her] brief and throwing it all over the end of the hallway, on the walls, furniture and floor; is not directable, will not follow commands; Assisted x4 assist to the shower and was combative with staff the whole time getting a shower. t. Review of a behavior note, dated 5/19/24 and timed 6:06 AM, showed at approximately 4:30 AM the cottonwood CNA found [resident name] drinking a bottle of hand sanitizer. The amount the resident drank was unknown; however, the bottle was 3/4 full when the CNA found the resident. u. Review of a 5/19/24 behavior note showed Resident has been changed two times this shift thus far d/t (due to) diarrhea and each time is combative toward staff hitting and kicking at staff. Try to redirect but continues to be combative. v. Review of a progress note, dated 5/19/24 and timed 5:06 AM, showed Resident had a large liquid bowel movement in addition to one episode of emesis. Resident had been going through both kitchens when staff were busy with other residents and eating several different things . 2. Interview with LPN #1 on 5/23/24 at 8:24 AM revealed resident #98 from the Cottonwood unit would wander into resident rooms on the Pine unit which upsets the [residents] over there. The LPN stated staff would attempt to redirect the resident back to the Cottonwood unit; however, redirecting the resident was difficult at times as s/he often refused. 3. Interview with CNA #1 on 5/23/24 at 8:35 AM revealed the resident was very difficult to care for, exhibited aggressive behaviors, and wandered into other resident's rooms. The CNA stated the resident had recently been staying in the back hallway and she would check on him/her every 2 hours; however, the resident often refused incontinence care. 4. Interview with CNA #2 on 5/23/24 at 8:43 AM revealed the resident would come into the Pine unit and urinate and defecate on the floor and wander into other resident's rooms. 5. Interview with the DON and ADON on 5/23/24 at 2:26 PM revealed the facility monitored the resident's behaviors and relied on evaluations and assessments from providers to assist with managing a resident that exhibited behaviors. The DON confirmed a thorough analysis of what triggered the resident's behaviors and interventions and a professional evaluation of the resident had not been completed.

Based on observation, staff interview, review of policy and procedures, and review of the 2022 FDA Food Code, the facility failed to ensure temperatures were monitored for 6 of 6 refrigerator/freezers which stored food for resident use outside of the kitchen (Cottonwood, Pine, Birch, Rehab, Spruce, first floor servery and second floor servery). In addition, the facility failed to ensure a sanitary environment in 1 of 1 food preparation area. The census was 116. The findings were: 1. Observation on 5/23/24 of the refrigerator/freezers outside of the kitchen showed the following concerns: a. The Frigidaire Gallery refrigerator located in the Cottonwood unit had milk, cheese, cottage cheese, and juices available for resident use. The thermometer located on the outside of the refrigerator showed a temperature of 35 degrees Fahrenheit (F) and the thermometer inside the refrigerator showed a temperature of 42 degrees F. b. The Frigidaire Gallery refrigerator located in the Pine unit had milk, yogurt, juice, and sandwiches available for resident use. The thermometer located on the outside of the refrigerator showed a temperature of 35 degrees F and the thermometer inside the refrigerator showed a temperature of 42 degrees F. c. The Delfield refrigerator located in the Cottonwood and Pine servery had thickened liquids, fortified drinks, pop, juice and sandwiches available for resident use. The thermometer located on the outside of the refrigerator showed a temperature of 38 degrees F. There was no thermometer inside of the refrigerator. d. The Delfield refrigerator located in the Birch servery had thickened liquids and fortified drinks available for resident use. The thermometer located on the outside of the refrigerator showed a temperature reading of def and inside thermometer reading of 38 degrees F. e. The Frigidaire Gallery refrigerator located in the Spruce unit had drinks, fruit, and sandwiches available for resident use. The thermometer located on the outside of the refrigerator showed a temperature of 38 degrees F and the thermometer inside the refrigerator showed a temperature of 42 degrees F. f. Interview with the dietitian on 5/23/24 at 11:40 AM revealed monitoring of the refrigerators and freezers on the units was not being done. 2. Observation on 5/22/24 at 11:20 AM showed cook #1 used gloved hands to place raw hamburger patties on a paper-lined baking sheet. After completing the task, the cook discarded his gloves and without performing hand hygiene donned new gloves and proceeded to pick up seasoning containers. Interview with the dietitian on 5/22/23 at 11:25 AM confirmed the dietary aide should have performed hand hygiene after taking off his gloves. The dietitian educated the dietary aide at that time. In addition, the dietitian revealed she required the kitchen staff to complete the Serve Safe certification within 3 months of hire. In an additional interview with the dietitian on 5/23/24 at 3 PM revealed the cook was to complete his Serve Safe certification by 4/30/24; however, as of 5/23/24 it had not been completed. 3. Review of the Food Storage/Inventory policy dated 8/2023, provided by the Infection Control nurse on 5/22/24, showed .7. All perishable items are stored in either refrigerators maintained at a temperature of 40 degrees F or below or freezers maintained between temperatures of 10 degrees F or below .10. A reliable thermometer is provided for each reach-in or walk-in refrigerator and freezer in an easily readable location. Refrigerator/freezer temperatures are documented daily using approve [sic] temperature logs. Any corrective actions are reported to supervisors immediately. 4. According to the 2022 FDA Food Code 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that . (I) EMPLOYEES are properly maintaining the temperatures of TIME/TEMPERATURE CONTROL FOR SAFETY FOODS during hot and cold holding through daily oversight of the EMPLOYEES' routine monitoring of FOOD temperatures . 5. According to the 2022 FDA Food Code showed 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

