Every finding on record at Valley View Care Center

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to:-Maintain the ice machine in a sanitary condition; and,-Maintain the kitchen in a sanitary condition.Findings include:I. Failure to maintain the ice machine in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 8/19/26, read in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. (4-601.11) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11)B. ObservationsThe initial tour of the kitchen was completed on 8/10/26 at 8:40 a.m., and revealed the following:The ice machine had dark black residue extending along portions of the interior seam. There was brown discoloration on the upper interior surface behind the door of the ice machine.A second observation of the kitchen was conducted on 8/12/26 at 10:45 a.m. Observations identified the same concerns as identified on 8/10/26 during the initial tour.C. Staff interviewsThe dietary aide was interviewed on 8/12/26 at 12:35 p.m. The dietary aide said he used the ice machine during his shift, filled the ice chest with ice, and locked the ice machine. The dietary aide said he was not familiar with the specific procedure used by the maintenance staff to sanitize the ice machine. The dietary aide said he knew that a sanitizing liquid was used and that the ice machine was supposed to be emptied before sanitizing. The dietary aide said maintenance staff were responsible for sanitizing the ice machine, but he did not know how often it was done. The dietary aide said he thought the ice machine was last sanitized about two months ago but he was not involved. The dietary aide said he had not noticed any dark or black residue or buildup inside the ice machine. The dietary aide said if he noticed any buildup, he would empty and sanitize the ice machine.The cook was interviewed on 8/12/26 at 12:48 p.m. The cook said he used the ice machine often and filled an ice chest each morning using an ice scoop. The cook said maintenance staff were responsible for sanitizing the inside of the ice machine every 60 days. The cook said the ice machine broke down about two months ago and maintenance staff repaired and sanitized it at that time. The cook said he had not seen the dark residue because it was located toward the back of the ice machine. The cook said he would report any buildup or unsanitary condition to the dietary manager (DM), and the DM would submit a work order. The cook said the black residue could fall into the ice and make the residents sick. The maintenance director was interviewed on 8/12/26 at 12:58 p.m. The maintenance director said maintenance staff were responsible for sanitizing the ice machine. The maintenance director said the ice machine was included on the facility's assigned maintenance tasks and was last sanitized about two months ago. The maintenance director said he observed the dark material along the interior seam of the ice machine and discussed it with corporate staff. The maintenance director said he thought the ice bin needed to be replaced.The DM was interviewed on 8/12/26 at 1:07 p.m. The DM said the kitchen team was responsible for cleaning the ice machine. The DM said maintenance and housekeeping staff were responsible for sanitizing the ice machine, and the dietary aide was responsible for parts of the ice machine, such as cleaning the filter. The DM said an outside company emptied and sanitized the ice machine every six months. The DM said it was last sanitized on 3/5/26. The DM said she relied on staff to verify the ice machine was cleaned and sanitized and planned to use a log moving forward. The DM said she did not know what the dark buildup along the interior seam was but considered it unsanitary. The DM said she would place a sign on the ice machine instructing staff not to use it, obtain bags of ice until the ice machine was sanitized, and contact the outside company to come out sooner.II. Failure to maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 8/19/26, read in pertinent part, The physical facilities shall be cleaned as often as necessary to keep them clean. (6-501.12) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (4-601.11) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11) The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment. (6-501.114)B. ObservationsThe initial tour of the kitchen was completed on 8/10/26 at 8:40 a.m., and revealed the following:The metal shelving beneath the juice dispensing system had areas of dark brown discoloration, corrosion, and flaking of the surface. A juice bag and dispensing components were stored directly on the affected surface.A second observation of the kitchen was conducted on 8/12/26 at 10:45 a.m. Observations identified the same concerns as identified on 8/10/26 during the initial tour.C. Staff interviewsThe dietary aide was interviewed on 8/12/26 at 12:35 p.m. The dietary aide said the corrosion had been present since he started working at the facility four months ago. The dietary aide said the shelving was deep cleaned every two weeks and the surface was always flaking. The dietary aide said staff removed everything from the shelving and scrubbed it with a sanitizer rag, green scrub pad, and sanitizer solution. The dietary aide said the registered dietitian (RD) inspected the kitchen monthly and provided recommendations but had not identified the corrosion as a concern. The dietary aide said the affected shelving needed to be replaced because it was not sanitary.The cook was interviewed on 8/12/26 at 12:48 p.m. The cook said he cleaned the shelving under the juice dispensing system with rags and soap and scrubbed it as best as he could. The cook said the more he scrubbed the shelving, the more the surface came off. The cook said the shelving had been in that condition for three to four years. The cook said he had not noticed any leaks from the juice bags. The cook said he thought everyone was aware of the condition but they could not fix it other than cleaning it.The DM was interviewed on 8/12/26 at 1:07 p.m. The DM said the shelving had been in that condition for a couple of years. The DM said when she worked as a dietary aide, she suggested placing a mat over the shelving to the previous nursing home administrator (NHA), who agreed it was a good idea, but the shelving was not fixed. The DM said staff cleaned the shelving, but the rust continued to come off. The DM said staff cleaned the shelving daily according to the cleaning logs and completed a deep cleaning monthly. The DM said the rusted shelving was unsanitary and should be removed and replaced.

Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for one (#7) of three residents reviewed for notifications out of 31 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #7 and/or the resident's representatives.Findings include:I. Facility policy and procedureThe Room Change/Roommate Assignment policy, revised November 2025, was provided by the nursing home administrator (NHA) on 8/13/26 at 2:04 p.m. The policy read in pertinent part, Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are considered when roommate changes are necessary. Prior to changing a room or roommate assignment all parties involved in the change/assignment (residents and their representatives) are given at least a 24-hour advance written notice of the change. Advance written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with their new roommate.II. Resident #7A. Resident statusResident #7, age [AGE], was admitted to the facility on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included dementia, anxiety and fibromyalgia (a medical condition causing tiredness and whole body pain). The 6/29/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. She was dependent on staff for hygiene, dressing, and bathing. She was independent with ambulation. B. Resident's representative interviewResident #7's representative was interviewed on 8/10/26 at 12:44 p.m. The representative said he was aware that Resident #7 had moved rooms a couple of times in the past several months. He said he was notified of a room change one time and was told they were moving her room because she did not get along with her roommate. He said he did not know why she moved rooms the other time. C. Record reviewA review of Resident #7's electronic medical record (EMR) revealed that Resident #7 was moved to different rooms on 5/27/26 and again on 5/28/26. A nursing progress note documented on 5/27/26 at 10:42 p.m. revealed that Resident #7 grabbed her roommate's left wrist causing pain and discomfort. Resident #7 was moved to another room for the night. Resident #7's representative, the NHA and the nurse on call had all been notified of the incident and the room change. -However, Resident #7 was moved to a different room again on 5/28/26 and there was no documentation to indicate the resident's representative was notified of the move. D. Staff interviewsThe social services assistant and regional clinical resource #1 were interviewed together on 8/12/26 at 12:10 p.m. The social services assistant said the process for moving a resident to another room started with a discussion with the interdisciplinary team (IDT) to talk about changing rooms. Once the room change was confirmed, she said social services reached out to the resident or the resident's representative and verbally notified them about the room change and obtained consent for the room change. Regional clinical resource #1 said the facility had a room change form that the social services department filled out, which included the reason why the resident was moving rooms and the consent from the resident or their representative. Regional clinical resource #1 said new roommates also got verbal and written notice that they were going to be getting a new roommate when a room change occurred that involved a roommate. Regional clinical resource #1 said there was no verbal or written notice given to Resident #7 or her representative, or the new roommate she moved in with on 5/28/26. The NHA was interviewed on 8/13/26 at 10:35 a.m. The NHA said the importance of notifying a resident or their representative about a room change prior to the room change was to give them a chance to appeal the room change. She said Resident 7's representative should have been notified of the second room change and it should have been documented that he was notified prior to 5/28/26.

Based on observations, record review and interviews, the facility failed to ensure residents were free from abuse for three (#30, #50, and #20) of seven residents out of 31 sample residents.Specifically, the facility failed to:-Protect Resident #30 from physical abuse by Resident #7;-Protect Resident #50 from physical abuse by Resident #27; and,-Protect Resident #20 from physical abuse by Resident #56. Findings include: Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #30's physical abuse by Resident #7, Resident #50's physical abuse by Resident #27, and Resident #20's physical abuse by Resident #56, which resulted in the deficiency being cited as past non-compliance with a correction date of 6/30/26. I. Incidents of physical abuse on 5/27/26, 6/2/26 and 6/27/26 On 5/27/26, Resident #30 reported to staff that her roommate, Resident #7, picked up a pair of Resident #30's pants that were on the floor of their shared room. When Resident #30 told Resident #7 that the pants were hers and took them from Resident #7, Resident #7 grabbed her (Resident #30's) left wrist two times and would not let go, which resulted in pain and a red mark to Resident #30's wrist. On 6/2/26, Resident #50, who was seated in a wheelchair, attempted to enter Resident #27's room. Resident #27, who was standing and ambulatory, made physical contact with Resident #50 by striking Resident #50 with an open hand/fist motion around the head and upper body area. Resident #50, who was unable to get away from Resident #27 due to being seated in a wheelchair, raised his hands and arms in an attempt to block or shield himself. Resident #27 moved a short distance away into the hallway, turned back toward Resident #50 and made additional striking motions to Resident #50 before walking away from the area. On 6/27/26, Resident #56 was walking past Resident #20 in the hallway. Resident #20 reached out and grabbed Resident #56's arm as he walked past her. Resident #56 responded by hitting Resident #20 in the back of the head with his hand. II. Facility plan of correction The corrective actions put into place by the facility in response to the physical abuse incidents involving Resident #30 and Resident #7 on 5/27/26, Resident #50 and Resident #27 on 6/2/26 and Resident #20 and Resident #26 on 6/27/26 were provided by the nursing home administrator (NHA) via email on 8/14/26 at 2:52 p.m. The corrective actions were as follow: -Resident assessments and monitoring; -Immediate separation of involved residents; -Room relocation where indicated; -Increased supervision and individualized monitoring; -Review and revision of care plans; -Behavioral interventions and redirection; -Environmental modifications; -Psychiatric/provider follow-up; -Medication evaluations where clinically indicated; -Increased supervision during identified high-risk periods; and, -Continued interdisciplinary review of intervention effectiveness. -Behavioral Interventions and Safety Precautions education was assigned to staff on 6/1/26 and completed by all staff on 6/30/26. -Abuse education was assigned to staff on 6/1/26 and completed by all staff on 6/30/26. The facility's date of compliance was 6/30/26. III. Facility policy and procedure The Abuse policy, revised 9/4/25, was provided by the NHA on 8/10/26 at 11:19 a.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents must not be subjected to abuse by anyone, including but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. Providing a safe environment for the residents is one of the most basic and essential duties of our community. Willful means a deliberate or intentional action carried out by the individual, regardless of whether the intent was to cause harm. For regulatory purposes, 'willful' means the person acted purposefully, not accidentally, even if they did not specifically intend to inflict injury, pain, or distress. The following approaches and interventions are designated as part of the community abuse prevention protocols: Residents at risk for abusive situations are identified and appropriate care plans are developed. IV. Incident of physical abuse towards Resident #30 by Resident #7 on 5/27/26 A. Facility investigation The facility's investigation revealed that on 5/27/26, an incident occurred between Resident #30 and Resident #7. Resident #30 reported that while she was in her room that she shared with Resident #7, Resident #7 picked up a pair of pants that were on the floor. Resident #30 stated that she informed Resident #7 that the pants belonged to her and took the pants back. Resident #30 reported that Resident #7 then grabbed her left wrist, squeezed it and twisted it. Resident #30 stated that Resident #7 grabbed her wrist twice and would not let go, causing pain to the area. Resident #30 was interviewed on 5/27/26. Resident #30 was able to clearly explain the incident that occurred with Resident #7 and communicate her concerns to staff during the assessment and interview. The nursing assessment noted redness/red marks to the resident's left wrist following the reported incident. Resident #30 denied that similar incidents had occurred previously. Resident #30 was assessed by licensed practical nurse (LPN) #4 on 5/27/26. The nursing assessment noted red marks/redness to Resident #30's left wrist area following the reported incident. Resident #30 reported pain/discomfort to the wrist related to the incident. A skin assessment was completed. No bruising, lacerations, abrasions, puncture wounds, bleeding, swelling, fractures or additional injuries were identified at the time of the incident. Resident #7 was interviewed on 5/28/26. Resident #7 was alert but confused and was unable to provide a clear, consistent or reliable account of the events that occurred with Resident #30 on 5/27/26. Resident #7's responses were frequently unrelated to the questions asked and she was unable to explain what occurred between herself and Resident #30. Due to severe dementia and cognitive impairment, Resident #7 demonstrated poor recall and limited ability to participate meaningfully in the interview. No staff member, visitor or other resident was identified as directly witnessing the incident. The investigation documented other residents and staff members were interviewed about abuse and nobody had any concerns. Resident #30 and Resident #7 were immediately separated. A nursing assessment was completed for both residents. Staff were instructed to closely monitor the residents' interactions and promptly intervene if further conflict was observed. The residents' care plans and behavioral interventions were reviewed and updated as indicated to reduce the risk of reoccurrence. Ongoing monitoring was implemented to ensure the safety and well-being of both residents and others residing in the facility. B. Resident #30 (victim) 1. Resident status Resident #30, age less than 65, was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included schizoaffective disorder (mental health condition with a combination of schizophrenia symptoms such as delusions or hallucinations and mood disorder symptoms such as depression or mania), bipolar disorder and anxiety. The 5/27/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated the resident had other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) one to three times weekly during the assessment look-back period. 2. Resident interview Resident #30 was interviewed on 8/10/26 at 12:30 p.m. Resident #30 said Resident #7 used to be her roommate. Resident #30 said Resident #7 came in their room (on 5/27/26) and grabbed Resident #30's wrist and twisted it. Resident #30 said she was able to get her wrist free and Resident #7 grabbed the wrist again and twisted it a second time. Resident #30 said it hurt when Resident #7 grabbed her wrist and twisted it and it made her cry. Resident #30 said it was upsetting because it reminded her of abusive people and situations in her life from before she had lived at the facility. Resident #30 said Resident #7 was no longer her roommate, but she said Resident #7 still came into her room at times. 3. Record review A review of Resident #30's behavioral care plan, initiated 11/23/22, revealed the resident presented with behavioral challenges related to inappropriate boundaries and false accusations. This was evidenced by a history of delusions, hallucinations, and manic behaviors; making false reports of male residents touching her; initiating inappropriate or intimate contact with male residents followed by accusations of inappropriate behavior; and difficulty establishing and maintaining safe interpersonal boundaries. Interventions included contacting the resident's guardian with increased or new behaviors to assist in providing support structure with Resident #30; offering supportive interventions, such as meaningful activities, time outside, listening to music and writing letters; redirecting Resident #30 away from peers that had a history of behaviors of grabbing or touching others; encouraging the resident to maintain distance from the men's hallway and encouraging her to stay a safe distance away from male residents; discussing observed behaviors with the resident; encouraging the resident to participate in her group therapy sessions; assisting the resident to develop more appropriate methods of coping and interacting when frustrated; providing positive interaction, such as stopping to talk with the resident as staff were passing by; explaining all procedures to Resident #30 before starting and allowing her to adjust to changes; monitoring behavior episodes and attempting to determine the underlying cause; offering and documenting non-pharmalogical interventions prior to administering medications; and intervening and encouraging the resident to take her conversations to a private area when speaking with peers about sexual topic conversations. The 5/27/26 at 10:37 p.m. nursing progress note documented that the nurse was advised by Resident #30 that her roommate, Resident #7, grabbed Resident #30's left wrist, squeezed and twisted it, leaving red marks to Resident #30's wrist. Resident #30 stated that Resident #7 grabbed her by the wrist twice and would not let go, causing her wrist to hurt. The NHA, the on-call nurse, the resident's representative and the physician were notified. As needed (PRN) Tylenol was administered to the resident and a skin check was completed. C. Resident #7 (assailant) 1. Resident status Resident #7, age [AGE], was admitted to the facility on [DATE]. According to the August 2026 CPO, diagnoses included dementia, and anxiety. The 6/29/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. 2. Resident observations During a continuous observation of Resident #7 on 8/11/26, beginning at 9:22 a.m. and ending at 10:22 a.m., the following was observed: At 9:23 a.m. Resident #7 was walking around the hallway and walked by Resident #30's room. Resident #7 looked in the doorway and then turned around and walked down the Aspen hallway. A staff member stopped to ask Resident #7 how she was doing and then left. Resident #7 wandered down the hall to the front entrance. Resident #7 turned around before going outdoors and walked toward the nursing station. Resident #7 wandered down the Bear Paw hallway. At 9:29 a.m. a staff member walked by Resident #7 and said hello. Resident #7 started looking out the doorway at the end of the Bear Paw hallway and pressing on the door. Resident #7 turned around and started walking down the hallway. Resident #7 sat down in an empty chair in the middle of the Bear Paw hallway. At 9:35 a.m. two staff members asked Resident #7 to go to her room. The two staff members walked with Resident #7 to her room and closed the door behind them. At 9:40 a.m. the two staff members came out of the room and Resident #7 was sitting on her bed with a stuffed cat in her arms. At 9:55 a.m. a staff member went into Resident #7's room and closed the door. At 10:02 a.m. the staff member came out of the room. Resident #7 was sitting on her bed playing with a doll. At 10:18 a.m. Resident #7's roommate went inside the room and closed the door. 3. Record review Resident #7's wandering/exit seeking care plan, initiated 3/31/26, revealed the resident often entered the rooms of other residents without invitation or awareness, creating the potential for interpersonal conflict and agitation among her fellow residents. Interventions included approaching Resident #7 when she was approaching the rooms of other residents and kindly redirecting somewhere else; identifying a pattern of wandering, distracting the resident from wandering by offering pleasant diversions, activities, food, conversation, television or a book; and providing the resident with structured activities. The 5/27/26 at 10:42 p.m. nursing progress note documented that Resident #7 grabbed her roommate's left wrist, causing pain and discomfort. Resident #7 was moved to another room for the night. Resident #7's representative, the NHA and the nurse on-call were notified of the incident and the room change. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 8/11/26 at 2:30 p.m. CNA #3 said Resident #7 walked up and down the hallways all day and staff tried to redirect her. CNA #3 said Resident #7 did not have any behaviors. She said the resident sometimes refused care but was easy to redirect when she refused care. CNA #3 said other residents were aware of Resident #7's wandering behavior and she did not wander into other residents' rooms. CNA #3 said Resident #30 did not have any behaviors or refusals that she was aware of. She said she was not aware of the incident between Resident #7 and Resident #30 on 5/27/26. Licensed practical nurse (LPN) #1 was interviewed on 8/12/26 at 2:00 p.m. LPN #1 said Resident #7 wandered around the facility aimlessly. LPN #1 said if the resident saw an empty chair or bed, she would go sit on it. LPN #1 said the staff needed to direct her away from the men's (Bear Paw) hallway because there were one or two residents on that hallway that did not like her wandering around. LPN #1 said Resident #7 wandered into other residents' rooms. LPN #1 said Resident #7 got upset if staff tried to take something that she was holding. LPN #1 said Resident #30 had a lot of delusions about her situation and her mental health disorders. LPN #1 said Resident #30 had a history of making false accusations and blowing things out of proportion. LPN #1 said he was Resident #30's nurse the day after she made the allegations of physical abuse against Resident #7 (on 5/27/26) and she did not have any red marks on her wrist. The NHA and the director of nursing (DON) were interviewed together on 8/12/26 at 4:25 p.m. The NHA said Resident #7 wandered aimlessly throughout the day and staff redirected her often. The NHA said Resident #7 tried to grab at things so staff had her hold onto the railing or hold their hands. The NHA said sometimes when staff were trying to redirect Resident #7, she would yell out but she did not get physically aggressive. The NHA said Resident #30 had some verbal behaviors. She said if Resident #30 would hear something on the television, she would fixate on that idea and think it was true for her life. The NHA said the resident got upset when others touched her personal things and sometimes thought other clothing that looked similar to hers belonged to her. The NHA said interventions staff had for Resident #30's behaviors included sitting down and talking with her, explaining things to her, establishing trust with her, calling her by her preferred name and sticking to her current medication regimen. The DON said Resident #30 had an increase in behaviors when she got closer to her Invega (long-acting injectable antipsychotic medication) shot being due for administration. The NHA said she was informed of the incident between Resident #7 and Resident #30 around 10:00 p.m. on 5/27/26 by the nurse who was on-call. The NHA said she asked the facility staff to make the appropriate notifications, separate the two residents, monitor them for 72 hours, check on them every 15 minutes and had them move Resident #7 to another room. The NHA said she substantiated the incident for physical abuse due to the new redness to Resident #30's left wrist. V. Incident of physical abuse towards Resident #50 by Resident #27 on 6/2/26 A. Facility investigation The facility's investigation of the incident involving Resident #50 and Resident #27 was provided by the NHA on 8/13/26 at 12:50 p.m. The investigation documented Resident #50 suffered physical abuse after entering Resident #27's room and Resident #27 struck Resident #50 multiple times. The facility's investigation documented that on 6/3/26, Resident #50 was observed motioning and gesturing to staff, indicating that he may have been hit by another person. Due to Resident #50's impaired speech and communication deficits, staff were unable to obtain clear details regarding the allegation. Multiple attempts were made to clarify the event; however, the resident was unable to identify who allegedly hit him, when the alleged incident occurred, where the alleged incident occurred, or how the alleged incident happened. During the investigation, Resident #50's electronic medical record (EMR) review identified nursing documentation, dated 6/2/26, describing a resident-to-resident altercation involving the alleged assailant and alleged victim. Documentation indicated security footage was reviewed and revealed Resident #50 attempting to enter Resident #27's room. Resident #27 struck Resident #50 with an open hand/fist motion toward the upper body and head area while Resident #50 remained in his wheelchair. Resident #50 was observed raising his arms and hands in an attempt to block or shield himself. Resident #27 then moved a short distance away into the hallway, turned back toward Resident #50 and made additional striking motions to Resident #50 before walking away from the area. Resident #50 remained seated upright in his wheelchair. Further investigation of prior interventions identified Resident #27 had removed the stop sign previously placed on his room door, which was intended to discourage other residents from entering his room. Investigation further revealed Resident #27 had removed the door chime previously used to alert staff of anyone entering or exiting in Resident #27's room door. A psychiatric medication follow-up was completed following the incident. The medication review identified that a previous gradual dose reduction (GDR) of Resident #27's psychotropic medications had not been successful due to increased anxiety, agitation, and behaviors related to the resident's personal space and interactions with other residents. Resident #27's psychotropic medications were reviewed and adjusted by the physician. Resident #27 was placed on one-one supervision. The facility's root cause analysis, dated 6/5/26, revealed the primary cause of the incident between Resident #27 and Resident #50 was peer-to-peer interaction influenced by cognitive impairment and impaired judgement, leading to impulsive responses in a shared environment, and a failed GDR of Resident #27's psychotropic medications. Based on the investigation's findings, including security footage review and documentation review, the allegation of resident-to-resident physical altercation was substantiated by the facility (see NHA interview below). B. Resident #50 (victim) 1. Resident status Resident #50, age less than 65, was admitted on [DATE]. According to the August 2026 CPO, diagnoses included anoxic brain damage (brain damage from lack of oxygen), alcohol use with alcohol-induced persisting dementia (alcohol-related brain damage) and mood disorder. According to the 6/5/26 MDS assessment, the resident had severe cognitive impairment with a BIMS score of zero out of 15. The MDS assessment documented the resident did not wander and exhibited physical and verbal behaviors directed towards others during the assessment look-back period. 2. Record review The 6/2/26 nursing progress note revealed Resident #50 was a victim in a resident-to-resident altercation on the previous shift. The resident denied pain and expressed that he felt safe in the facility. The behavior care plan, initiated 6/4/26, documented that Resident #50 was at risk for resident-to-resident altercations related to cognitive impairment, wandering behaviors, poor safety awareness, impaired impulse control, and entering other residents' rooms or personal spaces. Pertinent interventions included encouraging Resident #50 to participate in structured activities and supervised areas to reduce wandering into other residents' rooms, monitoring and documenting behaviors, triggers, and resident interactions that could increase the risk for altercations, providing verbal cues and redirection when Resident #50 wandered near or attempted to enter another resident's room, and using calm, simple communication during redirection. C. Resident #27 (assailant) 1. Resident status Resident #27, age less than 65, was admitted to the facility on [DATE]. According to the August 2026 CPO, diagnoses included schizophrenia, intracranial injury with loss of consciousness of unspecified duration, and history of traumatic brain injury. The 5/12/26 MDS revealed Resident #27 had severe cognitive impairment with a BIMS score of zero out of 15. The MDS assessment indicated Resident #27 wandered daily, had potential indicators of psychosis including delusions and hallucinations, and had physical and behavioral symptoms directed toward others on one to three days during the assessment look-back period. 2. Record review Resident #27's behavior care plan, revised 11/20/25, revealed the resident had the potential to be physically aggressive to others, including hitting, kicking, pushing, and grabbing others. These behaviors appeared to be related to underlying anger issues, chronic mental illness, a history of traumatic brain injury (TBI) cognitive communication deficits, poor impulse control, and difficulty expressing his needs effectively. Specific triggers for Resident #27' aggressive behavior included people entering his room without permission, individuals standing or walking too closely behind him, and overstimulation in busy areas (especially dining and common areas). The resident's confusion, impulsivity, and frustration could escalate rapidly if preventive strategies were not used. Interventions included the resident's aggressive outbursts were most commonly triggered by individuals entering his room without permission or standing too closely behind him, particularly at the doorway or within his personal space, and feeling crowded, especially in communal areas such as the dining room. De-escalation strategies included allowing the resident space and time when he became escalated and avoiding crowding or multiple staff approaching at once. Additional interventions, revised 3/20/26, included maintaining increased supervision during meals, busy unit times, and smoking periods, as these settings historically triggered incidents for Resident #27. Staff would monitor the area around the resident's room and intervene as needed to prevent other residents from entering his room or personal space to reduce risk of agitation and aggressive response. -On 8/11/26 (during the survey), Resident #27's behavior care plan was updated with an intervention to use a secondary notification system with a pressure sensitive device on the resident's floor by his bed as a non-restrictive safety intervention. The behavioral health physician's progress note, dated 3/2/26 at 7:30 a.m., documented Resident #27's current medications included Risperdal (antipsychotic medication) 1 milligram (mg) tablet one time a day for paranoid schizophrenia, and Zyprexa (antipsychotic medication) 12.5 mg one time a day related to schizophrenia. The provider documented a GDR was contraindicated on that date due to the severity of current symptoms, which would become unmanageable at lower doses. A dose reduction of the resident's other psychotropic medication was clinically contraindicated at that time due to a primary justification of target symptoms as indicated in history and present illness had not been sufficiently relieved by non-pharmacological interventions and medications, and would likely impair the resident's functioning and exacerbate his psychiatric instability, given the active symptoms described in the history and present illness. The nursing progress note, dated 3/7/26 at 1:10 p.m., revealed Resident #27 had started a taper of his risperidone medication (antipsychotic medication approved for the treatment of various conditions including schizophrenia) from 1mg to 0.7 mg for seven days, then 0.5 mg for seven days, then 0.25 mg for seven days and then discontinue the risperidone. The nursing progress note, dated 3/17/26 at 9:23 p.m., revealed the nurse responded to an altercation involving Resident #27. Resident #27 reported another male resident was in his room three different times and when Resident #27 asked the other resident to leave the room, a physical altercation began. The residents were separated, the physician was notified and a one-time physician's order for Ativan (antianxiety medication) 0.5 mg was obtained for Resident #27. The nursing progress note, dated 3/28/26 at 10:26 a.m. revealed Resident #27 continued on monitoring for a decrease in risperidone. He was currently taking 0.25 mg for seven days, then discontinue the use of risperidone if the resident was without adverse reactions. The resident was additionally receiving an increase in Zoloft (antidepressant medication) to 25 mg, and an increase in Zyprexa to 20 mg. The behavior progress note, dated 5/7/26 at 4:23 p.m., revealed Resident #27 was observed wandering throughout the facility during the day, walking periodically through hallways and common areas while engaging in self-talk and staff would continue to provide redirection as needed. The physician's progress note, dated 5/20/26, documented staff placed Resident #27 on one-to-one monitoring or every 15-minute checks for safety related to aggression. The behavioral health physician's progress note, dated 6/1/26 at 8:15 a.m. documented Resident #27 was recently physically aggressive toward other residents and staff in the dining room. The resident's Zyprexa dose was increased following the incident. Resident #27's psychotropic medications included risperidone 0.5 mg daily and Zyprexa 25 mg every evening. The nursing progress note, dated 6/2/26, at 10:18 a.m. documented Resident #27 had a new physician's order for Ativan 0.5 mg two times each day for agitation for 14 days. The nursing progress note, dated 6/2/26 at 11:55 a.m., revealed the nurse was in the dining room, when another staff member reported to the nurse that Resident #27 had assaulted another resident. Upon further investigation, the security footage revealed another resident (Resident #50) attempting to enter Resident #27's room. Resident #27 was observed hitting Resident #50 in the doorway of the room. Resident #50 attempted to block his own face. Resident #27 then moved out into the hallway, then turned around, unprovoked, and hit Resident #50 several times more. D. Staff interviews Resident #27's part time one-to one-monitor on 8/11/26 at 11:30 a.m. The part time one-to-one monitor said she was assigned as Resident #27's one-to-one monitor. She said the resident had not had any physical outbursts since she was assigned to provide one-to-one supervision of the resident in the past month. She said was aware Resident #27 had space and boundary issues and he stayed away from others in the hallway and smoking area. LPN #1 was interviewed on 8/12/26 at 3:18 p.m. LPN #1 said if a resident reported being hit by another resident, he would assess, offer pain medication, protect the residents, notify social services to investigate, and notify the DON and the physician. LPN #1 said a visible injury was not required for the incident to be considered abuse. LPN #1 said the absence of bruising, redness, or pain did not change that Resident #50 was struck multiple times by Resident #27. LPN #1 said Resident #50 could communicate through body language despite his cognitive impairment. LPN #1 said nursing staff assessed his body language for signs of fear, distress, or other psychosocial harm. LPN #1 said if Resident #50 nodded no when asked if he was scared, the nurse would interpret his response at face value as indicating he was not scared. LPN #1 said Resident #50 was not scared after the incident with Resident #27, but from a reasonable-person perspective, he would be mad if someone hit him. The NHA and the DON were interviewed together on 8/12/26 at 4:45 p.m. The NHA said Resident's #27 could be impulsive. The NHA said Resident #27's failed GDR was identified as the root cause analysis of the physical abuse incident on 6/2/26 when Resident #50 suffered physical abuse by Resident #27 after attempting to enter Resident #27's room. The NHA said the facility substantiated the incident as abuse. The NHA said the definition of abuse was any unwanted touching or verbal aggression, anything emotional, verbal or physical that would hurt someone. She said the absence of redness or bruising on the skin could still be considered physical abuse. The NHA said behavior interventions for Resident #27 included increased staff monitoring and observation in the facility and implementing one-on-one monitoring at times. The DON said a door chime had been installed on Resident #27's room door to notify nursing staff when the resident's door was opened, but this had been removed because the resident kept unplugging it. The DON was interviewed again on 8/13/26 at approximately 10:00 a.m. The DON said the facility had worked to implement non-pharmacologic interventions when possible to manage resident behaviors. She said for Resident #27, some of the non-pharmacologic interventions included staff redirecting the resident to his room for video games, and listening to music. The DON said a new pressure sensitive mat had been ordered and would be placed in Resident #27's room to alert staff when the resident's door was opened. CNA #1 was interviewed on 8/13/26 at 12:36 p.m. CNA #1 said a resident-to-resident altercation occurred on 6/2/26 between Resident #50 and Resident #27. CNA #1 said if she witnessed or suspected resident-to-resident abuse, she would redirect and intervene the residents to calm the situation and separate the residents. CNA #1 said she would report the incident to the