Based on resident and staff interview, medical record review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 2 sample residents (#5). This failure resulted in actual harm to resident #5 who had injuries to his/her hands/wrists. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 2/15/24. The findings were: 1. Review of resident #5's quarterly MDS assessment dated [DATE] showed the resident had a brief interview for mental status (BIMS) score of 3 out of 15 which indicated severe cognitive impairment. The resident had diagnoses which included non-Alzheimer's dementia. Review of the care plan provided by the facility on 2/27/24 showed Activity of Daily Living (ADL) self-care performance deficit related to dementia, poor safety awareness. Does not like showers. [Residents name] frequently has refusals of care, family states this is common behavior prior to admission. [S/he] is resistive to bathing and family reports [s/he] once went 3 weeks without bathing while [s/he] was in their care. The following concerns were identified: a. Review of a progress note dated 2/7/24 and timed 2:32 PM showed Nursing progress note: Resident continues to refuse shower, after CNA and nurse re-approach and encouragement. b. Review of a progress note dated 2/9/24 and timed 11:56 PM showed Alert Note, late entry: Voicemail left for daughter to notify of events of previous evening. c. Review of a progress note dated 2/9/24 and timed 2:44 PM showed Nursing Progress note resident was to go ER to have [his/her] hands/wrists x-rayed and refused to go [s/he] would not get out of [his/her] chair and adamantly refused to go. I called [his/her] daughter and granddaughter to let them know granddaughter will be up tonight to check on [him/her] and [s/he] feels that is necessary [s/he] will let us know and help with getting [him/her] to get an x-ray. Doctor was informed of the situation and states that is ok. d. Review of a progress note dated 2/9/24 and timed 7:05 PM showed Nursing progress note spoke with residents' granddaughter as her aunt received a call from CEO and I let her know what was shared with me about the shower resident received last night that it took 3 to give [him/her] a shower and [s/he] sat on the floor of the shower so they finished [his/her] shower with resident on the floor. Residents granddaughter reports resident complaining of back being sore she said no bruising to back, and stated no concerns with [his/her] hands and the bruising on them good range of motion to hands and arms. 2. Review of the Alleged Assailant Summary of the interview for CNA #1 showed Due for shower. Notified RN #1 that [s/he] refuses shower. Told to try tub and [s/he] refuses that too. 18 days since last shower. Family no longer. Told RN 31 that s/he was a shower and I will try. [resident name] reported shower yesterday and said no. I will do when I'm ready. Other aide approached. Agree to shower with 1 person. [CNA #2] told [s/he] can take [him/her] to shower. Then said [s/he] would have to wait, was picking up crumbs when by fridge, told [him/her] its time. Reached to hand to guide. Started screaming like death and dropped [his/her] self to floor. Reported to RN. Let [him/her] lay there for a while. Get up when I catch my breathe [sic] - RN said you have 10 seconds to get up or we will get you up. We got [him/her] in wheelchair. [S/he] fought and made body limp. Took to bathroom and [s/he] slid [his/her] self to floor. Showered while on the floor. No awareness of injury during shower. RN was present and I asked her to assess [him/her.] [CNA #2] helped. [Resident name] refused to stand up. Showered [him/her] while [s/he] was sitting, yelling don't do this, don't get water in my face .I was squatting in front of [him/her], holding [his/her] hands so [s/he] wouldn't hit us. [Resident name] usually combative so hands were helped [sic]. RN holding shower head and [CNA #2] shampooing [his/her] hair [Resident name] has a couple bruises to arms and hands already. No new bruises last night. We were not rough Attempted to help off the floor and s/he pushed back and made heavy. Asked RN to assess [him/her]. I left RN in room. [Resident name] dressed [him/herself] in night gown and underwear.RN reported that she was going to write up report - assuming it was document on combative. [Resident name] was calm in shower. 3. Review of the RN #1 interview on 2/12/24 at 12:07 PM showed .[S/he] was on the floor. Me, [CNA #1] and [CNA #2] helped [him/her] into wheelchair. [S/he] still was not happy about it. [S/he] was striking out and agitated.Helped [him/her] into shower. [S/he] did not want to stand up, let [him/her] sit, washed and shampooed and cleaned [him/her] . [CNA #2] had spray, [CNA #1] soap and rag. I was just trying to help block [him/her] from hitting. Documented injury, I was just talking about some of the bruises [s/he] had gotten from left had, middle, down forearm and some on right hand. Wasn't able to do a full assessment as [s/he] was still pretty irritated. 4. Interview with the resident on 2/27/24 at 1 PM revealed the facility treats him/her good, s/he had no concerns with any of the staff. S/he stated s/he did not the shower. Observation at that time of the residents arms showed on the left outer upper arm 2 reddish colored small circular bruises, and 1 on the back of the left upper arm. The right wrist had reddish bruising noted. 5. Interview with the DON on 2/27/24 at 12:55 PM confirmed the facility determined the resident received injuries from the incident and confirmed the staff members were terminated for resident abuse. The facility's correction plan showed the following: 1. The victim and assailants were separated and the victim was placed on frequent checks. Two CNA's and RN did have their backgrounds checked prior to the incident on 2/8/24, and were put on leave during the investigation. They were later relieved of their duties. The DON, administrator, social services, police, ombudsman, health department, adult protective services, licensing board, and family were notified. Identify other residents: 1. Other residents were interviewed and their response was documented. Twenty residents were assessed by the DON and ADON for bruises. Measures put into place: 1. The facility provided a mandatory education/training to the staff on abuse. Bathing Without a Battle was distributed to all staff on 2/15/24. No Process Improvement Plan (PIP) was created as this was an isolated event. Monitoring performance: 1. The facility was performing weekly audits and the resident care plan was updated. 2. The facility was taking the audits to the QAPI meetings.