Based on record review and interviews, the facility failed to maintain accurate medical records for advance directives for one (#2) of one resident reviewed out of 31 sample residents. Specifically, the facility failed to ensure Resident #2's medical orders for scope of treatment (MOST) form matched the resident's computerized physician orders (CPO) for cardiopulmonary resuscitation (CPR).Findings include:I. Facility policy and procedure The Advance Directives policy, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 1:54 p.m. It read in pertinent part, The community recognizes advance directives, every attempt will be made to honor residents' wishes unless to do so would violate state or federal law. The advance directive and CPR decisions will be reviewed in writing on admission and annually, when requested by the resident, or as needed. If the resident executes such documents, and later revokes or changes them, it is also the resident's responsibility to inform the community of such revocation or change. This is required so that the community can assist the resident in ensuring that his/her health care choices are properly communicated to health care professionals.II. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included unspecified moderate dementia with behavioral disturbance and mood disorder.The [DATE] minimum date set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. B. Resident #2's representative interview Resident #2's representative was interviewed on [DATE] at 3:03 p.m. The representative said she received a call from the facility that day ([DATE]) regarding Resident #2's MOST form. She said in February 2026, she and Resident #2 requested to update the MOST form from do not resuscitate (DNR) to CPR with selective treatment. She said she did not know why it took the facility so long to process the change.C. Record reviewReview of Resident #2's MOST form, which was located in the advance directives binder at the nurses' station, revealed the form was signed and dated on [DATE] by the resident's medical durable power of attorney (MDPOA). The nurse practitioner signed and dated the MOST form on [DATE]. The MOST form indicated the resident wished to have CPR with selective treatment, which included intravenous (IV) antibiotics and fluids, no intubation and avoidance of intensive care. Review of Resident #2's [DATE] CPO revealed a physician's order which indicated that Resident #2's code status (whether or not someone wants CPR or not) was DNR, ordered [DATE].-However, the [DATE] CPO did not correspond with the directive on the MOST form for the resident to receive CPR, after the resident's representative requested a change in [DATE]. III. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on [DATE] at 10:52 a.m. CNA #5 said Resident #2's current code status was DNR. CNA #5 said she would look in the resident's electronic medical record (EMR) to verify the resident's code status. CNA #5 said if Resident #2 was found unresponsive, she would notify the nurse and take direction from the nurse. CNA #5 said if she found conflicting information regarding the resident's code status, she would notify the director of nursing (DON).Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 11:01 a.m. LPN #2 said Resident #2's current code status was DNR with comfort measures. LPN #2 said if Resident #2 became unresponsive and had no pulse, she would call the hospice nurse immediately, take further direction from the hospice nurse, and follow the resident's MOST form. LPN #2 said she verified the resident's current code status using the MOST form and the EMR. LPN #2 said if the physician's order and the resident's MOST form did not match, she would follow the most recent MOST form and notify the DON and the physician.The DON was interviewed on [DATE] at 11:09 a.m. The DON said Resident #2's current code status was CPR. The DON said when there were conflicting physician's orders and MOST forms, the social services director (SSD) would typically discuss the resident's current wishes with the family and obtain a physician's order to update the orders. She said the new MOST form should reflect the resident's most current wishes. The DON said code status changes were communicated through the 24-hour log and during nurse-to-nurse shift report handoff. The DON said to ensure the correct code status was followed during an emergency, the most up-to-date MOST form should be kept in the advance directives binder, and the information should be communicated through the 24-hour log and nurse-to-nurse shift report handoff.The social services assistant and regional clinical resource #1 were interviewed together on [DATE] at 11:16 a.m. Regional clinical resource #1 said advance directives were reviewed quarterly during care conferences to ensure they were accurate. Regional clinical resource #1 said the physician reviewed the advance directives and updated the physician's orders.The NHA was interviewed on [DATE] at 11:20 a.m. The NHA said the facility's process for identifying and resolving conflicting code-status documentation was to review the resident's code status and conduct a full audit. The NHA said it was a team approach involving the interdisciplinary team (IDT) to ensure the resident's current wishes were accurately reflected in the medical record. The NHA said discrepancies were addressed through team meetings, risk management, and the quality assurance and performance improvement (QAPI) process. The NHA said medical records staff conducted audits of code-status documentation. She said audits were completed depending on the situation or when there was a problem, and the documentation was reviewed quarterly.

Based on observations, record reviews and interviews, the facility failed to ensure proper storage of all drugs and biologicals for one of two medication carts and one of one medication storage rooms.Specifically, the facility failed to discard expired medications.Findings include:I. Professional reference According to the Emergency Glucagon Kit for Caregivers, Fresenius Kabi USA ( 2026), retrieved on 8/20/26, from https://www.glucagonemergencykit.com/information-for-caregivers/, You must check the printed expiration date on the product tube, carton, or vial, and never use the medication past that date.II. Facility policy and procedureThe Storage of Medications policy, revised November 2020, was provided by the nursing home administrator (NHA) on 8/10/26 at 11:19 a.m. It read in pertinent part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.III. Observations and staff interviews On 8/11/26 at 10:00 a.m. the facility's medication storage room was observed with licensed practical nurse (LPN) #2. The following medication was found in the medication storage refrigerator:An Amphastar Glucagon Emergency kit had an expiration date of 9/20/25. LPN #2 said the emergency glucagon kit should have been removed when it was expired because expired glucagon was not effective to treat a serious low blood sugar.LPN #2 removed the expired glucagon and provided this to the DON. On 8/12/26 at 9:10 a.m. the Aspen medication cart was observed with LPN #1. The following items were found:There was one bag of four vials and one bag of 14 vials of midazolam 5 milligram (mg)/milliliter (ml) that all had an expiration date of 7/9/26. LPN #1 said the pharmacy had the vials on back order. LPN #2 and LPN #1 removed the midazolam vials and provided them to the DON. LPN #1 and LPN #2 said the medication vials would be delivered later that day. IV. Additional staff interviewThe director of nursing (DON) was interviewed on 8/11/26 at 10:25 a.m. The DON said expired medications should be removed from the medication storage refrigerator. He said it was the responsibility of all nurses to check for expired medications, and it was primarily the responsibility of the nurses working the night shift to check for expired medications. He said it was important to remove and discard expired medications because they would not be effective if they were expired. The DON was interviewed a second time on 8/12/26 at 9:30 a.m. The DON said expired midazolam should have been removed from the medication cart because the expired medication would not be effective if used.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on two of two units.Specifically, the facility failed to:-Ensure housekeepers cleaned residents' rooms from a cleaner area to a dirtier area;-Ensure housekeepers performed appropriate hand hygiene when cleaning residents' rooms; and,-Ensure housekeepers followed chemical dwell times (time product needs to sit on surfaces to kill germs) when cleaning residents' rooms.Findings include:I. Professional referenceAccording to the Spartan Chemical Company' BNC-15 product label instructions, retrieved on 8/18/26 from https://www.spartanchemical.com/about/news/bnc-15/, BNC-15 offers three-minute disinfection for most common bacteria and viruses and a 60-second disinfection for the HIV-1 and Influenza Type A/[NAME] Kong virus. In addition, BNC-15 provides Norovirus efficacy in five minutes and provides non-food contact sanitization in just 15 seconds.According to the Clorox Company's Clorox Healthcare Hydrogen Peroxide Spray Cleaner product label instructions, dated 2026, retrieved on 8/20/26 fromhttps://www.cloroxpro.com/products/clorox-healthcare/hydrogen-peroxide-cleaner-disinfectants/, Our bleach free hydrogen peroxide disinfectants are formulated for use on healthcare surfaces. Our one-step hydrogen peroxide disinfectant cleaners offer faster kill times, kills more than 40 bacteria and viruses in one minute or less.According to the Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection (revised July 2021), retrieved on 8/18/26 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention's (CDC) Environment Cleaning Procedures, (revised 3/19/24), was retrieved on 8/18/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It revealed in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs.Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions.II. Facility policy and procedureThe Infection Control and Surveillance policy, dated 12/12/25, was provided by the nursing home administrator (NHA) on 8/10/26 at 11:09 a.m. It revealed in pertinent part, An Infection Prevention and Control Program (IPCP) is established, implemented, and maintained to provide a safe, sanitary, and comfortable environment and to help prevent, identify, monitor, and control the development and transmission of communicable diseases and infections throughout the community.The IPCP is based on recognized national standards and guidelines (including CDC) and incorporates evidence-based infection prevention and outbreak management practices.III. Observations On 8/11/26 at 10:20 a.m. housekeeper (HK) #1 was observed cleaning resident room [ROOM NUMBER], a three resident occupancy room currently occupied with three residents. Without performing hand hygiene, HK #1 applied a glove to her right hand, leaving her left hand without a glove on it. HK #1 put both hands into the rag bin on the top of the cart with the BNC-15 premeasured cleaning solution and wrung out a rag. HK#1 entered the residents' room carrying the wet rag and a Clorox Healthcare Hydrogen Peroxide spray bottle hooked into the pocket of her pants. HK #1 sprayed the bathroom toilet and hand rails with the Clorox Healthcare Hydrogen Peroxide spray. She then wiped down a dresser in the room using her gloved right hand and the rag, while holding on to the dresser with her ungloved left hand. She used her ungloved left hand to move the resident's personal items around on the top of the dresser. After wiping down the dresser, HK #1 removed the right hand glove, and took the rag she had used to wipe the dresser to the dirty rag bin on her cleaning cart. Without performing hand hygiene or putting on gloves, HK #1 put both hands into the rag bin on the top of the cart with the BNC-15 premeasured cleaning solution and wrung out a rag. She again put a glove on her right hand and entered the room carrying the rag.HK #1 began to wipe the bottom of the sink bowl with the rag, then wiped the bathroom counter, the paper towel holder and the light switch while touching the bathroom door jam and the door with her ungloved left hand. HK #1 returned the dirty rag from cleaning the bathroom counter to the rag bin and removed the right hand glove. Without performing hand hygiene, she put a new glove on her right hand, and removed a clean rag from the cleaning solution bin using her ungloved left hand and entered the room carrying the rag. HK #1 used her ungloved left hand, pulled out a rolling three drawer plastic storage unit from under the residents' sink and wiped off the top of the storage unit with the rag. Using her ungloved left hand, she picked up an opened package of briefs and an opened package of personal wipes from the floor and placed them on top of the storage unit. HK #1 exited the room, picked up the broom from the cart and re-entered the room [ROOM NUMBER] carrying the broom. HK #1 swept the bathroom floor and used her ungloved left hand to hold the dustpan. After sweeping the bathroom floor, HK #1 exited the room and removed the right hand glove. She did not perform hand hygiene after removing the glove.HK #1 used both ungloved hands to wring out a mop pad. She entered room [ROOM NUMBER] without gloves, carrying the mop handle. She placed the handle over the mop pad to secure the pad, and mopped the bathroom. She exited the room and using her ungloved left hand, she held a glove folded in half to remove the dirty mop pad to place it into the dirty mop pad container on her cart. Without performing hand hygiene or putting on gloves, HK#1 re-entered the room carrying the broom. She swept under the three beds of all the residents, picked up slippers and placed them onto the top of the beds, picked up stuffed animals and placed them onto the top of beds, and picked up a bag of personal items and placed the bag on the top of a bed. She picked up a used plastic cup and placed the cup on top of a bed. She found a stuffed animal toy from a previous visit with a therapy dog, left the room carrying the dog toy through the hallway into the dining room, and returned the stuffed dog toy to the director of rehabilitation's office, which was in a room adjoining the dining room. -During the cleaning of room [ROOM NUMBER], HK #1 failed to perform appropriate hand hygiene, use gloves appropriately when needed, and change her gloves appropriately after cleaning dirtier areas prior to cleaning cleaner areas.Hk #1 failed to follow appropriate infection control procedures when cleaning the residents' room and handling the residents' personal items.At 10:58 a.m. HK #1 said she had finished cleaning the residents' room. On 8/12/26 at 10:28 a.m. HK #2 was observed cleaning resident room [ROOM NUMBER], a double occupancy room currently occupied with two residents. HK #2 completed hand hygiene, put on a pair of gloves and swept the side of the room by the window. He picked up and rearranged the resident's personal belongings from the floor as he was sweeping. He then held on to the top of the resident's bedside table and moved the resident's bedside table over by the wall so he could sweep. He left the room carrying the broom, which had dust and debris hanging from it, out to the cart where it was stored. HK #2 completed hand hygiene and put on a new pair of gloves. He wrung out a clean rag from the bin on the cart with the BNC-15 solution and re-entered room [ROOM NUMBER] with the wet rag. He began wiping the top of the dresser, moving the resident's personal items around on the dresser as he wiped off the top of the dresser. HK #2 did not allow the disinfectant solution to remain on the surface of the dresser for the recommended five-minute dwell time (see professional reference above). Two personal items from the top of the resident's dresser fell to the floor, and HK #2 picked up the items and placed them back on to the top of the dresser. HK #2 left the room with the dirty rag and placed it in the dirty rag bin on the cleaning cart. HK #2 performed hand hygiene and put on gloves, wrung out a clean rag, and entered the room carrying the clean rag. HK #2 began removing personal items from the dresser of the resident next to the door. Some of the items were placed on the bedside table which had not been cleaned. HK #2 wiped off the top of the dresser and without waiting for the dwell time, began replacing personal items back on the top of the dresser. He picked up a water pitcher that had fallen to the floor and placed the pitcher back on top of the cleaned dresser. The infection preventionist (IP), who had been standing outside room [ROOM NUMBER]'s door and observing HK #2 cleaning the room, told HK #2 that he had not followed the five-minute dwell time for the BNC-15 cleaning product. -HK #2 failed to follow appropriate infection control procedures when cleaning the residents' room and handling the residents' personal items. HK #2 failed to follow the recommended dwell time for the BNC-15 cleaning product. At 11:40 a.m. HK #2 said he had finished cleaning the residents' room. IV. Staff interviews HK #1 was interviewed on 8/11/26 at 10:59 a.m. HK #1 said she had been trained by another experienced housekeeper about nine months earlier when she started working at the facility She said the maintenance director provided information about the cleaning products and usage. HK #2 was interviewed on 8/12/26 at 11:43 a.m. HK #2 said he had been trained by an experienced housekeeper about three months earlier when he started working at the facility. The IP was interviewed on 8/12/26 at 1:00 p.m. The IP said she provided oversight and training to the housekeeping staff, including the use of personal protective equipment (PPE) and hand hygiene. She said she provided ongoing observation of housekeeping staff and additional training when needed. She said she would be providing most of the training for housekeeping staff in the future. The IP said all staff were expected to follow standard precautions as directed by the CDC and treat every body fluid as potentially infectious. She said all staff, including housekeeping staff, should consistently perform hand hygiene and wear appropriate PPE to prevent the transmission of illness. The IP said housekeeping staff should know and follow the dwell times for the cleaning products used by the facility. She said housekeeping staff should follow a process to clean from clean to dirty areas, and should not pick up resident's personal items from the floor.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of three sample residents received adequate supervision and were kept free from elopement.Specifically, the facility failed to provide Resident #1 with the supervision necessary to prevent elopement.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/10/25 to 9/11/25, resulting in the deficiency being cited as past noncompliance with a correction date of 9/8/25.I. Facility policy and procedure The Elopement and Wandering policy, dated 2/29/25, was received from the nursing home administrator (NHA) on 9/12/25 at 2:05 p.m. It revealed in pertinent part, To ensure the safety and well being of all residents with potential elopement risk. The goal of the facility is to provide a safe environment using least restrictive measures available in caring for residents who were exhibiting elopement behaviors. The facility defined wanderers as residents who moved around the facility in a non-goal directed manner, but did not make efforts to leave the premises. Elopers are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks. The elopement policy and procedure shall be explained to the resident or the responsible party as needed by a facility staff member. A Wander/Elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the interdisciplinary team during the initial care conference, or earlier if the elopement risk is of immediate concern. The elopement risk is assessed quarterly or as needed with change of condition. Nursing staff will address initial elopement risk concerns in the baseline care plan. If the resident is identified as an elopement risk, the following will be maintained: Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder.Implementing and care planning interventions to address safety and decrease risk of elopement. The care plan will be updated to include that an electronic alarm system is used for resident's safety.II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), the diagnoses included traumatic brain injury (sudden injury to the brain caused by an external force, such as a blow, bump, or jolt to the head), psychotic disorder with delusions (presence of delusions, which are false beliefs that persist despite evidence to the contrary), alcohol dependence with alcohol induced dementia (abnormal memory), mental disorder due to unknown psychological disorder (conditions that affect a person's thoughts, feelings, and behaviors) and mood disorder due to unknown physiological condition (conditions that affect a person's emotional state).The 8/24/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He was independent with eating, toileting, dressing, personal hygiene, transfers and ambulating without any devices.The MDS assessment indicated the resident wandered.B. Resident #1's representative interviewResident #1's guardian was interviewed on 9/11/25 at 10:39 a.m. She said Resident #1 had a history of behaviors and eloping from other facilities after speaking with his mother. The guardian said the facility called her when Resident #1 eloped from the facility on 9/5/25. The guardian said that the resident enjoyed being outside. The guardian said the facility had outside space available for him to enjoy versus other locations he had been at prior. The guardian said when Resident #1 interacted with his mother, she felt this led to him wanting to leave and actually leaving the facility.C. ObservationsOn 9/10/25 at 10:15 a.m. the facility was observed to be a totally secure building specializing in serving residents with severe mental illness, dementia and behavioral health issues. The entire campus had a six-foot high security fence around the whole campus with a wired overhang in the unrestricted front resident space to discourage anyone from climbing over the fence. Staff and visitors had to be keyed in and out of the front gate. On 9/10/25 at 10:48 a.m. Resident #1 was in his room with a one-to-one staff member in the hallway. On 9/10/25 at 12:55 p.m. Resident #1 was sitting on a bench in the front patio with a staff member nearby with a clip board documenting the resident's location. On 9/11/25 at 8:02 a.m. Resident #1 was outside in the front courtyard in line of sight of a staff member.D. Record reviewThe elopement care plan, dated 8/19/25, revealed the resident was identified as an elopement risk. Pertinent interventions included placing the resident's identification information in the facilities development binder (initiated 8/19/25). The secure placement care plan, dated 8/19/25, documented Resident #1 required a secure unit placement related to impaired cognition, history of alcohol dependence, neurological conditions and high risk of elopement. The care plan documented Resident #1 had a documented history of attempting to leave previous facilities without regard for safety and continued to verbalize a desire to leave the current facility. Due to Resident #1's impaired cognition, combined with his primary language being Mongolian, his ability to fully understand care instructions, consequences and safety risk if he were to leave unsupervised were limited. Pertinent interventions included placing the resident's information in the elopement identification binder (initiated 8/19/25), accompanying the resident when he was off the unit (initiated 8/19/25), monitoring exit seeking behaviors by redirecting away from doors (initiated 8/19/25), engaging the resident in meaningful activities (initiated 8/19/25), keeping eyes on the resident (initiated 9/6/25), keeping the resident in line of sight when awake (initiated on 9/6/25), monitoring the resident's hours of sleep (initiated 9/6/25), placing the resident on one-to-one supervision (initiated 9/8/25), assessing and documenting the resident's patterns of wandering (9/8/25) and monitoring the resident's desire for family contact and alcohol (initiated 9/8/25).On 9/10/25 the elopement care plan was updated (during the survey). The updated care plan documented Resident #1 had recently left the facility wearing a backpack, the staff were to increase monitoring of residents if seen with a backpack. The care plan documented the back pack could be a trigger that Resident #1 wanted to leave the facility. A behavior note, dated 8/28/25 at 3:43 p.m., documented Resident #1 spoke to his mother via telephone and the resident became increasingly agitated and ended up hanging up on his mother and walked away. A behavior note, dated 9/4/25 at 3:28 p.m., documented Resident #1's mother called the facility wishing to speak to the nurse. Resident #1's mother asked staff if the fence was electrified as Resident #1 told her he touched the fence and got shocked. The staff informed the caller the fence was not electrified and never had been.A progress note, dated 9/5/25 at 10:58 p.m., documented while completing building rounds at 9:45 p.m., Resident #1 was noted to be missing. A full building and perimeter search was completed. The DON, the NHA, the physician and the local police were notified that Resident #1 was missing. At 10:30 p.m. the resident was found by staff walking up the street. Resident #1 was noted to have a strong smell of alcohol. Resident #1 returned to the facility at 10:45 p.m. A skin check was done and the resident was placed on one-to-one supervision. A psychosocial services note, dated 9/8/25 at 11:01 a.m., documented that the social services director (SSD) met with Resident #1 post elopement on 9/5/25. Resident #1 continued to report his desire to relocate to his home country and his belief he did not need placement in the facility. Resident #1 reported his mother told him she was coming for him because he did not belong there. He reported it was coming soon when he was asked when this was going to happen.III. Facility investigation of Resident #1's elopement on 9/5/25On 9/10/25 at 2:54 p.m. the NHA provided the facility's investigation of Resident #1's elopement from the facility on 9/5/25. The investigation revealed Resident #1 was last seen on 9/5/25 at 9:30 p.m. during routine building rounds. During routine building rounds at 9:45 p.m., Resident #1 was not able to be found. The facility staff commenced a full building and perimeter search immediately after identifying Resident #1 was missing. The facility staff notified the NHA, the director of nursing (DON), the attending physician and the local police department. At 10:30 p.m. Resident #1 was located by facility staff a couple blocks away from the facility. Resident #1 was noted to have a strong odor of alcohol. Resident #1 willingly re-entered the facility at 10:45 p.m. with staff assistance. Resident #1 reported he got disoriented and did not know how to get back to the facility. Upon Resident #1's return, he was assessed by the nurse and placed on one-to-one monitoring by facility staff.The DON interviewed Resident #1 on 9/8/25 and Resident #1 reported he left the facility grounds by climbing the corner section of the perimeter fence. Resident #1 explained the tension wires were installed on the interior side of the fence and served as foot holds, allowing him to climb and propel himself over the fence. Resident #1 indicated that climbing the fence was easy for him to accomplish due to his physical fitness. The investigation documented there were no staff or other resident witnesses. The facility's security cameras did not capture the elopement, identifying a blind spot in coverage. Resident #1 was placed on one-to-one monitoring from staff and monitored for alcohol intoxication. IV. Staff interviewsLicensed practical nurse (LPN #2) was interviewed on 9/10/25 at 5:25 p.m. LPN #2 said she was assigned to be Resident #1's one-on-one for monitoring his whereabouts for elopement concerns. LPN #2 said Resident #1 had voiced in the past his desire to leave the facility to go to his home country. LPN #2 said she normally worked night shift and was on shift the night Resident #1 eloped from the facility. LPN #2 said Resident #1 had seemed baseline, completing normal routines with smoking and spending time outside, taking his medications and conversing with her. LPN #2 said the resident became agitated after a call from his mother on the day of the elopement. LPN #2 said the facility completed 15-minute checks on residents to ensure all residents were accounted for. She said Resident #1 was last seen outside in the front courtyard, prior to him eloping. LPN #2 said that once he was not located in the facility, the staff started a building and grounds search then began notifying appropriate parties. The SSD, the DON, the NHA and the regional nurse consultant were interviewed on 9/11/25 at 9:03 a.m. The SSD said Resident #1 had been a resident at the facility prior to his admission on [DATE]. The SSD said when the resident was previously admitted to the facility, Resident #1 was independent and appropriate on outings. The SSD said the resident had always expressed the want to go to his home country. The SSD said Resident #1's mother no longer had guardianship of Resident #1 and the facility was contacted by the appointed guardian to see if Resident #1 could return to the facility. The SSD said the facility received a call from the resident's mother with questions about the fence being electrified, which the fence was not electrified. The SSD said she reviewed the security cameras one to two times a week or more if needed. She said she reviewed them to observe for behaviors or as part of an investigation to reveal what occurred.

Based on observations, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect and exploitation for six (#1, #4, #3, #2, #8 and #7) of eight residents reviewed out of 13 sample residents. Specifically, the facility failed to: -Protect Resident #1 from physical abuse by Resident #8; -Protect Resident #4 from physical abuse by Resident #9; -Protect Resident #3 and Resident #8 from physical abuse by each other; -Protect Resident #2 from physical abuse by Resident #10; and, -Protect Resident #7 and Resident #8 from physical abuse by each other. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/4/25 at 10:57 a.m. The policy read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent abuse by anyone. Residents have the right to be free from abuse. Providing a safe environment for the resident was an essential duty of the facility. Residents at risk for abusive situations are identified, and appropriate care plans are developed. II. Incident of physical abuse on 4/16/25 by Resident #8 towards Resident #1 A. Facility investigation The 4/16/25 facility investigation was received from the NHA on 6/2/25 at 1:15 p.m. The investigation documented Resident #1 sat on his walker in the hallway and began to back up, almost running into Resident #8. Resident #8 reached out and hit Resident #1 with his arm in the middle of his back. The investigation documented facility staff responded to the altercation and separated the residents. The nurse completed an assessment on both residents and documented Resident #1 and Resident #8 had no changes in behavior and had no injuries. The investigation included interviews with Resident #1 and Resident #8. The facility investigation documented Resident #1 said there was no incident and no one had been abusive towards him. The facility investigation documented Resident #8 said nothing happened with Resident #1. The facility substantiated physical abuse by Resident #8 towards Resident #1. B. Resident #8 (assailant) 1. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician's orders (CPO), diagnoses included dementia with behavioral disturbance and Wernicke's encephalopathy (a neurological condition that can impact balance and cause confusion). The 3/11/25 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a brief interview for mental status (BIMS) score of zero out of 15. Resident #8 required set-up assistance from staff for standing and was independent with walking. The MDS assessment documented the resident had physical and behavioral symptoms directed towards others during the assessment look back period. 2. Record review The care plan, revised 3/27/25, revealed Resident #8 could become physically aggressive by striking out at others. The care plan documented potential triggers for Resident #8 included disagreements or confrontations with others and people invading his personal space. The care plan identified additional triggers on 3/10/25 to include prolonged waiting for the opening of the dining room for meals. Pertinent interventions included providing physical and verbal cues to alleviate anxiety (initiated 3/10/25), assisting the resident with goals for pleasant behavior (initiated 3/10/25), encouraging the resident to seek a staff member when agitated (initiated 3/10/25) providing support to Resident #8 if other residents were invading his personal space (initiated 4/21/25), offering non-pharmological interventions such as offering food, drinks or an activity of choice (initiated 4/21/25). The care plan directed staff to de-escalate the resident's behavior by reducing wait times, listening to music and watching western television shows (initiated 3/10/25). Review of Resident #8's electronic medical review (EMR) revealed Resident #8 was monitored for 72 hours after the altercation and no additional behaviors were documented. C. Resident #1 (victim) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included disorganized dementia, obsessive-compulsive disorder, anxiety and difficulty walking. The 3/20/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. Resident #1 required set-up assistance from staff for standing and walking. Resident #1 used a rolling walker with a seat while walking. The MDS assessment indicated the resident did not have behavioral symptoms directed towards others during the assessment look back period. 2. Resident interview Resident #1 was interviewed on 6/2/25 at 2:44 p.m. Resident #1 said he remembered when he was hit on the back by Resident #8. He said Resident #8 hurt him on the back. Resident #1 said he was doing fine now and was not afraid. Resident #1 said he did not know Resident #8 was standing behind him when he pushed his walker backward and he was not angry at Resident #8. 3. Record review The behavior care plan, revised 4/21/25, identified Resident #1 had a behavior pattern of yelling that had the potential to trigger and disrupt other residents to respond with agitation towards Resident #1. Interventions included anticipating and meeting the residents needs, assisting and developing appropriate methods of coping and redirecting Resident #1 from other residents during times of disruptive and yelling behavior. III. Incident of physical abuse on 4/27/25 by Resident #9 towards Resident #4 A. Facility investigation The 4/27/25 facility investigation was received from the NHA on 6/2/25 at 1:15 p.m. The investigation documented the facility reviewed video cameras from 4/27/25 at 2:10 p.m. The video revealed Resident #9 moved down the left side of the hallway towards his room. Resident #4 was observed self-propelling his wheelchair, traveling in the opposite direction of Resident #9. Resident #4 propelled himself past Resident #9's doorway. Resident #9 turned towards Resident #4 and struck him with his fist, hitting Resident #4 in the face and then went into his room. The video summary documented that staff members arrived in the hallway and assisted Resident #4 to move away from Resident #9's doorway. The investigation documented the nurse completed an assessment on both residents and documented Resident #4 and Resident #9 had no changes in behavior and had no injuries. The investigation included interviews with Resident #4 and Resident #9 on 4/28/25. The facility investigation documented Resident #4 said he did not know what the investigator was talking about. Resident #4 denied being involved in an altercation with anyone. The facility investigator interviewed Resident #9, who did not respond to questions and denied he was in an altercation. The facility substantiated physical abuse by Resident #9 towards Resident #4. B. Resident #9 (assailant) 1. Resident status Resident #9, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included schizophrenia (mental illness), traumatic brain injury and cognitive communication deficit. The 5/28/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. Resident #9 was independent with standing and walking. The MDS assessment documented the resident had no physical or verbal behaviors directed at others during the assessment look back period. 2. Record review The behavioral care plan, revised 3/10/25, identified Resident #9 had the potential to be physically aggressive, including hitting, kicking, pushing and grabbing others The resident had a history of causing harm to others and had poor impulse control. The care plan documented aggression was triggered when others entered Resident #9's room or followed too closely behind him. Pertinent interventions included administering medications ordered, assessing and anticipating Resident #9's needs, encouraging Resident #9 to seek a staff member when agitated, giving Resident #9 choices about his care and activities, redirecting other residents when others became too close to Resident #9 and when Resident #9 was agitated and intervening before agitation escalated. An additional intervention, implemented 5/7/25, directed staff to redirect others from Resident #9 in an attempt to decrease physically aggressive behaviors. The 4/27/25 nurse progress note documented that as Resident #9 was walking to his room, he hit Resident #4. The note documented Resident #4 held his hands up in a defensive manner. The camera footage showed Resident #9 hit Resident #4 on the head three times. A head to toe assessment was completed by the registered nurse (RN) and no injuries or bruises were present. On 5/30/25 the physician ordered an increase in Resident #9's antidepressant medication, Trazadone, to 75 milligrams (mg) four times a day, for impulsiveness and physical aggression behaviors. C. Resident #4 (victim) 1. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included dementia, anoxic brain damage and mood disorder. The 5/28/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. Resident #4 required partial to moderate assistance from staff to stand and sit and substantial assistance from staff to propel a manual wheelchair. The MDS assessment indicated the resident had no behaviors directed towards others during the assessment look back period. 2. Record review The behavioral care plan, initiated 3/10/25, revealed Resident #4 could become verbally aggressive and lash out at others if agitated. Interventions included administering medications as ordered, monitoring Resident #4 and intervening and redirecting when agitated to prevent escalation. IV. Altercation on 4/28/25 between Resident #8 and Resident #3 A. Facility investigation The 4/28/25 facility investigation was received from the NHA on 6/2/25 at 1:15 p.m. The investigation documented the facility reviewed video footage from 4/28/25 at 7:30 p.m. The video revealed Resident #3 and Resident #8 were in the hallway. When Resident #3 walked towards Resident #8, Resident #8 stood up and moved towards Resident #3, hitting Resident #3 multiple times. The footage showed Resident #3 hit the aggressor back after the assailant hit him a couple of times. The facility investigation documented staff responded from inside another resident's room and separated Resident #3 and Resident #8. The investigation documented the nurse completed an assessment on both residents and documented Resident #3 and Resident #8 had no changes in behavior and had no injuries. The facility investigation included interviews with Resident #3 and Resident #8 that were completed on 4/29/25 The facility investigation documented Resident #3 said he did not know why Resident #8 was mad at him. The investigation documented Resident #8 told the facility investigator that Resident #3 said inappropriate things repeatedly, and he hit Resident #3 so he would stop talking inappropriately. The facility investigator interviewed one staff member that reported he heard Resident #3 say explicit language to another resident. The staff member told the facility investigator he went to investigate and observed Resident #3 and Resident #8 in a fistfight and separated the residents. The facility substantiated physical abuse by Resident #8 towards Resident #3. B. Resident #8 (assailant and victim) 2. Record review Review of Resident #8's EMR revealed Resident #8 were placed on 15-minute checks until evaluated by the physician, and no additional behaviors were documented. On 5/2/25 the physician evaluated Resident #8 and frequent monitoring was discontinued. C. Resident #3 (victim and assailant) 1. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included disorganized dementia, schizophrenia, history of traumatic brain injury and encephalopathy (a brain condition that can cause impaired memory, behavior and level of consciousness). The 4/23/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. Resident #3 was independent with standing and walking. The MDS assessment indicated Resident #3 did not have behaviors directed at others during the assessment look back period. 2. Record review The behavior care plan, revised 9/18/24, revealed Resident #3 had the potential to be verbally aggressive due to dementia. Interventions included providing Resident #3 with choices for care and activities and providing the resident time to respond to staff, administering medications as ordered and redirecting other residents away from Resident #3 if Resident #3 was agitated. The 4/28/24 nurse progress note documented Resident #3 was walking toward another resident and the other resident got up and hit Resident #3 multiple times. The record review revealed, on 4/28/25, Resident #3 was placed on 15-minute checks for 72 hours and no additional behaviors were documented. V. Altercation on 5/5/25 between Resident #10 and Resident #2 A. Facility investigation The 5/5/25 facility investigation was received from the NHA on 6/2/25 at 1:15 p.m. The investigation documented the facility reviewed video footage from 5/5/25 at 6:30 p.m. The video footage revealed Resident #2 was walking in the hallway and approached Resident #10's doorway. Resident #10 was walking through the doorway and approached Resident #2. Resident #10 pushed Resident #2 with his arm. Resident #2 was observed to lose her balance and grab onto Resident #10. Resident #10 then pushed Resident #2, causing her to fall backward onto her elbow and wrist. The investigation documented that staff came around the hallway and immediately separated the residents. The facility investigation documented the nurse completed an assessment on 5/525 and contacted the physician to report that Resident #2 had pain in her wrist and elbow. The physician ordered Xrays of Resident #2's wrist and elbow which showed no acute fractures. The investigation documented Resident #10 was placed on one-to-one monitoring when he was outside of his room and 15-minute checks while in his room to prevent additional aggression for 72 hours. The facility investigation documented interviews with Resident #2 and Resident #10 on 5/5/25. The facility investigator documented that Resident #2 said she did not remember the altercation and told the investigator she was not fearful of anyone in the facility. The facility investigation documented Resident #10 told the facility investigator the altercation occurred because Resident #2 was in his room. The facility substantiated physical abuse by Resident #10 towards Resident #2. B. Resident #10 (assailant) 1. Resident status Resident #10, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included Wernicke's encephalopathy and history of traumatic brain injury. The 5/30/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. Resident #10 was independent with standing and walking. The MDS assessment indicated the resident had no behavioral symptoms directed at others during the assessment look back period. 2. Record review The behavioral care plan, revised 3/6/25, documented Resident #10 had challenges with impulse control and may act out physically by lashing out at others due to poor impulse control, which could lead to violent outbursts in the form of hitting, kicking and pushing. Interventions included assisting Resident #10 with appropriate methods of coping when a resident entered his room, intervening as necessary to protect the rights and safety of others, removing individuals from the situation and relocating them to alternative locations as needed, educating Resident #10 about the consequences of being physically aggressive, identifying what de-escalateed behavior and intervening when the resident became agitated to prevent escalations and guide Resident #10 away from the source of distress. The behavioral care plan, revised 4/24/25, was updated with an additional intervention for educating Resident #10 to ask for assistance from staff if another resident was being aggressive with him. The 5/5/25 nurse progress note documented Resident #10 used his forearm to push another resident (Resident #2) and was waving his arms and yelling. The behavioral care plan, updated 5/5/25, included the intervention for one-on-one monitoring while Resident #10 was outside his room and 15-minute monitoring while in the room. C. Resident #2 (victim) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included Alzheimer's disease and dementia. The 4/29/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of zero out of 15. Resident #2 was independent with standing and walking. The MDS assessment indicated the resident had behavioral symptoms directed towards others during the assessment look backperiod. 2. Observations On 6/4/25 at 2:30 p.m, Resident #2 was entering a resident's room and removing a stack of papers. Resident #2 wandered in the hallway with the papers for approximately five minutes and another resident assisted Resident #2 to return the papers. There were no facility staff present in the hallway. 3. Record review The behavioral care plan, initiated 8/8/24 and revised 5/5/25, identified Resident #2 had wandering behavior with a history of entering the rooms of other residents without invitation or awareness. Pertinent interventions included redirecting Resident #2 to familiar hallways and to the dining room area where she visited with her spouse and redirecting Resident #2 away from Resident #10 due to past aggression. The 5/5/25 nurse progress note documented Resident #2 was walking in the hallway and stopped and looked into Resident #10's room. Resident #10 came from his room and used his forearm to push Resident #2 and Resident #2 fell to the floor. The physician was contacted and gave an order for Xrays of Resident #2's right wrist and right elbow. VI. Altercation on 5/17/25 between Resident #8 and Resident #7 A. Facility investigation The 5/17/25 facility investigation was received from the NHA on 6/5/25 at 12:10 p.m. The investigation documented the facility reviewed video footage from 5/17/25 at 6:05 p.m. The video footage revealed Resident #7 and Resident #8 were standing next to each other in the hallway by the nurses'station. Resident #7 and Resident #8 exchanged words, Resident #8 approached Resident #7, reaching out and grabbing Resident #7's clothing. Resident #7 grabbed Resident #8's arms and pushed Resident #8 away from him. Resident #7 stumbled and fell backward to the floor. The investigation report documented the nurse completed an assessment on 5/5/25 and contacted the physician to report the occurrence and that Resident #7 had pain near his left hip and low back. The physician ordered a left hip Xray which showed no fracture. The investigation documented Resident #8 was placed on one-to-one monitoring when he was outside of his room and 15-minute checks while in his room to prevent additional aggression for 72 hours. The facility investigation documented interviews were conducted with Resident #7 and Resident #8 on 5/17/25. The facility investigator documented Resident #7 said he was pushed to the floor by Resident #8 and Resident #8 called him names when he was on the floor. When the facility investigator interviewed Resident #8, he reported he did not remember anything. The facility investigation documented one staff member heard the altercation from inside the nurses' station and looked out into the hallway where he saw Resident #7 fall to the floor. The facility substantiated physical abuse by Resident #8 towards Resident #7. B. Resident #8 (assailant and victim) 1. Record review Review of Resident #8's EMR revealed that on 5/17/25, Resident #8 was placed on 15-minute checks until evaluated by the physician and no additional behaviors were documented. On 5/20/25 the physician evaluated Resident #8 and frequent monitoring was discontinued. On 5/20/25 the physician ordered an antipsychotic medication, Risperdal, 1 mg, twice a day for aggressive behaviors. C. Resident #7 (assailant and victim) 1. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included Alzheimer's disease, dementia, restlessness and agitation. The 5/16/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. Resident #7 was independent with standing and walking. The MDS assessment documented Resident #7 had no physical or verbal behaviors directed at others during the assessment look back period. 2. Record review The 5/17/25 at 6:30 a.m. nurse progress note documented Resident #7 fell to the floor after Resident #8 grabbed Resident #7's arm, which caused Resident #7 to fall to the floor. The physician was notified and gave orders for an Xray for the left hip and pelvis. The record review revealed, on 5/17/25, Resident #7 was placed on 15-minute checks for 72 hours for monitoring purposes. The behavioral care plan, initiated 5/12/25, revealed Resident #7 had the potential to be verbally aggressive due to dementia and Alzheimer's disease. The resident had difficulty expressing his feelings and needs. The interventions included administering medications as ordered, assessing Resident #7's coping skills, allowing Resident #7 time to express himself and his feelings and giving Resident #7 as many choices as possible about his care and activities. VII. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/5/25 at 10:05 a.m. CNA #1 said she was assigned to provide care to residents on all of the hallways. She said CNAs were assigned to work on specific hallways but that she was a float CNA and helped on all of the hallways. CNA #1 said Resident #8, Resident #10 and Resident #9 had a history of physical and verbal behaviors towards staff and residents. CNA #1 said if a resident had increased agitation, staff redirected the resident to an activity such as listening to music or watching television. CNA #1 said that when CNAs provided care to residents it was possible there would be no staff members in the hallway to monitor residents in the hallways. CNA #1 said if a CNA was off the floor for a break or lunch or another reason, there were no coworkers assigned to monitor residents or the hallways. CNA #1 said staff helped each other but the hallways were not always monitored. CNA #1 said she had training related to things to watch for and intervene when residents had aggressive behaviors. She said she received training in abuse and de-escalation when hired and periodically during the year at staff meetings and during shift change reports. CNA #1 said Resident #8 exhibited spontaneous behaviors. She said the staff monitored and redirected Resident #8 when he acted aggressively. The social services director (SSD), the director of nursing (DON) and the NHA were interviewed together on 6/5/25 at 2:30 p.m. The SSD said Resident #8 had a history of physical and verbal aggression when others approached his space. The SSD said Resident #8 was spontaneous with behaviors and staff were unable to respond fast enough when Resident #8 had escalating behaviors. The SSD said Resident #8 had not had verbal or physical behaviors since the physician adjusted the resident's Risperdal medication on 5/20/25. The DON said when there was a resident-to-resident altercation, the charge nurse completed an assessment for each resident and notified the physician. The DON said after altercations, residents were placed on one-to-one care or 15-minute checks for close observation for injury or changes in behavior. The DON said Resident #1, Resident #7, Resident #4 and Resident #2 experienced pain from the altercations but had no injuries or changes in behaviors. The NHA said staff responded promptly to the altercations and redirected residents when necessary. The NHA said the facility had continuous video surveillance and recordings of the hallways and the display monitors were positioned inside the nurses'station. The NHA said the video cameras were in place and monitored by staff that worked inside the nurses'station. She said the video surveillance was not monitored continuously by a staff member, and the cameras were in use to help staff monitor all the hallways from the nurses'station when floor staff were helping other residents or were on a break. The NHA said the staff had been educated to not congregate in the breakrooms at the same time as coworkers and there should be staff on each hallway to care for residents and monitor behavior. The NHA said Resident #2 wandered throughout the facility. The NHA said Resident #2 was entering fewer rooms. The NHA said the staff redirected Resident #2 to her hallway, the dining room and the activities area to avoid her entering rooms uninvited. The NHA said the interdisciplinary team (IDT) would continue to review and monitor Resident #2 for wandering behaviors.