Based on review of facility incident reports and documentation, medical record review, staff interview and family interviews, and review of policy and procedures, the facility failed to ensure residents were free from abuse for 1 of 7 sample residents (#3) reviewed for allegations of abuse. This failure resulted in harm to resident #3, who sustained bruising. The findings were: 1. Review of the 6/12/19 progress notes on resident #3 showed medical history that included chronic depression with anxiety, post-traumatic stress disorder, Alzheimer's type dementia, and spinal stenosis. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] showed a brief interview for mental status (BIMS) score of 0 (indicating the resident was severely cognitively impaired), and further showed the resident required extensive assistance with activities of daily living. The resident was also coded as having behaviors that included verbal behaviors and rejection of care. The following concerns were identified: a. Review of the incident report submitted to the State Survey Agency on 7/1/19 showed the following: i. An allegation of physical abuse was reported by CNA #3 on 7/1/19 at approximately 10 PM. The facility's investigation showed CNA #3 and CNA #4 were in the resident's room performing resident care. CNA #4 grabbed (the resident) by each shoulder with her hands, and she pushed (the resident's) shoulders down onto the mattress forcefully and said, 'I'm not doing this today.' The CNA had her left knee on the bed while holding down the resident. Shortly after doing housekeeping duties in the room CNA#4 again went to the bed and held both sides of the blanket over (the resident's) upper arms, leaned over (the resident), pushing (the resident) down briefly while saying 'I'm not doing this today.' CNA #3 was unsure what prompted CNA #4 to come back to bedside as no assistance was needed. Both CNAs then left the room. ii. CNA #4 was interviewed by the facility and stated the resident was very active that night before putting him/her to bed, and she had to redirect the resident. In the attempt to redirect, the CNA stated the resident started to hit her so she grabbed the resident's wrist to stop him/her from hitting. The CNA stated she told the resident, let's not do this, no hitting tonight. The facility noted the CNA gave conflicting accounts of the incident, and of her care of the resident. iii. Two facility registered nurses completed a full head-to-toe assessment at that time on the resident and found multiple bruised areas: left outer elbow, left forearm, left second finger, right posterior bicep, and right wrist. It was the RNs' opinion that some of the bruises were new, and that some of the bruising did resemble finger print bruising. iv. The facility substantiated abuse, and terminated CNA #4's employment at the facility. b. Interview on 7/18/19 at 9:02 AM with the DON revealed CNA #4 was suspended 25 minutes after the incident occurred. The CNA was relieved of her duties at the facility after the investigation was completed. She further stated it was the facility's expectation that staff treat residents with respect and dignity. She added that all staff and traveling staff were trained on abuse. c. Interview on 7/18/19 at 11 AM with the resident's son and daughter revealed the resident had bruises all over both arms, and on the upper chest. Further, the son stated the resident had complained to the family that s/he was being handled roughly prior to this incident. d. Interview on 7/18/19 at 11:48 AM with the facility physician revealed he did exam the resident after the incident and noted the resident had older bruising to the left arm and new bruising to the right arm. He stated he only saw the resident's arms, and verified no pictures were taken of the bruising. e. Interview on 7/18/19 at 2:53 PM with CNA #4 confirmed she helped with the resident's care on 7/1/19 around 9:30 PM. The CNA stated she told the resident we are not going to do this tonight. She stated she tucked the blanket around the resident's shoulders, but denied harming the resident. 2. Review of the facilities policy Abuse of a Vulnerable Adult (undated) showed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.