Based on record review and interviews, the facility failed to ensure one (#3) of three residents at risk for elopement out of 17 sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #3 with the supervision necessary to prevent elopement. The facility's failures created a situation for the likelihood of serious harm to residents' health and safety if not immediately corrected. The facility was a totally secure building specializing in serving residents with severe mental illness, dementia and behavioral health issues. The entire campus had a six-foot high security fence around the whole campus with a wired overhang in the unrestricted front resident space to discourage anyone from climbing over the fence. The back fenced-in areas did not have the wired overhang, but access was restricted in the overnight hours when staff were not able to monitor residents in those areas. Staff and visitors had to be keyed in and out of the front gate. Prior to his admission to the facility on [DATE], Resident #3 was diagnosed with dementia and schizophrenia and had a known history of untreated schizophrenia. He continued to refuse treatment and denied having the diagnosis of schizophrenia. While in the hospital, the resident was assessed to have decisional incapacity with an inability to take care of himself; because of this, he was assigned a court-appointed guardian. While at the hospital awaiting mandated placement, he eloped from the hospital setting and had to be returned to the hospital by a police escort. Resident #3 eloped from the facility on 12/30/24 at approximately 7:15 p.m. and was not noticed to be absent from the facility until 12/31/24 at 11:30 a.m. (approximately 16 hours later) when staff were gathering residents for lunch. After an initial search of the facility and the surrounding neighborhood on the morning of 12/31/24, the facility discovered the resident had spent the night at the local hospital. The hospital assessed the resident, gave him a referral to a local homeless shelter and released him. The resident left the hospital and was found shortly afterward by facility staff wandering in an open field near the hospital. Facility leadership viewed video footage of the outdoor space as a part of their investigation to determine how Resident #3 got out of the secured fencing. The resident was viewed on video surveillance going in and out of the doors to the front yard. He was seen unscrewing the yard lights and poking at the fence. He made several trips in and out of the building to the front fencing. At approximately 7:00 p.m. on 12/30/24, during a time when staff were occupied by an unrelated resident incident, Resident #3 was seen on camera with a packed bag leaving his room and exiting the facility through a nearby door. The resident walked the fence line to the opposite side of the yard until he was out of sight of the camera and was not seen back on camera after that, nor was he observed by any staff anywhere on facility grounds. Facility staff checked the fence where Resident #3 was last seen on camera and discovered two holes in the lower corner where the two pieces of fencing came together. The overhanging guard wire on the top of the fence had been unscrewed and removed. It was the conclusion of the nursing home administrator (NHA) that Resident #3 had used facility silverware to make the holes in the fence and unscrew the security wiring. Then the resident used the holes in the fence to insert his feet, enabling him to pull himself up and climb over the fence where he removed the overhanging security wiring. Findings include: Observations, interviews and record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/25/25 to 2/26/25, resulting in the deficiency being cited as past noncompliance with a correction date of 1/2/25. I. Situation of serious harm Resident #3 had been homeless for six years prior to his admission to the facility on [DATE] and expressed a desire to return to the city where he had been living prior to his admission to the facility. The facility failed to ensure that facility staff performed regular checks to ensure residents' presence in the facility, particularly when all residents in the facility were known to have a history of elopement-seeking behavior. An interview with the NHA revealed that the facility staff had stopped conducting resident checks to ensure residents' presence in the facility prior to Resident #3's elopement on 12/30/24. Additionally, the facility was not checking the security fencing that surrounded the entire building for breaches where residents could elope. The facility's failure to prevent Resident #3, who had severely impaired cognition, poor safety awareness and a high risk for an elopement attempt, from leaving the facility unsupervised placed the resident at serious risk of harm, serious impairment or death due to the resident's inability to make sound decisions and ensure his own safety. II. Facility plan of correction The corrective action plan the facility implemented in response to Resident #3's elopement incident on 12/30/24 was provided by the NHA on 2/25/25 at 8:45 a.m. The correction plan revealed the following: A. Immediate action On 12/31/24, the facility began their investigation and developed a root cause analysis to determine the necessary corrective actions. Corrective actions included: -Resident #3 returned to the facility and was placed on one-to-one monitoring, but this made him anxious so the facility placed him on 15-minute checks; -Resident rounding was reinstated to account for resident location, checking resident count every 15 minutes for two weeks. Initiated 12/31/24; -Fencing repaired. Completed 12/31/24; -Front yard surveillance camera was adjusted to give staff a view of the whole front yard; completed 12/31/24; -Instituting daily inspection of the fencing, repair as needed for 4 weeks. Initiated on 1/2/25; -New lighting was installed to light up a larger area of the yard. Lighting was placed in a location inaccessible to residents to prevent unscrewing of the bulbs. Completed 1/2/25; and, -Education provided to all staff on rounding, elopement prevention and midnight census count; initiated 12/31/24 and completed 1/2/25. B. Identification of others affected The facility determined the deficient practice had the potential to affect all the residents in the facility. C. Systemic changes The director of nursing (DON) and the assistant director of nursing (ADON) educated all of the staff on the staff expectations to provide resident supervision with rounding, and conducting ongoing midnight census - heads in beds count, with all residents in the facility. The elopement book was updated to include all residents in the facility. In the event of a resident elopement, the facility had a packet of pertinent information to provide to emergency personnel to aid in finding a missing resident. The front fencing would be replaced with a like-new eight-foot fence. The estimate was approved for the job to move forward on 2/26/25 and the date of completion was to be determined. D. Monitoring The facility would evaluate the effectiveness of the plan in quality assurance and program improvement (QAPI) committee meetings for three months and implement additional interventions as needed to ensure sustained compliance. III. Facility policy and procedure The Elopement and Wandering policy, dated 2/29/24, was provided by the NHA on 2/26/25 at 3:40 p.m. The policy read in pertinent part, It is a goal of the facility to provide a safe environment using least restrictive measure available in caring for residents who are exhibiting elopement behavior. The facility defines 'wanderers' as residents who move around the facility in a non-goal directed manner, but do not make efforts to leave the premises. 'Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks. If the resident is identified as an elopement risk, the following will be maintained: -Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder; -Implementing and care planning interventions to address safety and decrease the risk of elopement; -A physical restraint use consent shall be obtained from the resident's responsible party if an electronic device is utilized; -A physician order will be required for the use of monitoring the device. The order will include checking the placement of the device every shift and checking the function of the device daily; and, -The care plan will be updated to include that an electronic alarm system is used for resident's safety. IV. Resident #3 A. Resident status Resident #3, age 71, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included schizophrenia, dementia and diabetes. The 1/9/25 minimum data set (MDS) assessment revealed the resident had severely impaired cognitive impairments with a brief interview for mental status score (BIMS) of zero out of 15. The resident was able to express ideas and wants and was able to understand verbal content in conversations. The resident was independent with most activities of daily living (ADL) but needed set-up or clean-up assistance with oral and personal hygiene and supervision with showering. The resident experienced hallucinations and delusions but was not assessed to be aggressive. The resident rejected evaluation of care and wandered daily during the assessment look-back period. The quarterly social services evaluation, dated 1/10/25, documented the resident completed a BIMS assessment and was found to be cognitively intact with a score of 15 out of 15 on the exam. B. Resident observation and interview Resident #3 was interviewed on 2/26/25 at 2:30 p.m. Resident #3 said he left the facility to return to the city where he had previously lived. He said he hopped the fence and started walking towards the highway. He said he had enough money saved to get a bus ticket, but he got thirsty on the way and stopped at the hospital for a drink of water. He said it was his downfall that he stayed at the hospital too long. Resident #3 said the hospital doctor talked to him and he thought the doctor was trying to find out if he was crazy. He said the hospital staff let him sleep in the back on a bed and in the morning he was given a referral to a local homeless shelter. He said he was going to the shelter when the police showed up and started asking him questions. Resident #3 said he did not trust the police because they were not telling him the truth about what was going on. He said he refused a ride with the police and then left the hospital on his own. He said the facility staff caught up with him and brought him back to the facility. Resident #3 said he did not want to move to another facility because he wanted to return to the city where he had several living opportunities and knew where to get a good sandwich. Resident #3 said if you leave the door open for me I will sneak out. On 2/26/25 at 3:33 p.m. Resident #3 was out in the front yard of the facility walking the perimeter of the fence, pushing on the fence and looking up at the overhanging security wiring. C. Record review 1. Care plans Resident #3's comprehensive care plan, initiated 8/1/23, documented that Resident #3 required placement on a secure neighborhood due to dementia and a history of elopement to unsafe environments. Resident #3's guardian wished for him to remain at the facility with no plan for discharge. Interventions included activities staff were to provide scheduled activities within Resident #3's capabilities, reviewing Resident #3 every 180 days by the interdisciplinary team (IDT) for appropriateness of secure unit placement, monitoring Resident #3 for exit-seeking behavior and redirecting him away from doors and promoting engagement in meaningful activity. Resident #3's comprehensive care plan included a care focus for elopement risk, initiated on 8/1/23 and revised 1/3/25. The care focus revealed that Resident #3 was an elopement risk related to previous elopements at a prior facility and a dementia diagnosis. Resident #3 would often express a desire to be outside, even to sleep. Resident #3 was often found walking along the fence trying to manipulate it so he could get out and would acquire objects to help him meet this goal. While wandering, Resident #3 would often look for weakness in the fence or an opportune time to leave the facility. Resident #3 could become agitated when being checked on or monitored. Interventions included identifying patterns of wandering and determining if wandering was purposeful or random without a goal, distracting Resident #3 by offering him the opportunity to sit outside listening to rock music, encouraging exercise, like jogging; and talking about animals (initiated 8/1/23, revised 1/3/25), implementing one-to-one supervision if needed and, if implemented, following the resident at a close enough distance that staff could see Resident #3 and intervene when needed, ensuring staff did not directly follow him and cause an increase in paranoia symptoms, if the one-to-one supervision was upsetting to Resident #3 switching staff members and giving him space (initiated 1/3/25), conducting frequent visual checks on Resident #3 throughout the day and night to ensure location and safety (initiated 2/25/25) and providing active listening when Resident #3 voiced ideations of leaving the facility in order to promote redirection (initiated 2/26/25). 2. Preadmission Screening and Resident Review (PASRR) The PASRR Level II evaluation, dated 7/23/23, documented that Resident #3 had been living on the streets, was unable to care for himself and ended up in the hospital for treatment of significant swelling in his legs. He had a long history of untreated schizophrenia, with symptoms including paranoid ideation, delusional thoughts, disorganized thinking and speech, flight of ideas and tangential (vague) speech. The assessment further revealed that Resident #3 had problems with his foot but could stand and ambulate independently. He would likely benefit from prompts and set up for showering. He could toilet and complete basic ADLs with little assistance. Due to his symptoms of psychosis, he would benefit from a supervised setting. Resident #3 was in denial about his mental health diagnosis and his need for treatment. Resident #3 lacked insight into his need for more stable housing and need for care. He was resistant to placement in long-term care and wanted to feel independent. Because Resident #3 did not meet the requirements for court-ordered medication, the PASRR assessor recommended the resident be offered an opportunity to accept medications on a voluntary basis. 3. Elopement and wandering risk assessment An elopement risk assessment, dated 1/10/25, revealed Resident #3 was an elopement risk related to previous elopement at a prior facility, dementia diagnosis, and history of being homeless. He spent most of his time outside on facility grounds walking and poking at the fence. This was documented as the rationale for continued need for the resident's secure placement. The assessment indicated the resident's guardian did not want the resident to return to community living. D. Resident #3's elopement incident on 12/30/24 The facility's investigation, dated 12/31/24, revealed the following information: On 12/31/24 at approximately 11:30 a.m. facility staff discovered that Resident #3 was not in the facility when they went to look for him for the lunch meal. Staff initiated an immediate search for the resident and were not able to locate him on the facility grounds or in the immediate neighborhood. Facility staff called the police for assistance and called the local hospital. At 11:30 a.m., the hospital was able to confirm that Resident #3 was at the hospital and they had assessed him. Resident #3 would not get a ride with the police and left the hospital on foot. Facility staff drove to the hospital and found the resident wandering in an open field. Resident #3 accepted a ride with staff to return to the facility. The investigation revealed that none of the staff on duty on the evening of 12/30/24 could give an accurate account of when Resident #3 was last seen in the facility. -Nursing staff had not conducted a monitoring check on the resident at any time on the evening of 12/30/24. The nurse on duty the morning of 12/31/24 documented on Resident #3's December 2024 medication administration record (MAR) that the resident's 6:00 a.m. magnesium and multivitamin tablets were administered. However, it was later discovered through the investigation that the resident was not in the facility at that time. Additionally, staff were not following the care plan to monitor Resident #3's exit-seeking behavior, notice his behavior at the fence looking for weakened fencing areas or monitoring his activity while standing at the fencing. Staff had stopped conducting frequent visual checks of the resident to monitor his location in the facility. It was not until after the resident's elopement that the intervention for frequent visual checks of Resident #3 was added to the resident's care plan. As a part of the facility's investigation, the NHA reviewed video footage of the facility for 24 hours. The video footage revealed Resident #3 had spent the evening of 12/30/24 going in and out of the building, examining the fencing. At one point early in the evening, the resident was observed unscrewing the light bulbs at the far end of the front facility yard. The resident was later seen, at approximately 7:00 p.m,. leaving his room and exiting the door near his room with a packed bag. The resident was then seen on the camera outside, walking the fencing and heading toward the side of the yard where he had spent most of his time that evening and in the location where he had unscrewed the outside light bulbs. The video footage revealed Resident #3 could be seen walking the fencing at 7:00 p.m. until he disappeared off-camera a few minutes later. The resident was not seen back on camera any time after that time. The NHA examined the fence in the area where the resident was last seen and found two holes mid-level in the fencing, one on each side, in the corner where the two pieces of fencing met and the over-hanging wiring had been unscrewed and removed in that section. When interviewed by the NHA upon Resident #3's return to the facility, the resident said he had packed a bag of his belongings and climbed over the fencing with the intention of returning to the city where he previously lived. Resident #3 told the NHA he did not cut the wires on the fence but he did unscrew the wires at the top of the fence and climbed over the fence. Resident #3 said he wanted to get to the city and stay with friends. The NHA asked the resident if he would like a referral sent to other facilities within the desired city's area and the resident agreed but stated he wanted to be able to walk into the community. The NHA explained to Resident #3 the importance of being safe and that the facility would need to contact his guardian to get approval. In conclusion, the investigation report documented that Resident #3 had eloped the facility between 7:00 p.m. and 7:15 p.m. on the evening of 12/30/24 and none of the staff noticed his absence until approximately 16 hours later, on 12/31/24 at approximately 11:00 a.m. V. Staff interviews Resident assistant (RA) #2 was interviewed on 2/25/25 at 1:45 p.m. RA #2 said the staff were conducting 15-minute checks of all residents to make sure residents were present in the facility and the back doors were locked every evening after the last resident smoke break. Licensed practical nurse (LPN) #1 was interviewed on 2/25/25 at 3:45 p.m. LPN #1 said the nurses were locking the back exit doors every evening after the last resident smoke break at 7:30 p.m. to ensure resident safety and minimize the risk of elopement attempts. LPN #1 demonstrated how the doors were locked. The locking mechanism was observed in practice and verified and the back doors were securely locked after the locking button in the nurse's station was activated. LPN #1 said facility staff took turns conducting 15-minute head counts to ensure all residents were accounted for. LPN #1 provided the resident head count binder and the resident head count procedure was observed in practice. Certified nurse aide (CNA) #2 was interviewed on 2/25/25 at 3:50 p.m. CNA #2 provided the resident head count checkbook and said staff from all disciplines took turns rounding and counting all residents to ensure that all residents were accounted for. CNA #2 said if the head count was not accurate, the staff would check the sign-out book to see if a resident was out on a known leave. CNA #2 said if there was no resident on an approved leave, the staff would alert the supervisor on duty and all staff would initiate a search using the census list to find out which resident was missing, while other staff would initiate a search on and off grounds for the missing resident. RA #1 was interviewed on 2/26/25 at 10:24 a.m. RA #1 said she assisted the CNAs with providing non-direct care resident-related tasks. RA #1 said one of the tasks she performed was monitoring Resident #3 in the dining room to make sure he did not remove silverware from the dining room because he was using it to loosen the fencing so he could elope from the facility. RA #1 said Resident #3 was on 15-minute checks and she had assisted staff in monitoring Resident #3's location since his last elopement in December 2024. RA #1 said Resident #3 spent most of his time in his room watching television or walking around the front yard pushing on the fencing. Registered nurse (RN) #2 was interviewed on 2/26/25 at 10:43 a.m. RN #2 said Resident #3 got up early and ate breakfast in the dining room and then spent the early afternoon before lunch wandering the facility's front yard. RN #2 said Resident #3 ate lunch in his room and then resumed wandering the yard but he rarely wandered in the hallways. RN #2 said Resident #3 had not attempted to elope on the day shift but he did successfully elope one time on the overnight shift. RN #2 said she had seen the resident checking the front fencing, pushing and pulling on the chain links. RN #2 said Resident #3 was hard to talk to but he had told staff that he did not believe that he belonged in the facility. RN #2 said the facility had a button to lock the back doors where there was no overhanging security fencing at 5:00 p.m. because there was less staff around to monitor that area on the evening and overnight shifts. RN #3 was interviewed on 2/26/25 at 10:51 a.m. RN #3 said he was aware that Resident #3 had eloped from the facility on 12/30/24 but he did not think that the resident wandered without intention. RN #3 said Resident #3 was on 15-minute checks all day, and staff regularly checked the perimeter fencing for signs of damage that would affect security and elopement prevention. He said the back facility doors were locked starting at 5:00 p.m. every evening. RN #3 said Resident #3 sometimes needed redirection when he was fixated on examining the front fencing but that staff had to also give him space if he became frustrated and agitated with the staff's attention and monitoring. He said staff also had to monitor Resident #3 closely at mealtime to make sure he did not take the silverware out because he would use it to disable the security fencing. CNA #1 was interviewed on 2/26/25 at 10:51 a.m. CNA #1 said she was recently hired and knew who Resident #3 was and had heard about his elopement. She said the resident had not attempted to elope since then. She said Resident #3 wandered outside during the daytime and spent a lot of time in his room. CNA #1 said if Resident #3 eloped from the facility, again staff would initiate a code and initiate an immediate search for the resident. CNA #1 said she had not yet received training on how to respond to a resident elopement. The NHA was interviewed on 2/25/25 at 5:30 p.m. The NHA said she arrived to work on 12/31/24 to find that the staff were unable to locate Resident #3 while conducting rounds to gather residents for the lunch meal. She said while staff initiated a search for the resident, she reviewed video footage of the facility inside and outside. She said she observed the resident on camera going in and out of the facility several times. The NHA said that at approximately 7:00 p.m., Resident #3 was observed leaving his room with a packed bag, going out front towards the security fence and disappearing off camera. She said she checked the fencing where the resident disappeared and discovered there were holes in the fence and the top overhanging security wire was removed. The NHA said staff alerted local police of the resident's absence and called the local hospital and discovered the resident was at the hospital. She said she sent staff to go get the resident and bring him back to the facility. The NHA said the IDT conducted a root cause analysis and found that staff had stopped conducting rounding to check for residents' presence in the facility and the integrity of the fencing was not being monitored. The NHA said following Resident #3's elopement incident, resident rounding had been initiated to ensure all residents were in the facility, the lighting had been replaced so that no one would unscrew the lightbulbs and the camera had been readjusted to give staff a full view of the entire yard. However, the NHA acknowledged that the facility cameras were not being continuously monitored by staff, so staff would not necessarily see a resident climbing over the fence, even with the camera readjustment. The NHA said the fencing was immediately repaired but it was found to be in poor condition in some areas, so the facility planned to replace the fencing just in the front at this time with a like-new eight-foot fence. The NHA provided the estimate and approval for the like-new eight fence for review. The NHA was not sure when the project would be completed.

Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment that included all resources, education, staff competencies and facility based risk assessments for a facility that was a totally secured locked facility for residents with mental illness and dementia diagnosis. Cross-reference F689: failure to prevent a resident from eloping a secured locked facility. Findings include: I. Facility policy and procedure The Facility Assessment policy, dated October 2018, was provided by the nursing home administrator (NHA) on 2/26/25 at 5:26 p.m. It read in pertinent part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. The facility assessment includes a detailed review of the resident population. The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps determine budget, staffing, training, equipment and supplies needed. It is separate from the quality assurance and performance improvement evaluation. II. Record review The facility assessment was last reviewed on 2/14/25 by the NHA, the director of nursing (DON), the medical director and the governing body and other members of the leadership team. The facility assessment failed to document: -The supplies, equipment and care needed when operating a totally secured locked facility; -The care required by the resident population, using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments; and, -Include staff training/education necessary to provide the level and types of support and care needed for the resident population needing to reside in a secured locked environment. III. Staff interviews The NHA was interviewed on 2/26/25 at 5:33 p.m. The NHA said the facility assessment was recently updated but she did not remember specifically what was written about the needs of the resident in relation to needing to live in a totally secure facility. The NHA said she would meet with the leadership team and discuss the resident needs and update the facility assessment to reflect more information on providing the resident population a safe and secure environment.

Based on record review and interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital. Findings include: I. Record review A request was made to the nursing home administrator (NHA) on 2/26/25 at 2:10 p.m., for the facility's hospital transfer agreement. -The facility was unable to provide a written agreement for the one area hospital. II. Staff interview The NHA was interviewed on 2/27/25 at 2:53 p.m. The NHA said the facility could not locate a hospital transfer agreement. The NHA said she reached out to the local hospital and would get a transfer agreement completed since she could not locate a current agreement. She said it was important to have a hospital transfer agreement in case the facility needed to send a resident out.

Based on observations and interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment in seven of 26 resident rooms and damaged areas in one of two resident halls out of two units. Specifically, the facility failed to: -Ensure blinds were intact in seven resident rooms; and, -Ensure the heating vents were intact and not falling off the heating units. Findings include: I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 2/26/25 at 5:26 p.m. It read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a clean, sanitary and orderly environment. II. Environmental tour and interview The environmental tour was completed on 2/25/25 at 9:30 am and again on 2/26/25 at 9:52 a.m. The following was observed: Resident rooms #6, #10, #11, #19, #22, #23 and #28 had broken window blinds that were yellow and heavily soiled with dust and debris. The window blinds in the dining room were broken and dusty. Resident room [ROOM NUMBER] had a broken doorframe and the heating units just outside of rooms #18 and #19 were bent and coming off the wall. The ceiling on the right side hallway where the mechanical lifts were stored had an approximate three-inch hole punched in the ceiling and the heating cooling vent in the ceiling was cracked. III. Resident interview The resident in room [ROOM NUMBER] said their blinds were very dusty, it bothered them and they had wanted it to be cleaned for a while. IV. Staff interview The NHA was interviewed on 2/26/25 at 5:33 p.m. The NHA said the facility was without a permanent maintenance director and was in the process of promoting a current staff member to the position. The NHA said she would take a look at the broken blinds and other areas of the facility for needed repairs. The NHA said she would consider the most appropriate type of window covering and get the broken blinds replaced. The NHA said the blinds should be on a routine cleaning schedule.

Based on record review and interviews, the facility failed to ensure five (#1,#7, #4, #10 and #3) of 15 residents reviewed for abuse were kept free from abuse out of 17 sample residents. Specifically, the facility failed to: -Protect Resident #1 from physical abuse by Resident #6 and Resident #2; -Protect Resident #7 from physical abuse by Resident #2; -Protect Resident #4 from physical abuse by Resident #5; -Protect Resident #10 from physical abuse by Resident #11; and, -Protect Resident #3 from verbal abuse by a staff member. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 2/25/25 at 9:57 a.m. It read in pertinent part, The community does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representatives, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of residents' property and exploitation. This includes, but is not limited to, freedom of corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Employees have a unique position of trust with vulnerable residents. II. Failed to protect Resident #1 from physical abuse by Resident #6 A. Incident of physical abuse between Resident #1 and Resident #6 on 1/24/25 On 1/24/25 at 4:40 a.m. Resident #1 went into Resident #6's room. Resident #1 climbed into bed with Resident #6. Resident #6 became upset and began to hit Resident #1. Certified nurse aide (CNA) #6's interview indicated Resident #1 went into Resident #6's room while Resident #6 was sleeping and got into bed with him. CNA #6 heard Resident #1 say wait, stop. As CNA #6 entered the room, Resident #1 was lying on the bed and Resident #6 was sitting up punching Resident #1 in the face. CNA #6 held Resident #6's hands and pulled Resident #1 up out of the bed. As CNA #6 was doing so, Resident #6 hit Resident #1 in the kidney area three more times. CNA #6 took Resident #1 to his room and put him into bed. Upon assessment, no injuries were noted on Resident #1 or Resident #6. Resident #1 and Resident #6 were not interviewable. The facility substantiated the abuse. B. Resident #1 (victim) 1. Resident status Resident #1, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included dementia and alcohol cirrhosis of the liver. The 12/12/24 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of zero out of 15. The assessment indicated the resident had wandering behaviors. 2. Record review Resident #1's care plan, initiated 9/29/22 and revised 2/7/25, identified the resident was at risk of injury related to wandering. Interventions included redirecting Resident #1 to his room when he was room seeking and staff were to be aware of Resident #1's location and assist him to his room or another safe place as needed. -There were no new interventions added following the 1/24/25 incident with Resident #2. The progress note, dated 1/24/25 at 7:05 a.m., documented that at 4:40 a.m. the CNA on rounds heard the sound of loud hits. The CNA went to investigate and found Resident #1 in another resident's bed. The other resident was hitting Resident #1 in the face. As the CNA was getting Resident #1 out of the other resident's bed, the other resident hit him in the back and kidney area three times. The CNA removed Resident #1 from the room and took him to his room and put him in his bed. The CNA reported the incident to the licensed practical nurse (LPN) on duty. There were no red bruised or open areas noted to the resident's face or back. C. Resident #6 (assailant) 1. Resident status Resident #6, age 76, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included dementia and alcohol cirrhosis of the liver. The 1/22/25 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of zero out of 15. The assessment indicated the resident had no behaviors. 2. Record review The progress note dated 1/24/25 at 7:22 a.m. documented the CNA doing rounds at 4:40 a.m. heard sounds of loud hits. The CNA went to investigate and found another male resident in Resident #6's bed. Resident #6 was hitting the other resident in the face. As the CNA was getting the other resident out of Resident #6's bed, Resident #6 hit him in the back and kidney area three times. The other resident was removed by the CNA. Resident #6 stated, I think I hit him in the face and back, he wouldn't get out. III. Failed to protect Resident #1 from physical abuse by Resident #2 A. Incident of physical abuse between Resident #1 and Resident #2 on 2/1/25 During the evening shift on 2/1/25 at 3:15 p.m., the nurse on duty heard a resident yelling in the hallway and ran over to investigate. The nurse witnessed Resident #2 standing in the hallway and Resident #1 pointing at Resident #2 and yelling Why? Why? Upon review of video footage, it was determined that Resident #2 was behind Resident #1 walking down the hallway when Resident #2 suddenly started kicking and punching Resident #1 from behind. The residents were separated, an investigation was initiated, 72-hour close monitoring was initiated with Resident #2 and the police were called. A door chime was purchased to help with giving Resident #2 some relief and reassurance that hopefully no other resident would accidentally go into his room. Upon review of video footage, it was determined that the alleged assailant (Resident #2) was behind the victim (Resident #1) walking down the hallway when the alleged assailant suddenly started kicking and punching the victim from behind. The assessment was completed, and there were no injuries noted. Resident #2 was interviewed and said Resident #1 was going into his room so he hit him. Resident #1 was unable to be interviewed. The facility substantiated the abuse. B. Resident #1 (victim) 1. Record review -Review of Resident #1's care plan revealed there were no updates to his care plan following the incident with Resident #2 on 2/1/25. The progress note, dated 2/1/25 at 4:01 p.m., documented the nurse, at 3:15 p.m., heard Resident #1 yelling in distress from the hallway. The nurse ran over and Resident #1 was standing and pointing at another resident and yelling Why? Why? and had burrito residue in his hair. Another resident was standing nearby in the hallway and stated I hit him, he was going in my room. Immediately separated residents. A head to toe skin check was done, and no new injuries noted. C. Resident #2 (assailant) 1. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included schizophrenia and anxiety. The 12/4/24 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of three out of 15. The assessment indicated the resident had no behaviors. 2. Record review Resident #2's physical aggression care plan, initiated 1/28/25, identified the resident had physical aggression toward staff and residents related to the disease process and trauma to phobia. Interventions included reducing stimuli around Resident #2 so he did not have anxiety induced episodes. Resident #2's behavior care plan, initiated 12/7/22 and revised 3/27/24, identified the resident had a behavior problem related to becoming intrusive to others and being physically aggressive. Interventions included Resident #2's triggers for striking out were related to others coming too close to his personal space, Resident #2's behavior was de-escalated by redirecting him from potential or actual altercations, assuring Resident #2 was monitored for aggressive behavior towards other residents and redirected to decrease altercations, intervening as necessary to protect the rights and safety of others, approaching/speaking to Resident #2 in a calm manner, diverting the resident's attention and removing the resident from the situation and taking him to an alternate location as needed. The progress note, dated 2/1/25 at 4:15 p.m. documented the nurse heard a resident yelling, at 3:14 p.m., in the hallway. The nurse ran over and saw Resident #2 standing in the hallway and the other resident was pointing at Resident #2 and yelling, Why? Why? and had Resident #2's food in his hair. When the nurse asked what happened, Resident #2 stated he was going in my room, so I hit him. The nurse separated the residents and placed Resident #2 on one-to-one supervision. Video footage revealed Resident #2 was behind the other resident as he was walking down the middle of the hallway, and then Resident #2 suddenly started kicking and punching the other resident from behind multiple times with no provocation as the other resident staggered away and started yelling out. IV. Failed to protect Resident #7 from physical abuse by Resident #2 A. Incident of physical abuse between Resident #7 and Resident #2 on 1/18/25 On 1/18/25 at 2:00 p.m. licensed practical nurse (LPN) #2 heard yelling outside the kitchen doorway. LPN #2 immediately went to investigate and found both residents had already separated. Upon reviewing the camera footage, it was determined that Resident #2 had kicked Resident #7 on the lower leg approximately two times. The residents were separated, the police were called and monitoring was initiated. The residents were separated and assessed. No injuries were noted. Resident #2 was interviewed and said he did not know what happened. Resident #7 did not recall the incident. The facility substantiated abuse. B. Resident #7 (victim) 1. Resident status Resident #7, age 67, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included Alzheimer's disease and dementia. The 11/1/24 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of six out of 15. The assessment indicated the resident had no behaviors. 2. Record review Resident #7's care plan, initiated 10/26/24 and revised 1/31/25, identified Resident #7 wandered related to Alzheimer's disease. Interventions included identifying patterns of wandering: was it purposeful, aimless, or escapist or was Resident #7 looking for something, intervening as appropriate, distracting Resident #7 from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, and providing structured activities, such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. C. Resident #2 (assailant) 1. Record review The progress note, dated 1/18/25 at 3:05 p.m., documented the nurse was charting in the nursing station at 2:00 p.m. when he heard yelling outside by the kitchen doorway. When the nurse immediately ran out to investigate, both Resident #2 and the other resident had already separated. When checking the camera footage, it looked like Resident #2 was walking past the other resident in the doorway and Resident #2 kicked the other resident in the leg one to two times. When questioned, Resident #2 stated I don't know what happened and walked away. Resident #2 placed on a one-to-one supervision. Resident #2's room was on the opposite side of the building from the other resident. V. Failed to protect Resident #4 from physical abuse by Resident #5 A. Incident of physical abuse between Resident #4 and Resident #5 on 1/24/25 On 1/24/25 at 7:04 p.m. Resident #4 entered the doorway of Resident #5's room. Resident #5 pushed Resident #4 out of the doorway causing her to fall. Upon reviewing the video of the altercation, the video revealed Resident #4 entering the doorway of Resident #5's room. Resident #5's hand and arm were seen pushing Resident #4 causing Resident #4 to fall down. Resident #5 refused to be interviewed, and Resident #4 was unable to be interviewed. An assessment was completed and Resident #4 had no injuries. The facility substantiated abuse. B. Resident #4 (victim) 1. Resident status Resident #4, age 74, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included Alzheimer's disease and dementia. The 12/12/24 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of zero out of 15. The assessment indicated the resident had wandering behaviors 2. Record review Resident #4's care plan, initiated 8/8/24 and revised 11/19/24, identified Resident #4 wandered related to Alzheimer's disease. Interventions included if Resident #4 was seen wandering into other residents' rooms, staff were to redirect her to her room, distracting Resident #4 from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, and providing structured activities, such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The progress note, dated 1/24/25 at 10:31 p.m., documented that at 7:04 p.m. Resident #4 entered the doorway of another resident. He pushed Resident #4 causing her to fall. Resident #4 landed on her left side and hit the left side of her head. Resident #4 was unable to give a description of the altercation. Resident #4 was assessed and neurological checks started. Resident #4 was assisted up and taken to her room and assisted to bed. C. Resident #5 (assailant) 1. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included Wernicke's encephalopathy (low thiamine) and alcohol induced dementia. The 12/6/24 MDS assessment revealed the resident's cognitive status was cognitively intact with a BIMS score of 14 out of 15. The assessment indicated the resident had no behaviors. 2. Record review Resident #5's behavior care plan, initiated 6/3/22 and revised 12/9/22, identified Resident #5 had behavioral challenges related to poor impulse control that put the resident at risk for verbal or physical altercations. Interventions included educating Resident #5 to ask for assistance from staff if another resident was being aggressive with him. assisting Resident #5 to develop more appropriate methods of coping and interacting, such as calling nursing staff for assistance if a resident entered his room and taking a minute to think before reacting, if reasonable, discussing the resident's behavior, and explaining/reinforcing why the resident's behavior was inappropriate and/or unacceptable. Resident #5's physical aggression care plan, initiated 6/3/22, identified the resident had the potential to be physically aggressive due to poor impulse control. Interventions included educating Resident #5 to the consequences of being physically aggressive (pushing or hitting) other residents and modifying the resident's environment, including placing a stop sign on the resident's door to distract other residents from entering. The progress note, dated 1/24/25 at 9:42 p.m., documented that at 7:04 p.m. a female resident entered the doorway of Resident #5's room. Resident #5 pushed her and she fell to the ground. Resident #5 denied pushing her but it was seen on camera. Resident #5 was put on behavior monitoring for 72 hours. Resident #5 did not want to talk about the incident. VI. Failed to protect Resident #10 from physical abuse by Resident #11 A. Incident of physical abuse between Resident #10 and Resident #11 on 2/10/25 On 2/10/25 at 12:04 p.m. Resident #10 was in the hallway and was going between the wheelchair of Resident #11 and another resident when Resident #11 struck out with his right arm and made contact with Resident #10's middle finger knuckle. Resident #10 yelled out he hit me, but it does not hurt. Resident #10 stated Resident #11 hit him and he did not know why. Resident #11 said Resident #10 was calling him names. The video review revealed Resident #10 was going between two wheelchairs. When he was to the back and right side of Resident #11's wheelchair, Resident #11 swung his arm back, making physical contact with Resident #10. Resident #11 stated Resident #10 was calling him names. The residents were assessed and no injuries were noted. The facility substantiated the abuse. B. Resident #10 (victim) 1. Resident status Resident #10, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included traumatic brain injury and dementia. The 11/1/24 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of zero out of 15. The assessment indicated the resident had no behaviors. 2. Record review Resident #10's care plan, initiated 1/2/25, identified Resident #10 was an elopement risk related to a traumatic brain injury and dementia. Interventions included identifying patterns of wandering: was it purposeful, aimless, or escapist or was Resident#10 looking for something, intervening as appropriate and distracting Resident #10 from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. C. Resident #11 (assailant) 1. Resident status Resident #11, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included hypertension and dementia. The 12/18/24 MDS assessment revealed the resident's cognitive status was intact with a BIMS score of 15 out of 15. The assessment indicated the resident had no behaviors. VII. Failed to protect Resident #3 from verbal abuse by a staff member A. Incident of verbal abuse between Resident #3 and a staff member on 12/4/24 On 12/4/24 at 2:50 p.m., it was reported a verbal altercation occurred between Resident #3 and a staff member. A former staff (FS) member interview revealed LPN #1 was at her cart passing medications. Resident #3 walked by and asked her for a styrofoam cup. Resident #3 said his cups were taken. LPN #1 told him she did not take them. Then LPN #1 and Resident #3 started yelling. Resident #3 demanded LPN #1 give him a cup. LPN #1 said no because Resident #3 was a hoarder. LPN #1 continued to yell, then Resident #3 said I'll punch you. LPN #1 stepped toward Resident #3 yelling for him to do it (hit her), repeating the statement several times. The FS member then yelled telling them to separate and for LPN #1 to lock her cart and move it and herself to the nurse's station. Resident #3 went to the men's hall. Resident #3 was assessed and no injuries were noted. The facility substantiated abuse. B. Resident #3 (victim) 1. Resident status Resident #3, age 71, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included schizophrenia and dementia. The 1/9/25 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of zero out of 15. The assessment indicated the resident rejected care. 2. Record review Resident #3's care plan, initiated 8/4/23 and revised 4/1/24, identified Resident #3 had paranoid delusions and was suspicious and paranoid. Interventions included caregivers were to provide opportunities for positive interaction and attention, stopping and talking with the resident as they were passing by and monitoring the resident for behavior episodes and attempting to determine the underlying cause. VIII. Staff interviews CNA #1 was interviewed on 2/25/25 at 3:38 p.m. CNA #1 said if there was an altercation between residents, she would separate the residents and ensure they were safe. She said she would call for assistance. She said she would notify the charge nurse. She said she knew Resident #11 could get upset and she had seen him throw a cup. She said she was not familiar with any of the other residents. She said if she witnessed any kind of altercation between a resident and a staff member, she said she would try to remove the resident from the situation and tell the staff member to step away, then report it to the director of nursing (DON). CNA #2 was interviewed on 2/25/25 at 3:47 p.m. CNA #2 said if she saw an altercation, she would separate the residents to make sure they were safe and report the incident to the abuse coordinator. She said when Resident #2 became agitated, she would remove him from the situation and offer him a snack, offer him his room or offer for him to watch television (TV). She said she had not seen any issues with the other identified residents. LPN #1 was interviewed on 2/25/25 at 3:53 p.m. LPN #1 said if she saw an altercation between residents, she would call other staff for assistance, separate the residents, make sure the area and residents were safe and notify the DON and/or the NHA. She said she would start the paperwork, notifications and write a behavior note. LPN #1 said when Resident #11 became upset, it was important to keep him at arm's length from the other residents because he could reach out. She said Resident #2 liked to karate chop when in an altercation with another resident. She said he was aware of other residents who liked to wander around his area of the facility. She said the facility placed a stop sign in front of the doorway as a deterrent for the other residents. She said interventions for Resident #2 included to distract him and to offer him the opportunity to go outside. She said Resident #6 liked to keep to himself. She said she had not seen any behavior from him. LPN #1 said she and Resident #3 had a previous altercation and she did not work with him anymore. She said Resident #3 did not like her and they had a large disagreement that caused them to both raise their voices and Resident #3 threatened to hit her. She said she had to take training (professional improvement planning) and now the other nurses addressed his needs. She said she had never seen Resident #3 put his hands on anyone. Registered nurse (RN) #1 was interviewed on 2/25/25 at 4:00 p.m. RN #1 said she would address Resident #3's needs knowing the strong dislike Resident #3 had with LPN #1. She said all the nurses worked as a team. She said when any kind of altercation occurred, the staff separated the residents and made sure everyone was safe. She said an assessment would be completed as well as the abuse coordinator would be notified. She said the provider and families were notified also. The NHA, who was also the facility's abuse coordinator, was interviewed on 2/26/25 at 2:50 p.m. The NHA said her staff were to separate the residents and make sure they were safe, to try to de-escalate the situation and try to find out what happened. She said she was to be notified as soon as the situation was safe. She said it was important to try to find triggers to help prevent future altercations and educate the staff on them. She said there had been training with staff on approaches and to give residents space. She said she had been at the facility for around two months and she was working on new approaches with staff. She said it was important to her for all the residents to feel safe in their own home.

Based on record review and interviews, the facility failed to establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf for one (#8) of four residents reviewed for personal funds out of 17 sample residents. Specifically, the facility failed to provide Resident #8 a copy of her personal funds statement on at least a quarterly basis. Findings include: I. Resident status Resident #8, age 72, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included major depressive disorder and borderline personality disorder. The 1/28/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required no assistance with her activities of daily living (ADL). II. Resident interview Resident #8 was interviewed on 2/25/25 at 10:47 a.m. Resident #8 said she was supposed to get a personal funds statement every three months and she had not received a statement from the facility since June 2024. She said it had been seven months since she had received her last statement. She said the business office manager (BOM) was responsible for printing out the personal funds statements. Resident #8 said when she had asked for a personal funds statement, it took the business office two months to print it out. She said she was frustrated with the process. She said she should not have to ask for her personal funds statements and she should automatically get them. III. Record review Review of Resident #8's electronic medical record (EMR), under the business office task dated 4/18/24, revealed a resident personal funds statement for the period of 12/30/23 to 3/29/24. Resident #8 signed off that the statement was received, however, there was no date documented for when the resident signed it. There was no further business office documentation in Resident #8's EMR. On 2/26/25 at 10:56 a.m. a request was made to the BOM for documentation regarding when Resident #8 received her quarterly personal funds statements. -The facility was unable to provide documentation to show that Resident #8 had received her quarterly statements. IV. Staff interviews The BOM was interviewed on 2/25/25 at 4:12 p.m. The BOM said she was in charge of making sure residents received personal funds account statements. The BOM said residents got a copy of their personal funds statement when they asked for it. However, she said she sent out personal funds statements to residents every month. The BOM was interviewed a second time on 2/26/25 at 10:56 a.m. The BOM said she was not sure when Resident #8 last received a personal funds statement. She said she would have to look into it. The nursing home administrator (NHA) was interviewed on 2/26/25 at 9:17 a.m.The NHA said residents could request a personal funds statement at any time. The NHA said she did not know how often residents should receive personal funds statements from the facility. She said resident fund management services (RFMS) was run by the corporate office. She said the corporate office was responsible for sending out residents ' personal funds statements. The NHA said she did not know that residents should receive personal funds statements on a quarterly basis.

Based on observations and interviews, the facility failed to provide a meal service for residents in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for residents served in two of two dining rooms. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served and seated in the dining room. I. Facility policy The Frequency of Meals policy, revised July 2017, was provided by the nursing home administrator (NHA) on 5/15/24 at 1:27 p.m. It read in pertinent part, The facility will serve at least three meals or their equivalent daily at scheduled times. Meals will be served four to six hours apart to help assure that residents receive nutritional requirements. A schedule of meal times and snacks shall be posted in resident areas. II. Posted meals The posted meal times for the main dining room were scheduled to begin breakfast at 7:00 a.m. to 8:30 a.m., lunch at 11:00 a.m. to 12:30 p.m. and dinner at 5:00 p.m. to 6:30 p.m. III. Resident interviews Resident #47 was interviewed on 5/14/24 at 11:56 a.m. Resident #47 said lunch was supposed to be served at 11:00 a.m. everyday but it was always late. Resident #47 said it was quite boring sitting at the table waiting to be served his meal. Resident #1 was interviewed on 5/14/24 at 12:00 p.m. Resident #1 said lunch was supposed to be served at 11:00 a.m. However, he said it was always served late and he would fall asleep waiting to be served. Resident #1 said the dietary staff always served the room trays first. Resident #41 was interviewed on 5/14/24 at 12:22 p.m. Resident #41 said the lunch meal was always served late. She said sometimes she would have to leave her food on the table and return to her room to use the bathroom because she had to wait for so long. She said when she returned from the bathroom her meal was cold. III. Observations The main dining room was observed on 5/13/24 at 10:54 a.m. The main dining room was divided into the left dining room and the right dining room. There were two residents sitting in the right dining room and four residents sitting in the left dining room. There were two tables that were broken. One was not being used and the other had one resident sitting at it. During a continuous observation on 5/13/24 during the lunch meal, beginning at 10:54 a.m. and ended at 12:16 p.m., the following was observed in the main dining room: -At 11:27 a.m. staff began to serve residents their drink of choice. Lunch had not been served. -At 11:59 a.m. a resident entered the dining room and was told by staff there was not a place for her to sit and she would have to wait for an empty seat. -At 12:16 p.m. the first resident was served lunch. The lunch meal service was one hour and 16 minutes late. During a continuous observation on 5/14/24 during the lunch meal, beginning at 11:00 a.m. and ended at 12:39 p.m., the following was observed in the main dining room: -At 11:00 a.m. residents started entering the dining room for lunch. -At 11:36 a.m there were 26 residents in the dining room waiting to be served lunch. -At 11:45 a.m. one resident in the right dining room was served his meal and an unidentified staff member sat with him to assist. -At 11:59 a.m. a certified nurse aide (CNA) asked for the first resident's lunch order. -At 12:05 p.m. the first resident was served in the left dining room. Four residents in the left dining room were observed sleeping. Another resident entered the dining room. However, there were no chairs available to sit in. He exited the dining room. -At 12:20 p.m. Resident #1 asked the staff for a yogurt and was told the facility did not have any more yogurt. Another resident asked for orange juice and was told the facility was out of orange juice. -At 12:22 p.m. all residents in the left dining room had received their lunch. The staff began to serve the right dining room. -At 12:39 p.m. the last resident was served lunch. The lunch meal was not completed until 12:39 p.m., one hour and 39 minutes after the posted meal time of 11:00 a.m. IV. Staff interviews Dietary aide (DA) #1 was interviewed on 5/15/24 at 1:17 p.m. DA #1 said the cook that worked on Mondays and Tuesdays was always late serving lunch. The nutrition services manager (NSM) was interviewed on 5/15/24 at 1:19 p.m. The NSM said the lunch meals on 5/13/24 and 5/14/24 were late because of the cook. The NSM said the cook needed training on the timeliness of meals.The NSM said the meals should be served timely at the posted meal times. The NSM said the dining room was small so the facility tried to serve residents as they were seated and clean up after them as soon as they were finished so another resident could take their place. The NHA was interviewed on 5/15/24 at 1:49 p.m. The NHA said meals should be served timely because residents were waiting. He said there had to be so many hours between meals per the regulation. The NHA said late meals were unacceptable and the cook had been educated three times in the past for late meals. The NHA said she had put in an order for new dining room tables and chairs.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure the walk-in refrigerator maintained a safe operating temperature of 41 degrees Fahrenheit (F) or below to prevent food from spoiling; and, -Ensure all damaged tiles were repaired to ensure all surfaces in the kitchen were cleanable. Findings include: I. Ensure the walk-in refrigerator maintained a safe operating temperature of 41 degrees F or below to prevent food from spoiling A. Professional reference The Colorado Retail Food Regulations, (1/1/19), were retrieved on 5/17/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Time/temperature control for safety food cold holding shall be maintained at 5 degrees Celsius (C) (41 degrees F) or less. B. Facility policy and procedure The Kitchen Sanitation and Infection Control policy and procedure, undated, was provided by the nursing home administrator (NHA) on 5/15/24 at 4:30 p.m. It revealed in pertinent part, All local, state, and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. All refrigerated and frozen foods will be stored and handled properly. All dry and staple food items will be stored properly. All refrigerated foods should be stored at or below 41 degrees F. Frozen foods should be stored at a temperature that keeps frozen food solid. C. Observations On 5/13/24 at 9:10 a.m. the thermometer that was hanging on a shelf in the walk-in refrigerator indicated the internal temperature was 45 degrees F. There were two cooling fans out of six total that were observed to not be functional. Two products were tested to obtain the temperature of the items. A fruit cup's temperature was taken and it measured 52.2 degrees F. A yogurt's temperature was taken and it measured 52.1 degrees F. DA #1 said all of the food would be disposed of. D. Record Review On 5/13/24 at 9:15 a.m. the temperature log from 5/1/24 through 5/13/24 was reviewed. It revealed a few days were not recorded for the walk-in refrigerator. Other entries revealed the refrigerator averaged 38 degrees F. The 5/13/24 morning entry was incomplete upon survey entrance. D. Interviews Dietary aide (DA) #1 was interviewed on 5/14/24 at 9:14 a.m. DA #1 said all refrigerators should be at or below 41 degrees F. He said food could go bad if the temperature was higher than 41 degrees F. DA #1 said he did not know why the log was not completed upon survey entrance in addition to the missing entries for a few days in the month of May 2024. DA #1 said the dining staff needed to take the temperature of the refrigerator first thing in the morning to ensure the food maintained the appropriate temperature overnight. DA #1 said he needed to throw away all the products in the refrigerator because of the lack of documentation and accuracy of the log in addition to the internal temperature of food items reaching 52 degrees F. He said he could not determine how long the issue had been present. DA #1 said it was important to prevent residents from eating the food that had gone bad or had the potential to make people sick. He said the food could quickly develop Salmonella or other bacteria which would cause residents to get sick. The nutrition services manager (NSM) was not available for an interview on 5/14/24. However, the NSM was notified by the NHA related to the refrigerator's high holding temperature. The NHA was interviewed on 5/14/24 at 9:30 a.m. The NHA said it was dangerous to have food being held at 52 degrees F and she said she would ensure all products in the refrigerator were thrown away and they would fix the refrigerator and order new products. The NHA said it was important not to serve the residents spoiled food or food that was not held at safe temperature because it could cause the residents to become sick. The infection preventionist (IP) was interviewed on 5/15/24 at 4:11 p.m. The IP said all refrigerators need to hold food at 41 degrees F or below to make sure food was kept cold. She said food could go bad when not kept cold at appropriate temperatures and microorganisms could develop which could lead to residents getting sick and potentially even death could occur, depending on the severity of the sickness and the resident's co-morbidities and age. II. Ensure all damaged tiles were repaired to ensure all surfaces in the kitchen were cleanable. A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 5/17/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. B. Facility policy and procedure The Kitchen Sanitation and Infection Control policy and procedure, undated, was provided by the NHA on 5/15/24 at 4:30 p.m. It revealed in pertinent part, All local, state, and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. The director of food and nutrition services will be responsible for providing safe foods to all individuals. C. Observations On 5/15/24 at 9:19 a.m. the floor of the kitchen, which included the dry storage room, was observed. Approximately 15 tiles were observed to be broken and no longer adhered to the floor. One floor tile by the dishwasher was missing. A few wall tiles were observed to be broken in the dry storage room. The ceiling was sagging in areas of the kitchen and was visibly dirty with brown stains and grease stains. D. Staff interviews DA #1 was interviewed on 5/13/24 at 10:12 a.m. DA #1 said the tiles in the kitchen should be cleanable which meant they could not be broken. He said not only was it an infection control issue since they could not be cleaned and there might be mold and bacteria under the tile, but it was also a slip and trip hazard working in the kitchen. DA #1 said there was water dripping from inside of the wall and that could be why the ceiling was sagging. DA #1 said the kitchen floors, walls and ceilings were visibly dirty because the kitchen staff did not clean them. DA #1 said it had been a few months since the kitchen was deep cleaned. He said it was hard to be motivated to clean and keep the kitchen looking good when the environment was in poor condition. He said he notified his supervisor and administration of both structural issues with the floor and ceiling but they had not been repaired due to the budget and the amount of money it would cost. The NSM was interviewed on 5/14/24 at 2:50 p.m. The NSM said she was aware of the broken tiles, dirty ceiling and walls. She said the kitchen was deep cleaned once every three months. She said she notified administration about the repairs needed and they had obtained quotes to replace the floor, walls and ceiling but it cost too much money and the corporation would not approve it. The NSM said all surfaces should be cleanable and she needed to have staff deep clean the entire kitchen and she hoped all broken walls, floor, ceiling would be repaired. The IP was interviewed on 5/1/24 at 4:11 p.m. The IP said the floor, walls and ceiling should be cleaned to prevent microorganisms from developing. She said broken tiles could harbor microorganisms between the broken tiles and underneath it. She said it was not a sanitary working condition and it was not safe since the broken tiles were a trip and fall hazard. The IP said, due to the broken tiles, the surfaces were not cleanable and the tiles should be repaired on all surfaces. She said the kitchen needed to be deep cleaned and a routine cleaning should occur and she would be more involved with the process to ensure the kitchen remained clean and safe. The NHA was interviewed on 5/15/24 at 4:45 p.m. The NHA said she was aware of the broken tiles, wall and sagging ceiling. She said she had requested a quote and sent the quotes to corporate but they refused to fix it due to the cost of the repairs. She said the kitchen needed to be gutted and cleaned up and staff needed to be educated on proper kitchen sanitation. She said the kitchen staff needed to have more oversight to ensure the kitchen ran smoothly and did not pose any health concerns or safety concerns.

Based on interviews and record review, the facility failed to ensure one (#10) of fifteen residents reviewed for choices out of 32 sample residents remained free of resident right restrictions in order to promote and facilitate resident self- determination. Specifically the facility failed to ensure Resident #10 received baths consistently according to his choice of frequency and bathing preference. Findings include: I. Facility policy and procedure The Dignity policy and procedure, revised February 2021, was provided by the nursing home administrator (NHA) on 5/15/24 at 4:30 p.m. It revealed in pertinent part, The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident' s facility stay. II. Resident #10 A. Resident status Resident #10, age less than 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included personal history of traumatic brain injury, mononeuropathy of unspecified lower limb (nerve damage), other chronic pain, other muscle spasm, polyneuropathy (nerve damage) and unspecified psychotic disorder with delusions due to known physiological condition. The 4/25/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score 12 out of 15. He required set-up assistance for eating and oral hygiene. He was dependent on staff for toileting hygiene. He required substantial assistance for showering and required moderate assistance for personal hygiene. The assessment indicated the resident did not refuse care within the review period. B. Resident interview Resident #10 was interviewed on 5/13/24 at 2:23 p.m. Resident #10 said he preferred to receive assistance with bathing on Wednesdays and Saturdays. He said he preferred to take a bath over a bed bath. He said the staff told him if they could not give him his bath on his preferred bath day they would make it up to him later in the week. He said the staff did not follow-up later in the week to give him his missed bath. Resident #10 said there were no scheduled bath aides on the weekends and the certified nurse aides (CNA) would refuse to help him bathe. C. Record review The resident' s bathing preferences were reviewed on 5/14/24 at 1:30 p.m. The resident' s bathing preferences documented the resident wanted to have assistance taking a tub bath on Wednesdays and Saturdays. The resident's activities of daily living (ADL) bathing task logs for the month of March 2024 through May 2024 (3/1/24 to 5/14/24) were reviewed on 5/14/24 at 1:35 p.m. The task logs revealed the resident did not receive his baths according to his specified day preferences of Wednesdays and Saturdays for six baths out of 17 opportunities. The task logs further revealed the resident did not receive one tub bath as he specified, but instead, he received a bed bath on one out of 17 opportunities. III. Staff interviews CNA #2 was interviewed on 5/15/24 at 11:37 a.m. CNA #2 said that it was hard to give all of the residents their baths/showers, especially on the weekends. She said there was no bath aide scheduled on the weekends. She said the CNAs were busy attending to the residents' other needs. CNA #2 said other CNAs often refused to give residents their baths on the weekends because they did not believe it was their responsibility and they thought the responsibility fell on the bath aide. CNA #2 said she had a sheet which had all of the residents' preferred shower/bath days on it. She said Resident #10 preferred to receive baths on Wednesdays and Saturdays. Registered nurse (RN) #1 was interviewed on 5/14/24 at 11:45 a.m. RN #1 said he was not sure why Resident #10 did not receive his baths on his preferred days. He said Resident #10 should receive baths per his preference in order to make sure the resident' s choices in his home were followed and also to give the resident a sense of control in their home. RN #1 said it was all of the staff' s responsibility to ensure the resident received baths according to his preferred days and bathing type. He said the responsibility would not only fall on the bath aide, but the CNAs should be able to help with showers/baths in addition. The director of nursing (DON) was interviewed on 5/15/24 at 2:14 p.m. The DON said the residents had the right to make their own choices. She said the residents should get their baths on their preferred days and preferred bathing type. The DON said the CNA staff were under the wrong impression that the bath aide was responsible for all the baths and that he had been addressing the issue through education with the staff. The nursing home administrator (NHA) was interviewed on 5/14/24 at 3:45 p.m. The NHA said residents' choices and or preferences should be adhered to. The NHA said the DON had provided education to the CNA staff to clarify roles and responsibilities and to ensure baths were adhered to on the residents' preferred days and according to their preferred bathing type.

Based on record review and interviews, the facility failed to incorporate the recommendations from the PASRR (preadmission screening and resident review) Level II determination and evaluation report into the assessment, care planning and transition of care for one (#2) of five residents out of 32 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommend in Resident #2 's PASRR Level II report; and, -Ensure the PASRR recommendations were included in Resident #2 's care plan. Findings include: I. Facility policy and procedure The PASRR Completion policy, revised 9/26/23, was provided by the nursing home administrator (NHA) on 5/16/24 at 4:30 p.m. It read in pertinent part, If the resident has a PASRR Level II, the community is responsible for ensuring that any recommendations from the PASRR Level II are implemented and care planned for the resident. II. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included personality change due to known physiological condition, personal history of traumatic brain injury, psychotic disorder with hallucinations due to known physiological condition and anxiety disorder. The 3/4/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview of mental status (BIMS) score of five out of 15. The assessment indicated the resident required supervision assistance with eating. He required partial assistance with oral hygiene and personal hygiene. He was dependent on staff for toileting and showering. The assessment indicated the resident had not been evaluated for a PASRR Level II. -However, the resident had been evaluated for a PASRR Level II and had recommendations (see record review below). III. Record review A review of the Resident #2 's PASRR Level II, dated 12/21/16, revealed the resident had inappropriate social behavior and physical aggression. Resident #2 could be sexually inappropriate with staff and peers alike. He tended to touch females in their breast and buttocks region when they were close by. He also used rude gestures frequently and it was unclear if the use of these gestures was related to some type of frustration on his part. The behavior continued despite redirection and per his neuropsychological report, would likely continue on an ongoing basis given the resident 's severe cognitive impairments. When the behaviors occurred, staff was to calmly redirect Resident #2 with clear and simple directions such as please don't touch me (directions more complex would not be understood by Resident #2 given his cognitive impairments). The PASRR Level II documented it may have been helpful to observe what was going on in the environment before the behaviors occurred as the staff tried to identify the triggers for the behavior. If the triggers could be identified, staff could work to anticipate the resident 's needs and ultimately and hopefully curb the concerns. Staff needed to have a plan in place so that he was not allowed to touch his peers inappropriately. The plan should address all areas of the resident's day, to include passing others in the hall and sitting in the dining room and common areas, as well as any possible roommate concerns. The PASRR Level II documented the services were to be provided by a qualified community mental health professional such as individual therapy twice monthly. The facility was to offer psychotherapy to Resident #2, per his recent neuropsychological report, to monitor symptoms and to provide support for him and facility staff in dealing with inappropriate sexual behaviors. -A review of the comprehensive care plan, dated 3/27/24, did not reveal the resident 's PASRR Level II screening and specialized services recommendations for his mental illness. -The social services progress notes reviewed from 1/13/24 through 5/13/24 revealed there was no documentation to indicate the facility had reached out to a mental health provider to establish services for psychotherapy twice per month as recommended on the Level II PASRR. -A review of the May 2024 CPO did not reveal a physician 's order for the resident to be seen for psychotherapy twice per month. The performance improvement plan (PIP) was provided by the social services director (SSD) on 5/15/24 at 3:40 p.m. It was initiated March 2024, related to the Level II PASRR identification revealed the facility needed to adhere to the specialized services recommendations and integrate the Level II PASRR into the resident 's care plan. The PASRR Level II action item had a target date of 4/12/24. -The PIP action item related to the Level II PASRR was not completed upon review on 5/13/24. IV. Staff interviews The SSD was interviewed on 5/12/24 at 4:34 p.m. The SSD said the PASRR recommendations were not followed up on according to her review of Resident #2's medical record. She said Resident #2 had not received psychotherapy twice monthly, but the resident met with a psychiatrist once per month. The SSD said the reason the facility did not identify that Resident #2 was not receiving the care and services that were recommended in the Level II PASRR was because the facility did not do a whole house audit to identify which resident 's had Level II PASRRs. She said she would audit all residents' PASRRs and ensure all recommendations were followed and maintain a spreadsheet to track PASRRs due and follow-up on all recommendations. The SSD said she would obtain the necessary psychotherapy services for the resident through a community partner that would meet weekly with Resident #2. The nursing home administrator (NHA) was interviewed on 5/16/24 at 3:45 p.m. The NHA said education, training and audits would be put in place to ensure the facility maintained tracking of PASRR evaluation completion and follow up on recommendations.