Based on medical record review, and family and staff interview, the facility failed to provide care that met professional standards of quality for 2 of 14 sample residents (#111, #119) receiving nursing care. This failure resulted in resident #111 becoming unresponsive and being transported to the emergency room . The findings were: 1. Review of the 8/1/15 hospital history and physical showed resident #111 had end-stage [MEDICAL CONDITIONS], and had been admitted to the skilled nursing facility for rehabilitation following hip surgery. Review of the facility 7/31/15 admission evaluation, timed 3:15 PM, showed the resident had respiratory symptoms that included difficulty clearing secretions, shortness of breath at rest and with exertion, and difficulty coughing. Respiratory effort was noted to be labored. The resident's temperature was normal at 98.6 degrees Fahrenheit, and his/her oxygen saturation was recorded as 88% while receiving 4 liters per minute of supplemental oxygen via a nasal cannula. The following concerns were identified: a. Review of the 8/1/15 physical examination, timed 4:01 AM, showed the resident was short of breath with rest and exertion, and was noted to be using accessory muscles to breathe. Review of the 8/1/15 oxygen saturation check, timed 4 AM, showed the resident's oxygen saturation was recorded as 92% while receiving 4 liters per minute of supplemental oxygen. b. Further review of the 8/1/15 hospital history and physical showed the resident's family came to visit at 7:30 AM the morning of 8/1/15 and found the resident seated in a chair with his/her supplemental oxygen turned off. S/he was .unresponsive and had some shaking movements similar to what patient's family described as a [MEDICAL CONDITION]. (His/Her) oxygen was quite low and because of that, (s/he) was transferred back over to the emergency room . c. Interview with a family member on 8/3/15 at 10:12 AM revealed when family arrived to visit the resident at 7:30 AM on 8/1/15, the resident was unresponsive and convulsing. The family asked the nurse at the nurses' station for assistance and the nurse did not come to assess the resident. Further, the family member stated the nurse was asked for assistance three times, and the nurse did not come to assess the resident until family called for an ambulance. d. Review of the medical record showed no nursing assessment was completed on the resident on 8/1/15 before transfer documentation timed at 8 AM. The transfer documentation showed the resident had an elevated temperature of 101 degrees Fahrenheit, and his/her oxygen saturation was recorded as 86%. Interview with the administrator and DON on 8/6/15 at 5:40 PM confirmed the resident's supplemental oxygen had been turned off, and revealed the facility did not know if the oxygen saturation charted on 8/1/15 at 8 AM as 86% was taken before or after the resident's supplemental oxygen was turned back on. e. Further interview with the administrator and DON on 8/6/15 at 5:40 PM confirmed the nurse on duty the morning of 8/1/15 failed to go to the resident's room and assess him/her after the family reported to the nurse that the resident was in distress and confirmed the facility expectation in such circumstances would be the nurse would immediately perform a head-to-toe assessment of the resident and make a determination of resident needs. f. Interview with the resident's physician on 8/6/15 at 4 PM revealed the resident had no lung capacity and would become hypoxic without supplemental oxygen. g. Further review of the 8/1/15 hospital history and physical showed the resident had a possible [MEDICAL CONDITION] event and this could be related to [MEDICAL CONDITION]. The patient was hypoxic when they found (him/her) and (his/her) oxygen was not turned on and certainly that could be a contributing factor. Additionally, the resident was found to have elevated troponin levels, indicative of a non-ST elevation [MEDICAL CONDITION] infarction (a type of [MEDICAL CONDITION]). 2. Review of the 5/14/15 quarterly MDS assessment for resident #119 showed the resident had [DIAGNOSES REDACTED]. Review of the 7/10/15 physician progress notes [REDACTED].i.d. (twice daily) before meals. Review of physician orders [REDACTED]. The following concerns were identified: a. Review of the 7/21/15, timed 7:18 AM, nurse's note showed Reported to this nurse by (another nurse's name) that resident had blood glucose of 34 on sat. 7/18/15, 32 on sun. 7/19/15, 36 on mon. 7/20/15, then (his/her) blood sugar was 38 this am. b. Review of the recorded blood glucose evaluations for the dates of 7/18/15, 7/19/15, and 7/20/15 did not show any such low blood glucose measurements. c. Further review of the medical record failed to show any evidence the resident's physician was contacted regarding low blood glucose levels on the dates of 7/18/15, 7/19/15/ and 7/20/15. d. Interview with the resident's physician on 8/6/15 at 3:35 PM confirmed she had not been notified of the resident's low blood sugars, and would expect to be notified of low blood sugars. e. Interview with the administrator and DON on 8/6/15 at 4:45 PM confirmed the facility's expectation that low blood glucose measurements, and any interventions taken to treat the low blood glucose, would be documented and the physician notified.