Based on observations, record review and interviews, the facility failed to ensure one (#23) of five residents reviewed for ancillary services out of 33 sample residents received routine dental care and 24-hour emergency dental care. Specifically, the facility failed to refer Resident #23 to the dentist to obtain dentures timely. Findings include: I. Facility policy The Ancillary Service policy and procedure, dated 11/4/13, was provided by the nursing home administrator (NHA) on 5/15/24 at 3:25 pm. It read in pertinent part Ancillary services, including, but not limited to dental, vision, audiology and podiatry will be provided to the resident per state and federal regulatory guidelines; at the resident/responsible family members request; and as needed. Any resident needing or requesting ancillary services such as dental, vision, audiology and podiatry will have their needs met timely. Social services/designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner. II. Resident Status Resident #23, age greater than 65, admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia (abnormal thought process), epilepsy (abnormal electrical brain activity), chronic obstructive pulmonary disease (abnormal oxygen exchange). The 4/30/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview of mental status (BIMS) score of 11 out of 15. He was independent of eating, transfers, toileting, dressing, and personal hygiene. The assessment revealed the resident did not have any broken or loose fitting full or partial dentures. The assessment documented the resident did not have any mouth or facial pain, discomfort or difficulty with chewing. -However, the resident was edentulous (missing all teeth). III. Resident interview and observations Resident #23 was interviewed on 5/13/24 at 1:57 p.m. Resident #23 said he was struggling to eat because he did not have dentures. Resident #23 said a staff member from the facility told him they were going to help him get dentures. He said he had still not been seen by a dentist and had been in the facility since January 2024. Resident #23 said he was tired of eating grilled cheese sandwiches. He said he had been eating grilled cheese sandwiches, since they were easy to chew without dentures. Resident #23 said he did not know how he was supposed to eat if he had no teeth. Resident #23 opened his mouth and only gums were observed. IV. Record review The resident had a physician's order that indicated the resident may have a podiatrist, ophthalmologist, dental and audiology as needed, ordered on 1/31/24. A review of Resident #23's comprehensive care plan, revised on 4/30/24, revealed the resident's dental issues were not addressed in the resident's plan of care. A review of Resident #23's electronic medical record (EMR) did not reveal the resident was offered or provided access to dental services. A physician progress note, dated 2/1/24, revealed Resident #23's needed help finding his dentures. Resident #23 was edentulous and needed upper and lower dentures. A food preference assessment, dated 2/3/24, revealed the resident had trouble chewing certain foods because he had no teeth. A social service progress note, dated 2/5/24, revealed the social service director (SSD) spoke with the social worker at the previous facility Resident #23 resided about his dentures being lost. The other facility had not located the lost dentures. The note documented Resident #23 was added to the resident list for the next dental visit. A nutrition assessment, dated 2/7/24, revealed that Resident #23 dentures were lost. A care conference progress note dated 2/13/24, documented Resident #23 had a poor appetite and had lost his dentures at the previous facility. The family attended the conference and expressed concern about his missing dentures. V. Staff interviews The SSD was interviewed on 5/15/24 at 12:06 p.m. The SSD said residents could see a dentist every six months and as needed. The SSD said the facility had a dentist that came to the facility, but that dentist stopped visiting the facility in December 2023 and stopped accepting Medicaid as a payment source in March 2024. The SSD said she had to find another provider to provide services on site in the facility. The SSD said she got a contract for a new dentist, but a date had been set up for the initial visit. The SSD said as soon as the new dentist came to the facility she would start the a post eligibility of income (PETI) process so Resident #23 could get his new dentures. She said once the PETI process was initiated it would take one to two weeks to get approved and then dentures could be ordered. The SSD said the new dentist was able to fit residents for new dentures. The SSD said Resident #23 had no teeth left. The SSD said Resident #23 had told her once he would really like to get his dentures made. The SSD said the facility did not send the resident to a dentist in the community, because they were waiting for the new dentist to come to the facility. The director of nursing (DON) was interviewed on 5/15/24 at 1:03 p.m. The DON said he was not aware that Resident #23 was missing his dentures. The DON said if a resident reported dental issues the SSD was to be notified to get services scheduled. The DON said if a resident had dental issues it could affect their eating. Licensed practical nurse (LPN) #1 was interviewed on 5/15/24 at 1:32 p.m. LPN #1 said she was not aware Resident #23 had any dental concerns or did not have dentures. Certified nurse aide (CNA) #1 was interviewed on 5/15/24 at 1:35 p.m. CNA #1 said she was aware Resident #23 had no teeth. CNA #1 said Resident #23 ordered grilled cheese sandwiches a lot because they were soft to chew.

Based on interviews and observations, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in the main kitchen. Specifically the facility failed to: -Ensure the kitchen's oven was maintained to function properly; -Ensure two of six burners were functioning properly; and, -Ensure the kitchen oven door was repaired to ensure the oven maintained consistent and appropriate cooking temperatures for cooked food. Findings include: I. Facility policies and procedures The Kitchen Sanitation policy and procedure, undated, was provided by the nursing home administrator (NHA) on 5/15/23 at 4:30 p.m. It read in pertinent, All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. II. Observation On 5/13/24 at 9:06 a.m. the oven door was not latched and there was approximately a one inch gap between the oven door seal and the oven. The oven door was opened with difficulty as it appeared that the bottom left latch was not attached or not functioning properly preventing the door from opening with ease. It prevented the door from closing securely. The stove top burners were observed and only four of six burners were functional. III. Staff interviews Dietary aide (DA) #1 was interviewed on 5/15/24 at 10:37 a.m. DA #1 said the oven and stove had been broken for at least a year and a half. He said he had notified his supervisor and the former facility administrator and nothing had been done due to the budget. He said the kitchen was overlooked for repairs and maintenance, which was very frustrating and made it difficult to complete his job. He said the broken burners resulted in not being able to cook as efficiently and things took a longer time to cook with the amount of burners they had functional. He said the broken oven door led to inadequate temperature control and he said it would not reach past 350 degrees Fahrenheit (F), which meant they had to cook food longer to ensure the food was cooked to the correct temperature. He said this often delayed resident meal service. DA #1 said it was a safety concern since the oven door did not close all the way and if grease or any flammable cooking products fell from the stove top into the oven then the oven could catch fire. The nutrition services manager (NSM) was interviewed on 5/14/23 at 11:25 a.m. The NSM said the oven had been broken for a long time and she had put in requests to repair the oven, but the facility refused to repair it. She said she had been informed that due to the budget, they were unable to repair the oven. The NSM said the oven's temperature was inconsistent but would not go beyond 400 degrees F. She said this led to inconsistent cooking times. She said there were broken burners on the stove that made it difficult for the cooks to complete the meals timely. The NHA was interviewed on 5/15/24 at 3:45 p.m. The NHA said she was aware of the broken oven and stove top burners. She said she notified the corporation but they refused to repair the oven and stove top due to budget constraints. She said she would make sure the oven and stove top burners were repaired soon to ensure all foods are cooked to safe temperatures adequately and consistently.

Based on observations, record review and interviews, the facility failed to ensure the nutritional and hydration needs were consistently met for two residents (#13 and #15) of three out of 26 sample residents. Specifically, the facility failed to implement interventions to prevent a significant weight loss for Resident #13 who was at nutritional risk due to poor nutritional intake and who required staff assistance for cueing at meals. The facility failed to identify assistance needed with meals in timely manner and address Resident #13's nutritional needs. Lack of timely interventions to aid Resident #13 to maintain her nutritional status led to a significant, unplanned weight loss of 13.4% in four months. In addition, the facility failed to ensure Resident #15 had consistent weekly weights obtained and implement interventions when Resident #15 had weight loss. Findings include I. Facility policy The Nutrition Parameter policy, date of review was 2020, provided by the corporate registered dietitian (CRD) on 12/2/21 at 10:57 a.m., read in pertinent part; Based on a resident's comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Procedure: Resident needs are met during all aspects of care with resident centered care practices in place Resident's weights are taken regularly and are accurate.Weight changes are addressed with respect to reason for change and appropriate interventions are made. Keys to Meeting This Policy: Malnutrition risk factors are addressed for at risk residents. Hydration, calorie and protein needs and resident response are reviewed in team meetings. Nutrition interventions are started within two- four days of identification of a problem and documentation in the medical record. Nutrition interventions are ordered to individual needs as documented in the medical records including care plans and, as needed, with minimal data set (MDS) triggers. If a resident's condition declines, physician documentation may be requested to support an unavoidable deterioration. Nutrient needs are addressed on a regular basis via assessment or medical order for change of condition Meal observation are completed regularly by the RDN or designee for changes in food and fluid intake. Optimal Conditions: Nutrition interventions are offered, when possible using regular food and meal service. Interventions are changed to reduce satiety and response is positive. Nutrition care process is utilized for nutrition assessment and altered as conditions change Nutrition interventions address calorie, protein, fluid and micronutrient needs and determined by nutritional assessment by the RDN Interventions may be prescribed or care planned with documentation to support use and changes in the medical record Resident needs are compared to response to intervention for optimal cost control and to reduce waste and supplement dependence. II. Resident #13 A. Resident status Resident #13, age 79, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/14/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired. He required extensive assistance with two people for bed mobility, transfers, hygiene and toilet use. He required extensive assistance from one person for hygiene and eating. He had no behaviors. He was on a mechanically altered diet. No weight loss or gain was coded. B. Observations and interviews Resident #13 was observed and interviewed on 11/29/21 at 9:21 a.m. He laid in bed and tried to talk but had extremely dry lips and mouth. His lips were stuck together and he managed to speak and said he needed some milk.He asked again and wanted help to get some milk. He had no fluids at bedside but was able to push his call light for assistance. Certified nurse aide (CNA) answered the call light and he asked for some milk. No milk was supplied and no fluids were offered after the CNA left the room. -At 11:45 a.m. he had his call light on and when the CNA answered the light he asked for water. She told him she would get him some and left the room. Ten minutes later no one one returned to the room to offer or provide fluids. -Continuous observation from 12:39 p.m. to 3:18 p.m. revealed the infection preventionist (IP) was in Resident #13 room to collect a specimen for a COVID-19 test and he said I am thirsty. CNA#3 was in the room and told the IP the resident was on thickened liquids and he needed help with his fluids. No fluids were offered or brought into the room for him during the almost three-hour observation. -At 1:15 p.m. the resident remained in his bed. No cares and or staff had been in the room since 12:39 p.m. -At 2:50 p.m. the resident turned on his call light, an unidentified CNA answered the light and he asked for water. No water was offered. CNA did not come back with any fluids and no fluids were at the bedside. -At 3:18 p.m. the call light was on again and he asked for water, CNA#8 told him they would be getting him up for dinner soon and left the room and did not offer any fluids. On 11/30/21 at 10:13 a.m. Resident #13 was observed in the dining room. He was given one eight ounce (oz) cup of juice and he drank the entire cup down in one big gulp. He was given two more cups of eight oz juices and he drank those down just as fast. The juice was poured from a juice pitcher. CNA#1 then moved the resident on the scale in the dining room. That made the resident mad. He was given a 12 oz glass of milk and he gulped that down fast and yelled give me more milk and threw his cup across the room. His dentures were falling out of his mouth because they were too big. CNA #1 moved him to another table in the dining room where there were full cups of eight oz juices left behind from another resident. He proceeded to pick up the juice and the CNA took it away from him and reminded him he needed thickened liquids. The CNA gave him a 12 oz cup of thickened milk and he drank that in one big gulp. The CNA told him that was his last cup of milk. Nurse aide (NA) #1 assisted him back to his room. Continuous observation on 12/1/21 from 7:41 a.m. to 10:42 a.m. licensed practical nurse (LPN) #1 assisted Resident #13 with a nutritional supplement in his room. She held the drink for him and he was unable to use the straw so he drank it from the spout. He told the nurse he was hungry and wanted to get up. She said he usually stayed in bed because he hated to get up for breakfast. She said the restorative aide assisted him with meals and helped in the dining room but she quit a few months ago. CNA #2 assisted him up and took him to the dining room. He was given three cups, an eight oz of juice, one 12 oz of water (thickened) and one eight oz cup of coffee. He drank all the fluids and sat at the table for a little while -At 8:16 a.m. he was assisted back into his room and observed to be put into bed. No food was offered to him in the dining room and no fluids offered in the room before laying him down. -At 8:35 a.m. food trays were delivered to the Bear Claw unit which was where Resident #13 resided. NA #1 was interviewed and said all the food trays were delivered to the residents on the unit. Observation revealed no food trays left in the cart. No food tray was offered or delivered to Resident #13 in his room. -At 9:30 a.m. Resident #13 remained in his bed. No fluids were at bedside. -At 10:42 a.m. the food trays for lunch were delivered to the Bear Claw unit. Resident #13 remained in bed. NA #1 opened the food tray cart which revealed no food tray for Resident #13. No food tray was offered or available for Resident #13. NA #1 was interviewed and said Resident #13 refused his meals. She said he only wanted milk. No milk was offered to him. -The facility failed to offer food and assistance to the resident at meals (cross-reference F677 for ADLs). He was not offered fortified oatmeal at each meal that he liked to eat several times a day per the nutrition care plan. Resident #13 was interviewed on 12/1/21 at 11:00 a.m. He said he was thirsty and wanted milk. He said the facility never gave him milk and he wanted some. He said he was upset they do not give him milk. C. Record review Resident #13's weight record revealed: 7/10/21 152.5 pounds (lbs) 7/30/21 152.3 lbs 8/6/21 154.2 lbs 9/1721 142.0 lbs, 10.5 lb weight loss from 7/10/21 10/29/21 138.5 lbs, 3.5 lb weight loss from 9/17/21 11/26/21 134.5 lbs, an additional 4 lb weight loss since 10/29/21; in total 18 lbs weight loss, 13.4% which was considered significant. -There were no nutritional notes addressing the resident's weight loss on 9/17/21, 10/29/21 or 11/26/21 until the weight loss was identified on survey (see nutrition note 11/29/21). There was no interdisciplinary meeting to determine the root cause of the resident's weight loss nor were his dietary preferences consistently monitored (see meal observations above). The nutrition care plan revised on 7/6/21, read in pertinent part; Resident #13 was unable to take himself to the dining room for meals. Staff will transport Resident #13 to his meals and assist him with feeding as needed. Often he will refuse the meal that was served but will eat oatmeal anytime it was offered and he loves milk. Often he will keep his eyes closed during meals and frequently will not open his mouth for feeding and will say ' No ' but then will open his mouth to take the bite. He required constant cueing and encouragement. The resident's risk of formal nutrition will be minimized through the review date. Resident #13 prefered foods with soft and or pureed texture. His family states he would often eat oatmeal several times a day. Dietary to serve fortified oatmeal when he requested oatmeal. Restorative nursing to provide a dining program to assure adequate food and fluid intake as well as maintain self feeding practices.Explain and educate the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity or malnutrition risk factors. Monitor weights as ordered and monthly.Obtain food preferences and offer as much as possible. Offer food alternates of equal nutritional value when the resident refuses a meal. Provide, serve diet as ordered regular diet mechanical soft texture and nectar thickened liquids. Monitor intake and record every meal. Offer fortified foods at all meals.Offer fortified whole milk and fortified oatmeal at all meals. Provide supplements as ordered: Med pass between meals at 10:00 a.m., 2:00 p.m. and at night. Magic cup one time a day at dinner. Assist the resident with meals as needed. If the resident was not using utensils, feed the resident. Put finger food in the resident's hand to encourage eating finger foods. Obtain and monitor lab and diagnostic work as ordered. Report results to the medical director (MD) and follow up as indicated. Registered dietitian (RD) to evaluate and make dietary change recommendations as needed. Nutrition note dated 7/6/2021 for Resident #13 read in pertinent part: Oral intake of meals and supplements meets assessed needs of 1785-2142 kilogram per calorie (kcal), 71.4 grams (gm) protein, and 1785-2142 ml fluid. Wt in usual range of 148-157 lbs# and the resident had regained wt that was lost during COVID-19 illness. His lowest wt during recovery was at 147.6#. 4/12/21 nutritional labs within normal except elevated blood urine [MEDICATION(S)] (BUN/Creatinine) ratio Recommend to encourage between meal fluids. Resident #13 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He also received a med pass three times a day between meals and at night and a magic cup at dinner. Ensure was discontinued related to resident filling up on it and refusing meals. Wt had been maintained since ensure was discontinued. The September 2021 meal intake records documented that Resident #13 consumed the following: -76 percent (%) to 100% of meals on 13 occasions out of 95 meals; -51 to 75% of meals on 14 occasions out of 95 meals; -26 to 50% of meals on 17 occasions out of 95 meals; -0-25% of meals on 24 occasions out of 95 meals; and, Refused meals on 27 occasions out of 95 meals. The October 2021 meal intake records documented that Resident #13 consumed the following: -76 percent (%) to 100% of meals on nine occasions out of 93 meals; -51 to 75% of meals on nine occasions out of 93 meals; -26 to 50% of meals on 24 occasions out of 93 meals; -0-25% of meals on 26 occasions out of 93 meals; and, Refused meals on 25 occasions out of 93 meals. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Magic cup was refused twelve out of 30 days; [MEDICATION(S)] medication had no refusals; and, Medpass was refused three times out of 30 days. The November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] tablet 7.5 milligrams (ml), give one tablet by mouth one time a day at bedtime for specified depression. Order date was 10/6/21. (This medication was ordered to stimulate the resident's appetite, see RD interview below). -Encourage increased fluid intake every shift. Order date was 4/7/2020. -Regular diet, mechanical soft texture, nectar consistency. Staff needs to feed the resident. Order date was 3/12/2020. -Med pass (supplemental drink) is given three times a day: 10:00 a.m., 2:00 p.m. and bedtime. Order date 3/3/2020. -Magic cup (fortified supplemental ice cream) one time a day at dinner. Order date was 1/11/2020. -Provide fortified foods at meal times, no specific directions. Order date was 12/10/19. -Multiple vitamins-minerals give one tablet by mouth one time a day for. Order date 2/19/19. -Provide fortified foods at meal times. Order date 12/10/19. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Magic cup was refused four out of 30 days; [MEDICATION(S)] medication was refused two of 30 days; and, Medpass was refused seven times out of 30 days. The November 2021 meal intake records documented that Resident #13 consumed the following: -76 percent (%) to 100% of meals on five occasions out of 90 meals; -51 to 75% of meals on 11 occasions out of 90 meals; -26 to 50% of meals on 13 occasions out of 90 meals; -0-25% of meals on 15 occasions out of 90 meals; and, Refused meals on 46 occasions out of 90 meals. Nutrition note dated 11/29/21 for Resident #13 read in pertinent part: Resident #13 had been followed by the nutrition assessment review (NAR) since weight (wt) loss began between 8/20/21 to 9/17/21 (13.5 pounds with 9/17/21 wt of 142#). Wt loss was confirmed on 9/24/21. On 10/5/21 [MEDICATION(S)] was discontinued and [MEDICATION(S)] was ordered for increased agitation and decreased oral intake (declined from 75 percent (% ) in August to 30% in September) resulting in wt loss. Resident has been on [MEDICATION(S)] for two months without increase in appetite and wt loss continues with an additional 6.4# lost during this time with 11/26/21 wt of 134.5#. Resident #13 was frequently refusing medications including [MEDICATION(S)] and med pass. In October his oral intake declined to 17.4% of meals with about five meal refusals a week. In November, oral intake was now minimal with all lunches refused for the last 16 days along with four breakfasts and eight dinners. Oral intake of meals was now about 6.2%. Fluid intake has also declined. Resident #13 was offered fortified oatmeal and fortified milk at all meals, med pass three times a day between meals and at night, multivitamin with minerals magic cup at dinner, but with refusals further wt loss was anticipated. 10/7/21 nutritional labs: hemoglobin and hematocrit (H/H) 12.9 low /38.6 low, mean corpuscular volume (MCV) 102 high, blood urine [MEDICATION(S)] and creatinine (BUN/Creat) ratio 26 high, chloride 111 high, total protein 5.1 low, [MEDICATION(S)] 3.3 low, cholesterol 86 low. Labs reflect minimal food and fluid intake. Recommend to notify physician of minimal oral intake related to meal and supplement refusals. May want to consider comfort care. Consider discontinuing [MEDICATION(S)] medication since cholesterol was low and intake was minimal. Consider checking serum folate and Vitamin B12 for depressed H/H and elevated MCV. -The nutrition note above was written after weight loss was identified on a survey. D. Interviews NA #1 was interviewed on 11/30/21 at 1:30 p.m. She said Resident #13 did not eat much, he stayed in bed most of the time. She said he needed help with his fluids and his meals. She said he liked milk. She said his wife came in one time and talked directly into his ear and he would eat for her. So she tried to talk directly into his ear and he was always more cooperative with that. She had no official training on who eats what, so she tried to get him to eat but he refused at times. She said no fluids were left at the bedside because he needed help to drink and he asked for fluids when he wanted them. Licensed practical nurse (LPN) #1 was interviewed on 12/1/21 at 10:40 a.m. She said Resident #13 had weight loss. She said since the restorative program stopped he stayed in bed a lot. She said he drank the Med Pass (nutritional supplement) mostly and his fortified milk. The corporate quality assurance nurse (CQAN) was interviewed on 12/1/21 at 10:43 a.m. She said the facility did not have a restorative program at this time. She said Resident #13 was being seen by the therapy department. -However, the therapist was unavailable for an interview. The dietary manager (DM) on 12/1/21 at 11:10 a.m. She said the CNAs took the residents' food orders and then a food tray was set up for them. She had a list of residents and a food card with the residents' diet order and any restrictions listed. She said the resident's name was crossed out on the list when the food tray was prepared. She said that was the procedure they followed for every meal so no resident missed a food tray. Some resident names were not crossed out on the list and she said those residents refused breakfast. Resident #13's name was crossed out of the breakfast and lunch meal on 12/1/21 (see above) which meant he did receive a meal according to the DM. -However, during observations on 12/1/21 Resident #13 was not offered any food during the breakfast or lunch meal. The corporate registered dietitian (CRD) was interviewed on 12/1/21 at 12:00 p.m. She said Resident #13 was on fortified oatmeal at every meal and he drank that out of a cup not a bowl. She said the staff were supposed to offer food to all residents even when they stated they did not want anything. She said thickened liquids were not at the bedside because of a choking risk. The staff had to assist the resident who was on thickened liquids. She said the thickened liquid was added to juice, coffee and milk for Resident #13. She said the team discussed comfort measures for Resident #13 in October 2021. -However, there was no discussion of comfort measures identified in the nutritional progress notes/assessments in October 2021 when the resident had weight loss. The registered dietitian (RD) was interviewed on 12/1/21 at 1:07 p.m. She said she did the nutritional assessments for the new admissions and annually. She said the dietary manager started the assessments from observations and talked with the facility staff about each resident. She worked with the director of nurses (DON) with meal intakes and weights to get the most accurate plan for the residents. She did see residents that triggered for weight loss and changes with their diet. She made recommendations to the DON in the monthly meetings. She recommended a medication to help Resident #13 with his appetite and to fortify his foods. She said he loved oatmeal and rarely refused that. She said the team discussed having him go on comfort care. She said she expected the staff to offer and assist the residents with food and fluids even when they were on comfort care. She said weight loss could occur when no assistance was given to the residents. She said an action was needed for training staff on meal assistance. She said Resident #13 was not on hospice services. III. Resident #15 A. Resident status Resident #15 was admitted on [DATE]. The November 2021 computerized physicians orders (CPO) indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/14/21 minimum data set (MDS) revealed the resident was severely cognitively impaired and could not understand others or be understood by others. The resident was independent with toileting, transferring, personal hygiene, bathing and eating. The MDS indicated it was not known if the resident had experienced weight loss. Resident's weight documented on the MDS assessment was 116 lbs. According to the chart below, the resident experienced a weight loss of 4.9 percent from 9/3/21 to 12/1/21. The gaps in between were times when the resident was not weighed. B. Record review Weight records documented: 9/3/21, 123.9 pounds 9/14/21,116 pounds 12/1/21,118.1 pounds, a weight loss of 5.8 lbs over three months, which was 4.7%. Clinical physicians orders dated 12/29/2020 included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan updated on 7/19/21 indicated that Resident #15 had diabetes and often refused her diabetes medications. The care plan included offering the resident healthy choices for meals. The resident will only eat bread, fish and chicken. She will not drink anything but coffee. The care plan indicated that weekly weights should be taken due to Resident # 15 being a nutritional risk. -However, weekly weights were not obtained (see weight record above). Progress nutritional note dated 8/2/21 indicated the resident refused to be weighed in April, May and July 2021. -No interventions were noted when the resident refused to be weighed nor was it indicated on her nutrition care plan (see above). The resident weight chart indicated that the resident's weight had not been taken between 9/14/21 and 12/1/21. See documentation below for October 2021. There were no weights taken in November 2021 and no documentation why they were not taken. -The re-weight of the resident occurred on survey 12/1/21. The 11/29/21 progress note documented, Weight review: Weight on 9/3/21 was 123.9 pounds, resident refused to be weighed in October. 11/19/21- 110.8 pounds which is a 13.1 pound weight loss in 10 weeks. Request re-weigh to confirm weight loss. -No interventions were noted to determine if the resident had a true weight loss. The 12/1/21 progress note documented, nutritional update: resident was re weighed on 12/1/21 with a weight of 118.1 pounds. Weight loss since 9/3/21 was 5.8 pounds.This is a 4.7 percent weight loss. Documentation indicates the resident had eaten 60 percent of her meals. The resident will usually take the Glucerna if she did not eat her meal. -However, see staff interviews below about staff not being able to go into the resident's room to check how much she had eaten. Clinical physicians orders were updated on 12/2/21 for Glucerna nutritional shake four times per day for weight loss (during the survey). C. Staff interviews The corporate registered dietitian (CRD) was interviewed on 12/2/21 at 11:05 a.m. She said Resident #15 ate in cycles and took her food to her room. She said the resident would exhibit behaviors in the dining room until she got her tray. She said the staff had to inspect the meal tray before it went to the resident's room. She said she referred the resident to social services quality improvement (SSQI) to see if there was something else they could do to help the staff monitor the residents food intake. The registered dietitian (RD) was interviewed on 12/1/21 at 1:31 p.m. She said Resident #15 refused to have her weight taken on several occasions. She said the staff should monitor the food that went in her room and what was thrown away. She said the resident's behaviors affected her meal intake. She said the resident refused medication for her diabetes. Certified nurse aide (CNA) #1 was interviewed on 11/30/21 at 9:47a.m. She said Resident #15 wanted her meals right away or she exhibited behaviors in the dining room. She said the resident was fixated on coffee and bread and hoarded her meals in her room. She said it was difficult to tell how much the resident was eating because she would usually not let anyone in her room. She said sometimes one staff member could go through the resident's room while another staff member assisted the resident to get her food from the dining room. Nurses aide (NA)#1 was interviewed on 12/2/21 at 9:12 a.m. She said Resident #15 would not let staff in her room so it was difficult for them to track how much she was eating. She said the resident hid food in her dresser and closet and staff would not often find it until it was rotten. The DON was interviewed on 12/2/21 at 2:20 p.m. She said Resident #15 will eat bread. She said the resident sucks on her food and then spits it in the trash. She said the resident would sometimes go to the store and the only food she would buy was cheese crackers and tea. She said Resident #15 would usually drink her Glucerna drink.