Based on medical record review and family and staff interview, the facility failed to provide necessary care to maintain the highest practicable well-being for 1 of 5 sample residents with a change in condition (#111). This failure resulted in the resident becoming unresponsive and returning to the hospital. The findings were: Review of the 8/1/15 hospital history and physical showed resident #111 had end-stage [MEDICAL CONDITIONS], and had been admitted to the skilled nursing facility for rehabilitation following hip surgery. Review of the facility 7/31/15 admission evaluation, timed 3:15 PM, showed the resident had respiratory symptoms that included difficulty clearing secretions, shortness of breath at rest and with exertion, and difficulty coughing. Respiratory effort was noted to be labored. The resident's temperature was normal at 98.6 degrees Fahrenheit, and his/her oxygen saturation was recorded as 88% while receiving 4 liters per minute of supplemental oxygen via a nasal cannula. Review of the 8/1/15 physical examination, timed 4:01 AM, showed the resident was short of breath with rest and exertion, and was noted to be using accessory muscles to breathe. Review of the 8/1/15 oxygen saturation check, timed 4 AM, showed the resident's oxygen saturation was recorded as 92% while receiving 4 liters per minute of supplemental oxygen. Further review of the 8/1/15 hospital history and physical showed the resident's family came to visit at 7:30 AM the morning of 8/1/15 and found the resident seated in a chair with his/her supplemental oxygen turned off. S/he was .unresponsive and had some shaking movements similar to what patient's family described as a [MEDICAL CONDITION]. (His/Her) oxygen was quite low and because of that, (s/he) was transferred back over to the emergency room . Interview with a family member on 8/3/15 at 10:12 AM revealed when family arrived to visit the resident at 7:30 AM on 8/1/15, the resident was unresponsive and convulsing. The family asked the nurse at the nurse's station for assistance and the nurse did not come to assess the resident. Further, the family member stated the nurse was asked for assistance three times, and the nurse did not come to assess the resident until family called for an ambulance. Review of the medical record showed no nursing assessment was completed on the resident on 8/1/15 before transfer documentation timed at 8 AM. The transfer documentation showed the resident had a temperature of 101 degrees Fahrenheit, and his/her oxygen saturation was recorded as 86%. Interview with the administrator and DON on 8/6/15 at 5:40 PM confirmed the resident's supplemental oxygen had been turned off, and revealed the facility did not know if the oxygen saturation charted on 8/1/15 at 8 AM as 86% was taken before or after the resident's supplemental oxygen was turned back on. Further interview with the administrator and DON on 8/6/15 at 5:40 PM confirmed the nurse on duty the morning of 8/1/15 failed to go to the resident's room and assess him/her after the family reported to the nurse that the resident was in distress and confirmed the facility expectation in such circumstances would be the nurse would immediately perform a head-to-toe assessment of the resident and make a determination of resident needs. Interview with the resident's physician on 8/6/15 at 4 PM revealed the resident had no lung capacity and would become hypoxic without supplemental oxygen. Further review of the 8/1/15 hospital history and physical showed the resident had a possible [MEDICAL CONDITION] event and this could be related to [MEDICAL CONDITION]. The patient was hypoxic when they found (him/her) and (his/her) oxygen was not turned on and certainly that could be a contributing factor. Additionally, the resident was found to have elevated troponin levels, indicative of a non-ST elevation [MEDICAL CONDITION] infarction (a type of [MEDICAL CONDITION]).

Based on observation, medical record review, staff interview, and review of policies and procedures, the facility failed to ensure monitoring, assessments, and skin care interventions were consistently provided for 3 of 14 sample residents (#10, #19, #57) who were at risk for developing pressure ulcers. This failure resulted in actual harm for one resident (#10) who developed a facility acquired, unstageable, tunneling pressure ulcer. The findings were: 1. Review of the medical record for resident #10 showed staff first noted a blanchable red area on the resident's right buttock on 2/21/12 and a protective dressing was applied. Further review showed the area did not improve and the resident was admitted to the hospital for intravenous antibiotic therapy from 5/24/12 to 6/2/12. According to the hospital risk management documentation, dated 5/25/12, the pressure ulcer at that time had worsened and was "unstagable", "open", "drained pus" and "tunneling." During an interview on 6/20/12 at 8:15 PM, the DON stated she had identified and addressed the following concerns regarding this resident's care prior to the survey: The nurses did not report the development of the pressure ulcer to the physician until 3/1/12, nor did they follow the wound protocols for treatments and preventive skin care measures. During the months of February, March, April, and May 2012 staff did not perform the dressing changes daily as ordered, and both the nursing and PT staff did not consistently assess, monitor, and document the appearance of the pressure ulcer. Review of the 6/21/12 wound care record showed the pressure ulcer had heavy serosanguinous drainage and measured 0.3 centimeter (cm) in length, 0.3 cm in width and 3.0 cm in depth. In addition there were four underminning areas that measured 3 cm, 2.8 cm, 1.4 cm, and 2 cm. The following concerns were identified during the 6/18/12 to 6/21/12 survey: a. PT #1 was observed performing pressure ulcer care and dressing changes for resident #10 on 6/19/12 at 1:10 PM. During the observation PT #1 wore two pairs of gloves. She removed one pair after completing the dressing change on the resident's leg wound, but did not perform hand hygiene prior to using the second pair for removing the dressing that covered the pressure ulcer on the right buttock. When she removed the gauze packing, yellow drainage from the pressure ulcer got on the PT's gloves and disposable pad positioned under the resident. The PT removed the gloves, and again did not perform hand hygiene before she used her ungloved hands to spray the pressure ulcer with the wound cleansing solution. Then she donned a clean pair of gloves and irrigated the area, applied Santyl cream, packing, and dressings. Hand hygiene was not observed until all of the above tasks were completed. b. According to the plan of care the resident needed a pressure reducing "RoHo" cushion in the wheelchair. Periodic observations from 6/18/12 to 6/21/12 revealed the cushion in the resident's wheelchair was not the "RoHo". During an interview on 6/21/12 at 2:45 PM nurse manager #1 confirmed the resident did not have the RoHo cushion in the wheelchair. At that time the nurse manager stated it should have been in the wheelchair because the resident needed it. c. Review of the June 2012 weekly wound care records and nursing notes showed no documentation of the measurements and status of the pressure ulcer from 6/10/12 to 6/21/12. d. During an interview on 6/20/12 at 4:20 PM, PT #1 and PT #2 stated the pressure ulcer continued to worsen because the various treatments were not evaluated for effectiveness in a timely manner to enable more timely consideration for alternative approaches. 2. Observation on 6/20/12 at 8:20 PM showed LPN #2 perform a dressing change for resident #57 on his/her coccyx. Review of the 6/12/12 Hospice Physician Communication Record and Plan of Care Order showed the resident had a stage II pressure ulcer on his/her coccyx. Review of the Interdisciplinary Progress Notes dated 6/12/12 showed a small open area that measured 0.5 by 0.5 cm. Review of the Progress Notes dated 6/19/12 showed the wound measured 0.3 by 0.6 cm and the wound bed was "slightly macerated (softening)", and at that time the wound protocol was to be initiated. The following concerns were identified: a. Review of the treatment flowsheet for May 2012 showed the resident was to have wound care completed each shift and was scheduled three times daily. Further review showed the dressing change was not documented as provided 7 of 27 times. b. Review of the documentation in the May and June 2012 treatment flow sheets for weekly skin assessments showed the resident's skin was only assessed two times in May. Further, the resident was not assessed on 6/5/12, the week before the pressure ulcer was found on 6/12/12. c. Review of the 6/14/12 Provider Consultation Progress Notes showed an order that the resident was not to be up in the chair for more than 90 minutes "at any one time." Review of the June 2012 treatment flowsheet showed the order was noted, but there was no additional documentation to show the length of time the resident was up in the chair. Observation on 6/20/12 from 10:30 AM through 4 PM, except for one 30 min break in the observation time, showed the resident remained in his/her wheelchair the entire time. In an interview on 6/20/12 at 4 PM, the resident stated she had not laid down during the 30 minute break in observation. The resident was alert and oriented. d. Interview with the DON on 6/21/12 at 2:15 PM, revealed skin assessments were to be completed for all residents each week. She further stated nursing staff are to follow physician orders [REDACTED]. 3. Observation on 6/18/12 at 5:38 PM revealed resident #19 had a bariatric (oversized) bed without an air overlay mattress. On 6/19/12 at 10:10 AM the resident refused to allow a nurse surveyor to observe CNAs #6 and #8 who were providing personal care. After completing care, CNA #8 stated the resident had a "small slit" (described as an open area) at the "top of the crack" between the buttocks. The CNA stated they applied [MEDICATION NAME] (a barrier cream) to the area after completing personal care. Review of the medical record showed the open area was first identified in nursing notes dated 3/28/12. The last documentation found in the nursing notes was dated 3/30/12 at 4 AM. It read: "Open area remains to buttocks. [MEDICATION NAME] applied." Review of the skin checks showed they were not completed weekly, but there was no mention of the open area when they were completed. Review of the 4/3/12 care plan verified the resident had a "slit in coccyx, between upper buttocks." The interventions listed were "Wound and Skin Protocol: [MEDICATION NAME] between upper buttocks. Barrier wipes. Nurse to do visual check after pericare is completed after bms when possible." The following deficient practice was identified: a. During an interview on 6/20/12 at 10:45 AM, wound care nurse #1 stated she was "unaware" of any sacral skin issues, but after reviewing the resident's record, the wound nurse stated she did remember. However, she was unable to find any further documentation related to the wound. During the interview, the nurse also stated the resident's mattress was not a pressure relieving mattress and that she had not been informed of any concerns for the resident. She confirmed the open area was in a "pressure sore area" and had not been assessed by the wound care team. b. On 6/20/12 at 1:30 PM the wound care nurse reported she had assessed the resident's sacral/coccyx area and the resident's skin was intact. However, it had been open (Stage II pressure ulcer) and was still reddened and fragile. She stated the resident had never had an air overlay mattress. c. Review of the "Wound Protocol" last revised 4/12/12 showed staff were to "Describe Location/Stage of Wound...Assessment/Evaluation: Perform skin assessment/evaluation...Note location, size and appearance of affected area(s)...Location, appearance, size, and staging (if pressure ulcer use E-Z graph classifications)...May use skin creams prn to affected areas at risk: [MEDICATION NAME].Air mattress overlay...Document assessment/evaluation, interventions and residents response. Document on the wound in IDT notes. Complete weekly skin assessment/evaluation...and document in MAR. Document the wound on the E-Z graph sheet...weekly..." d. The ointment specified in the resident's care plan was not listed in the "Wound Protocol."

Based on observation, medical record review, and staff and resident interview, the facility failed to ensure 2 of 10 sample residents (#21, #48) identified by the facility as having pain, had an effective pain management program. Due to the facility's failure in developing and implementing a pain management program, resident #48 experienced avoidable pain during staff assisted transfers. The findings were: In regard to pain concerns: 1. Review of the admission MDS assessment completed on 1/24/11 showed resident #48 had active [DIAGNOSES REDACTED]. Review of the psychologist's consultation dated 3/9/11 showed the resident exhibited behavioral problems including aggression during care. Further review of the consultation showed "...back pain should be targeted as a potential variable related to physical aggression." The evaluation showed that "Chart review and resident assessment reveal that (the resident) has a history of back injury and surgery...(the resident) reports that medication helps pain intensity somewhat and that, at home, (s/he) used heat and pressure to help manage (his/her) low back pain." Continued review of the consultation showed the psychologist made detailed recommendations that were discussed with the interdisciplinary team. These recommendations were to train staff to assess pain prior to transfer using a simple pain rating scale or a simple yes/no pain question. In addition, she recommended the charge nurse be familiar with the resident's problems with pain, and to "consult with family members, review the chart, and discuss the issue with (the) resident so that everyone was on the same page about (his/her) potential for significant pain." The recommendations also included the need for staff to be trained regarding non-medicinal options for pain control. Finally a recommendation to, "...consider requesting re-evaluation of current pain management medication for optimum effectiveness..." Review of the resident's medical record showed there was no nursing pain assessment completed to show the resident's pain frequency, tolerable limits, or to further develop the recommendations made by the psychologist. However, review of the 4/19/11 care plan showed pain was a problem area. The care plan interventions for pain showed staff were to provide pain medication as ordered, and alternative approaches to medication such as rest, warm blanket and diversionary activity. The last intervention was to monitor for signs of pain including changes in behavior and grimacing. The care plan also showed behaviors were identified as a problem and pain was shown as a contributing factor. The care plan referred to an attached sheet, a behavior plan developed by the psychologist. Review of this "Behavioral Prescription" showed it was developed from the above mentioned 3/9/11 psychology consultation. Two specific behaviors were identified: Offensive sexual conduct, and physical aggression toward nursing staff during transfers. The interventions for the physical aggression toward staff during transfers were to assess the resident's level of pain prior to transfer, consultation with therapy to determine the best transfer techniques, and for the charge nurse to provide pain management. Prior to the recent hospitalization and subsequent re-admission, the March 2011 MAR indicated [REDACTED]. Review of the April 2011 MAR indicated [REDACTED]. According to the 4/8/11 notification to the physician, the nurse wrote, "Resident was readmitted ...enclosed are the following orders. Do you agree?" The physician documented agreement. However, review of these 4/8/11 admission orders [REDACTED]. Interview with RN #3 on 5/12/11 at 10:35 AM revealed they (nursing staff) were instructed not to question re-admission orders [REDACTED]. The following concerns were identified: a. Review of the April 2011 behavior tracking form showed there were 26 episodes when the resident was involved in "hitting." Review of the behavior tracking form for May 2011 showed one episode on 5/2/11 of the resident "hitting other residents." Although the evaluation identified physical aggression as a possible reaction to pain, review of the April and May 2011 pain flow sheets showed they were blank, at no time during the months had the possibility of pain been assessed. b. Observation on 5/12/11 at 11:05 AM showed CNAs #4 and #5 transferred resident #48 from the wheelchair to a dining room chair. The aides failed to ask the resident about any pain prior to the transfer. The resident was able to participate in the transfer with some weight bearing. However, the resident did not want to move as fast as the aides planned. The aides wanted the resident to get up on the count of three. The resident delayed this count and eventually got up from the wheelchair with some moaning. c. Interview with CNA #5 on 5/12/11 at 10:07 AM revealed she was familiar with the resident and had transferred him/her many times. The CNA stated most of the time the resident said, "ouch, ouch, ouch" when s/he was touched, repositioned or transferred. The CNA did not think the resident received any pain medication. d. Interview with CNA #6 on 5/12/11 at 10:30 AM revealed she was aware the resident had back pain. The CNA stated the resident would say that his/her back hurt when moved. The CNA also revealed "most of the time" the resident would "hit, bite and pinch" when s/he was transferred or moved. The CNA stated the nurse was notified when these things happened, but was unsure if the resident received any pain medication. e. Interview with the resident on 5/12/11 at 9:45 AM revealed s/he had pain in the lower back. The resident was unable to describe the intensity of the pain, but stated the pain was worsened with movement. The resident further revealed s/he did not receive any pain medications. The resident stated "It would be nice." The resident then stated that s/he had "gotten used to it" when asked about his/her back pain. f. Interview with a performance improvement staff member and LPN #2 on 5/12/11 at 9:48 AM verified the resident needed to be monitored for pain according to the care plan, but acknowledged there was no documentation to show this was happening. In addition, there were no orders for pain medication if the resident should need them, and nothing to show that any non-medicinal approaches were being used to relieve the resident's back pain. 2. Medical record review for resident #21 showed a 3/17/11 order for a [MEDICATION NAME] (a pain medication) 75 micrograms per hour to be changed every 3 days. In addition, there was a 3/17/11 order for [MEDICATION NAME]/apap 10/500 milligram tablet to be given every four hours as needed for pain. The following concerns were identified with monitoring the effectiveness of the pain medication: a. Review of the pain flow sheets for April and May 2011 showed the resident received the PRN pain medication 128 times in April, and 43 times in May from 5/1-5/11. Most times, the pain flow sheets showed the resident rated his/her pain at a 6 on a scale of 1-10 prior to the medication being administered. Of the 106 times when the effectiveness of the pain medication was re-evaluated, the flow sheets showed some relief with pain levels reduced to a 3-4 on a 1-10 scale. However, this left 65 times in which there was no re-assessment completed to show if the medication was effective in reducing the resident's pain. b. Review of the medical record failed to show a pain assessment that identified the resident's acceptable level of pain c. Interview on 5/10/11 at 1 PM with the resident revealed s/he felt the pain medication was somewhat effective. Interview with LPN #1 on 5/11/11 at 2:40 PM revealed the frequent use of the PRN pain medication had not been communicated to the physician. Based on medical record review and staff and resident interview, the facility failed to effectively assess, care plan, and treat depression for 2 of 10 sample residents (#3, #48) who were identified as having symptoms of depression. The findings were: 1. Review of the medical record showed resident #48 was admitted to the facility on [DATE]. At that time the resident did not have any [DIAGNOSES REDACTED]. Review of the CAA narrative notes for mood state, dated 1/24/11, showed the resident had indicators of depression including thoughts of being "better off dead" or of hurting him-/herself in some way." The CAA further showed the resident would be monitored closely, and the physician would be notified. In addition, a referral would be made to a psychologist for evaluation. Review of the medication orders showed the resident was started on [MEDICATION NAME] (an anti-depressant) on 1/31/11. Review of the April 2011 MAR indicated [REDACTED]. Review of the 4/8/11 re-admission orders [REDACTED]. The following concerns related to depression were identified: a. Review of the psychologist's evaluation dated 3/9/11 showed a recommendation to "Monitor for increased signs/symptoms of depressed mood, increased irritability/agitation, becoming more socially withdrawn..., and statements about death or dying, feeling helpless, worthless, etc. Re-refer if necessary." Review of the behavior monitoring sheets for March, April, and May 2011 failed to show signs and symptoms of depression were being monitored. b. Review of the 4/25/11 significant change MDS assessment showed the resident triggered for mood state. The CAA narrative notes dated 4/25/11 related to mood showed the resident continued to have feelings of depression, and "...doesn't feel like (s/he) is up to standard." There was no discussion of any anti-depressant medication at that time. Review of the medical record failed to show any additional assessment related to the residents depression or the acknowledgment that the medication was discontinued and possibly still needed. c. Review of the 4/19/11 care plan revealed it failed to address the resident's depression. d. Review of the April and May 2011 MARs showed the resident was not receiving any medication to treat depression. Interview with RN #3 on 5/12/11 at 10:35 AM verified the antidepressant was not re-ordered when the resident returned from the hospital, and she was told the facility policy was not to question re-admission medication orders. At that time, the RN stated the resident had benefited from the medication when it was in use. e. Interview with the resident on 5/9/11 at 5:30 PM revealed feelings of "not fitting in." Interview with the social worker on 5/12/11 at 8:40 AM revealed she was aware of the resident's behaviors and signs and symptoms of depression. She stated the resident was recently moved from another neighborhood and was still adjusting to this change. The move to a different neighborhood occurred a few days prior to the hospital admission. She was not aware of the discontinued medication or the lack of monitoring for signs of depression. 2. Review of the history and physical dated 2/23/11 for resident #3 showed s/he had a history of [REDACTED]. Review of the medical record showed a faxed request dated 3/2/11 from the nursing staff to the resident's physician for an increase in the [MEDICATION NAME] to 75 mg for increased depression. Further review of the medical record showed a communication written on 4/28/11 stated the resident showed another increase in depression, was sleeping more, and not eating well. The following concerns were identified: a. Review of the "Behavior/Intervention Monthly Flow Record" for March, April, and May 2011 revealed no evidence depressive behaviors were assessed or monitored. Review of the nursing notes by a performance improvement staff member on 5/12/11 at 9:45 AM revealed no evidence the resident was assessed for signs and symptoms of depression. b. Interview with social service worker #1 on 5/12/11 at 9:45 AM revealed she was not aware of the most recent increase in this resident's depression. c. Review of the current care plan showed depression was not addressed except for "medications as needed."