Based on observation, interviews and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for four of 49 sample residents (#8, #47, #62 and #20). Specifically: -Resident #8 - The facility failed to ensure pain was controlled, that neurological (neuro) checks were obtained following a fall, and failed to ensure the resident's change of condition was properly monitored following discovery of a large bruise on the resident's right upper, inner thigh. The resident sustained [REDACTED]." -Resident #47 - The facility failed to assess and monitor the resident's skin condition. -Resident #62 - The facility failed to adequately assess and provide appropriate interventions for the resident's pain. -Resident #20 - The facility failed to monitor the resident's neurological status after a fall (Cross reference F323 Supervision to Prevent Accidents). The findings include: 1. Resident #8 Resident #8, [AGE] years old, was admitted to facility on [DATE], with diagnosis, according to the face sheet, that included dementia with delusion and behavior disturbance, [MEDICAL CONDITION], personal history of mental disorder, [MEDICAL CONDITION], and urinary incontinence. The quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated resident #8 was coded as moderately impaired with poor decision-making and required supervision. The resident had a short- and long-term memory problem. She also required total assistance of two persons for all activities of daily living including transfer, dressing, toilet use and personal hygiene, and required set up for eating. The resident also was identified as always incontinent of urine. According to [DATE] MDS, the resident was in pain on daily basis. The MDS did not indicate any falls; however, a fracture was coded. The resident's care plan, dated [DATE], identified the resident was at risk for falls. One of the interventions listed was "any falls will be monitored for injury per facility protocol." Per facility protocol (requested and reviewed on [DATE]), #8 of the Fall Management Policy and Procedure read, "If (the) resident experience(s) a fall with head injury or the fall is un-witnessed, neurological checks will be initiated." a. Documentation of Fall and Bruising On [DATE] at 9:40 p.m., a nurses' note (NN) read that the resident had an un-witnessed fall. The resident was complaining of discomfort and pain to thigh. The note read that the resident had dark, purple bruise measuring 18 cm long by 17 cm wide. The doctor on call was notified and ordered to hold Aspirin, check vital signs for five days, monitor bruise and call primary physician if any changes. In the same note the nurse stated, "resident was requesting pain meds this evening." On [DATE] at 10:30 a.m., the next NN in the record, read in pertinent part, "Continue to have large deep purple bruise inner right thigh. Complains of pain right pelvic area, able to bear weight but does not ambulate ...Order received for right hip and pelvic x-ray." (The right thigh, where the [DATE] accident report denoted bruising, was not included in the [DATE] x-ray order.) The results of the x-rays were negative for fracture. At 9:00 p.m., the NN read that the resident "complained of a lot of pain with transfers." On [DATE] at 1:00 p.m., a NN read: "continue to complain right lower extremity (RLE) pain with movement." On [DATE] at 5:25 p.m., a NN read: "Received call from dr. (physician name) concerning X-ray from [DATE] and leg pain. On [DATE] at 6:00 p.m., the resident was sent to emergency room via ambulance for evaluation. X-rays taken on [DATE] at 7:40 p.m. revealed the resident had a fractured right femur fracture. b. Facility failure to assess and monitor resident #8's status after [DATE] (1) Physical Assessment, Evaluation, and Communication of Change of Condition Review of the facility policy regarding Changes in Resident Condition (requested and reviewed on [DATE]), revealed it read in pertinent part: "Changes of condition are communicated from shift to shift through the 24 hour report management system ...Changes in resident status that affect the problem(s)/goal(s) or approach on his/her plan of care are documented as revisions and communicated to the IDT (interdisciplinary team)." Examples of Clinical Condition Changes were falls, any change from resident base line, onset new concern, incident (i.e. skin tear, bruise etc.) Documentation in (the) resident's medical record include(s) "assessment of resident condition and ongoing monitoring of resident condition, care provided." Record review revealed no comprehensive assessment of the resident's status immediately after her fall and no comprehensive assessment in the days that followed, notwithstanding the resident's complaints of pain to thigh, pelvic area and pain with transfers. -See above; record review revealed there were no NN after [DATE], until three days later on [DATE] at 10:30 a.m. There was no documentation in the record on the resident's bruise or her mobility. -The 24 hours reports/communication notes were requested several times during the survey (,[DATE] - [DATE]). The facility was not able to provide any documentation regarding the resident's "un-witnessed fall," complaints of pain, or bruise on the 24-hour reports. (2) Neurological Assessment According to the Resident Assessment and Monitoring for Long-term Care, Established Tools and Guidelines for Clinicians, HC Pro publishing, 2006, Barbara Acello, pages 58 and 59 (in pertinent part) "Standards of long-term care nursing practice require for an unknown or suspected head injury, neuro-checks (neurological checks) (should be performed) for a minimum of 72 hours ...Immediately after a fall, monitor neuro-checks every 15 minutes. If the resident is stable, period between neuro-checks may be increased to every 30 minutes for two hours, every 60 minutes for two hours, every four hours for 24 hours and then once a shift." -According to Mosby's Clinical Nursing, 5th Edition (2002) page 238 (in pertinent part): "Neurological assessment includes determination of the patient's baseline status, ability to verbalize, ability to follow commands, orientation to person, time, place and situation, responsiveness to pain, light pressure, pupillary response to light, and use of the Glascow Coma Scale. The Glascow Coma Scale rates responsiveness for three factors: eye opening, motor response, and verbal response to various stimuli and creates a score for comparative value. Diminishing function on all of these assessments indicates a deterioration of the patient's neurological condition." -Review of the resident's record (NN, Medication and Treatment Records) revealed no documentation of the resident's neurological status after the "un-witnessed fall." -On [DATE] at 3:00 p.m., an investigation of the resident's "un-witnessed fall" on [DATE], was requested and at approximately 3:10 p.m., the Director of Nurses (DON) was interviewed. During the interview, the "Incident/Accident Report" was provided and reviewed. The form was signed by the licensed practical nurse and dated [DATE] at 9:30 p.m. There was no documentation to show an initial assessment for possible head injury such as presence or absence of head trauma, level of consciousness, pupil reaction to light, and handgrip strength, was conducted. There was no on-going, comparative assessment of the resident's neurological status. The DON was unable to provide any other documentation prior to exit [DATE], that showed the resident's neurological status was assessed and monitored after her "un-witnessed fall" [DATE]. The DON also was unable to provide any other documentation that showed staff was monitoring the condition of the resident's condition. The DON confirmed there was no other documentation available on [DATE] at 1:30 p.m. (3) Care Plan Record review revealed no evidence that an acute care plan was initiated at time of the "un-witnessed fall" on [DATE], regarding the fall and directions to staff regarding expectations for monitoring the resident's condition. The resident's fall care plan was not updated. c. Failure to Comprehensively Assess and Manage Resident Pain Review of the physician's orders revealed the following pain medications were prescribed for the resident at the time of the fall: Tylenol with [MEDICATION NAME] #3 PRN (as needed) - pain and Tylenol 650 mg PRN - pain. Further review of orders revealed the resident had orders to have her pain assessed every shift. The resident's acceptable level of pain was noted to be 0. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. -Review of the [DATE] MAR indicated [REDACTED]. The pain assessment in the MARs did not reflect that resident was complaining of pain, which was contrary to the documentation in the NN (see above). -Review of the [DATE] IPNR revealed the resident received Tylenol #3 at [DATE] at 9:00 p.m., ? hour prior to the "un-witnessed fall" and discovery of bruising to the resident's right thigh. Pain medication, Tylenol #3, was next noted on IPNR as administered at [DATE] at 1:00 p.m. See above; the MAR indicated [REDACTED]. -Moreover, staff failed to follow facility policy regarding the documentation of PRN medications. Specifically, according to the facility's Medication Administration policy (requested and reviewed on [DATE] at 3:20 p.m.), "Each time a medication is administered it must be documented. When PRN medications are administered, the following documentation is provided: date and time of administration, dose, route (if other than oral), complaints of symptoms for which medication was given, results achieved from giving medication and the time the results were noted, as well as the signature or initials of person recording administration of medication." Finally, there was no plan regarding the resident's pain and pain management until [DATE], after the resident's right femur fracture was identified. 2. Resident #47 Resident #47, [AGE] years old, was admitted to the facility on [DATE] with diagnoses, according to face sheet, that included [MEDICAL CONDITION], chronic psychotic conditions, dementia with behavioral disturbance, aggressiveness and other unspecified disorder of joint. The most current MDS assessment, with an Assessment Reference Date (ARD) of [DATE], documented the resident had short- and long-term memory problems and was dependent on staff with her daily decision-making. The resident required extensive physical assistance of one/two person/s with all activities of daily living, including bed mobility, transfers, dressing, eating, and toileting. There were behavior symptoms identified on the assessment as [MEDICAL CONDITION]. a. Observation On [DATE] at 12:45 p.m., observations revealed the resident had a bruise on her left hand. The bruise was dark purple color and covered almost whole back of resident's left hand. b. Record Review On [DATE] at approximately 2:30 p.m., the DON presented a report/note "Review of Injury of Unknown Origin (bruises/skin tears)." This document revealed that resident's hands/wrists were restrained by the dentist office staff to provide dental care. Review of the resident's record revealed an acute care plan was initiated on [DATE], regarding the resident's reddened area and bruising after dental appointment on left hand/wrist. The approaches listed were: -assess for pain/discomfort every shift and PRN (as needed), -assess for excessive bruising due to daily aspirin intake, -notify MD if any presence of pain/discomfort. NN dated [DATE] at 2100 (9:00 p.m.) revealed the resident went to dentist for routine cleaning and dental work. There were no other notes reflecting the bruise, pain or discomfort as indicated in acute care plan. Further review of the NN from [DATE] to [DATE] revealed no further documentation on the resident's bruising. Review of the resident's skin assessments revealed the resident's skin was assessed twice: on [DATE] and on [DATE]. Under the skin section, where staff are to record any specific abnormal findings including bruising, neither assessment identified the resident's left hand bruise. c. Interview The DON was interviewed on [DATE] at 2:30 p.m. She stated that the incident was not investigated because the incident was witnessed and happened in the dentist office; however, she agreed the care plan approaches were not followed up and there was no documentation that showed staff was monitoring the condition of the bruise. 3. Resident #62 Resident #62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's quarterly minimum data assessment (MDS), dated [DATE], indicated the resident usually understood others, and was usually able to make himself understood. The resident's Brief Interview for Mental Status (BIMS) score was a 9 out of 15, indicating moderate cognitive impairment. The resident required extensive assistance for all Activities of Daily Living (ADLs) except for eating, for which he required supervision. The Pain Assessment Interview section of the assessment was not conducted for the resident. The MDS Coordinator, who was responsible for completing that section, stated on [DATE] at 11:00 a.m. that she did not conduct the pain assessment interview because she felt he would not understand the questions and would not be reliable in his answers. A physician progress notes [REDACTED]. A physician's order, dated [DATE], read, "PT (physical therapy) clarification order to provide skilled PT 2x/wk x 1 month to include manual thorax therapy, e-stim, u/s as effective to address low and mid back pain." The resident received PT services from [DATE] - [DATE] to address "sprains and strains" of the lower back pain. A PT Encounter Note, dated [DATE], read, "Skilled interventions addressed this reporting period include; manual therapy for soft tissue mobilization to decrease pain...Pt received STM to lumbar area/paraspinals to decrease low back pain." The PT Discharge Summary, dated [DATE], included a short-term goal to have "decreased pain in the low back as demonstrated by a VAS score of ,[DATE] during functional task performance. The pain level on [DATE] was documented as ,[DATE], and the level on [DATE] was ,[DATE]. The Summary of Progress documented: "Patient has progressed through Plan of Treatment and achieved stated goals....Recommended services upon discharge: Restorative Nursing/Maintenance program." There was no documentation a restorative nursing program put into place for the resident following this recommendation. The MDS Coordinator was interviewed, on [DATE] at 4:00 p.m., and she explained the communication protocol between Therapy and Nursing was for Therapy to notify Nursing (specifically the MDS Coordinator) of restorative nursing recommendations. The MDS Coordinator confirmed the resident did not begin a restorative nursing program after the completion of skilled PT services on [DATE]. The MDS Coordinator stated, "I wasn't getting those forms from him...They (Therapy) should let me know. I make a restorative program and let the CNAs know." (Repeated, unsuccessful attempts to contact the physical therapist by phone were made in order to clarify the PT's pain scoring system and rationale for recommending the restorative nursing program for resident #62.) During an interview with resident #62, on [DATE] at 3:20 p.m., the resident was asked if he had been experiencing any pain. He stated, "My lower back. They don't ever give me something for my pain." On [DATE] at 2:00 p.m., the resident was again asked if he had any back pain. The resident responded, "Yes, a lot." When asked how long he had experiencing the pain, he stated, "For a month." The resident's Pain care plan, initiated on [DATE] and last updated on [DATE], documented the goal: "potential for pain related to history [MEDICAL CONDITION] and impaired mobility. Resident is usually able to make his needs known and tell staff if he is having pain." A listed intervention was: "Pain will be assessed every shift by nursing staff using verbal descriptor scale." Documentation by nurses on Resident #62's June Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On each of the Weekly Nursing Documentation assessments for the months of May and June, nurses wrote that the resident "denies" pain. A pain scale score of 1 through 10 was not documented, as directed by the assessment form. On [DATE] at 4:15 p.m., a medication pass nurse was asked how pain was assessed each shift for resident #62. The nurse explained that the resident was able to verbalize if he was in pain, and that the resident had not asked her for any pain medication during the month of June. The nurse acknowledged she did not specifically ask the resident if he had any pain for the daily shift assessments. The nurse stated, "He's able to tell us if he wants the medication." On [DATE] at 10:00 a.m., the Director of Nursing (DON) explained that for both the shift pain assessments and the weekly pain assessments, nurses were supposed to specifically ask if a resident was experiencing any pain. The DON stated, "If a resident says yes, there should be interventions made and then follow-up." The facility's Pain Management policy, dated, ,[DATE], included the following procedures: "..All residents will be assessed for pain by utilizing a pain assessment tool....When a resident complains of pain, ask the resident to rate the pain on a scale of zero (none) to ten (severe)...If the resident is unable to verbally respond, show them the Visual Analog Scale and ask them to point to the face that resembles their pain as closely as possible...Document your findings on the pain assessment tool or the pain assessment flow sheet and/or MAR (medication administration record) as applicable...Success rate is increased utilizing a multi-disciplinary, multi-treatment modality approach and using a combination of [MEDICATION NAME] and adjuvant drugs and therapies. Do not forget the non-pharmacological interventions such as repositioning, relaxation, aromatherapy, visualization, desensitization, massage, and humor therapy, etc.." 4. Resident #20 Resident #20, age 61 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The [DATE], Minimum Data Set (MDS) revealed the resident usually understood others and others usually understood the resident. The resident scored 12 on the Brief Interview for Mental Status (BIMS), an indication that the resident was cognitively intact. The MDS indicated that the resident had [MEDICAL CONDITION] and no behavioral symptoms. The resident was ambulatory and was independent with all activities of daily living (ADLs). The resident was steady with balancing during transition and walking. The resident was without limitations to all four extremities. The resident was frequently incontinent of urine and continent of bowel. The MDS indicated no fall history from admission. a. Closed Record Review Closed record review revealed: -The resident was discharged from the facility to the hospital on [DATE], for a scheduled procedure ([MEDICAL CONDITION]). The resident was readmitted from the hospital to the facility on [DATE]. The resident died at the facility on [DATE]. -Cross-reference F323; following re-admission [DATE], the resident experienced falls ,[DATE], ,[DATE], ,[DATE] and [DATE] (two falls). Specifically, the resident had a witnessed fall in the bathroom tub on [DATE], and then he had three unwitnessed falls which occurred on [DATE], [DATE] and finally on [DATE], he was found on the floor twice. The resident died on [DATE], about four hours after his last fall. On [DATE] at 7:50 p.m., Nurses' notes read in pertinent part, "Resident was found on the floor in dining room by entry way at the TV room, res (resident) was assessed @ this time no c/o (complaints of) pain or discomfort was asking for something for agitation. PRN (as needed) [MEDICATION NAME] (a medication that causes or sedation) given @ this time. Helped him to bed...VS & neuros started per protocol...Will continue to monitor." Review of the GLASGOW COMA SCALE/PUPIL RESPONSE EVALUATION (GCS/PR) form utilized by the facility to assess neurological status indicated a neurological evaluation was to be done every 15 minutes four times after the initial evaluation, then every 30 minutes six times then, 4 times every hour. The GCS/PR for resident #20, dated [DATE] and initiated at 7:30 p.m., was incomplete. The GCS/PR revealed no indication that the resident's pupil reaction to light (PERL) was done between 7:30 p.m. and 11:00 p.m., as indicated by the form/facility policy. The resident was medicated with [MEDICATION NAME] (a sedative) at 7:30 p.m. At 11:00 p.m., the resident was discovered with decreased responsiveness and was found without vital signs (VS) on [DATE] after 11:10 p.m., per nurses' notes. In pertinent part, nurses' notes dated [DATE] at 12:00 a.m. read, "At 2300 (11:00 p.m.) on [DATE], CNA's called this writer to Res (resident #20's) Rm (room) ...Resident had decreased responsiveness....(resident) non-responsive. At 2310 (11:10 p.m.) writer called on call MD... then returned to resident...VS...Resident remained unresponsive. Resp (respirations) were agonal and writer called 911...Amb (ambulance) arrived & attempted V/S on resident & run cardiac strip. Amb attendant determined that per their protocol no attempt would be made to resuscitate resident....Rs (resident) was not able to be resuscitated." b. Staff Interviews The facility Consultant and Consultant RN #2 (CRN #2) were interviewed together on [DATE] at 12:26 p.m. In regards to the fall of [DATE] at 7:50 p.m., the Consultant acknowledged that the resident's pupil reaction to light (PERL) was not assessed on that date, as indicated on the GCS/PR evaluation scale. She stated, "The GCS/PR scale should be completed." The CRN #2 stated, "They were monitoring other VS and other indication, I disagree, other VS were okay." (Cross reference F323)

Based on observations, record review and staff/resident interviews, the facility failed to provide two (#66 and #15) of 49 sample residents the care and services necessary to prevent pressure sores and to promote healing of pressure sores. Specifically: -Resident #66 developed three pressure areas on his heels, at least one of which developed after the facility had identified his shoes as a factor. The third pressure area, a Stage III, became infected and required antibiotic treatment. -The facility failed to ensure resident #15, who was at risk for the development of pressure ulcers, and had an open area on her buttocks, received the necessary treatment and services in a timely manner. The findings include: A. References According to the U.S. Department of Health and Human Services, Clinical Practice Guideline Number 15, a Quick Reference Guide for Clinicians for Pressure Ulcer Treatment, 1994, pressure ulcers can cause the resident to experience pain and discomfort from tissue damage, wound cleaning, or dressing changes. -Thorough resident assessments must be conducted to identify the residents at risk of developing pressure sores. -All individuals at risk for pressure sore development should have a systematic documented skin inspection at least once a day. -Preventive measures include the following: Identify the at-risk residents who need the preventive measures, ensure adequate nutritional and water intake to maintain the skin's tolerance to pressure, and protect the skin from damage from external pressure by utilizing frequent position changes and pressure-relieving devices; e.g., cushions, protective boots or special mattresses. -Pressure ulcers should be assessed for classification or stage, location, size, and condition of the pressure ulcer and surrounding tissue. According to the U.S. Department of Health and Human Services, Clinical Practice Guideline Quick Reference Guide for Clinicians Number 3, Pressure Ulcers in Adults: Prediction and Prevention, 1992, and Number 15, treatment of [REDACTED]. -All individuals at risk for pressure sore development should have a systematic documented skin inspection at least once a day. -Pressure sores are to be assessed for "location, size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and [MEDICATION NAME]. -Identification of a pressure sore while the pressure sore is a Stage I or unblanchable [DIAGNOSES REDACTED] (redness) of intact unbroken skin is critical. When a resident develops a Stage I pressure sore, more vigilant assessments and nursing interventions, such as more frequent turning and repositioning, must be utilized to prevent the Stage I pressure sore from deteriorating into an open wound (Stages II, III, or IV). Residents who have developed a pressure sore are at a higher risk to develop additional pressure sores. -Any person at risk for developing pressure ulcers should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if consistent with overall patient management goals. -Written repositioning schedules should be developed even when patients are using a pressure-reducing support surface. These surfaces serve only as adjuncts to strategies for positioning and careful monitoring. Reposition the sitting individual so points under pressure are shifted at least every hour." According to the Wound, Ostomy and Continence Nurses Society (2003), Clinical Practice Guideline for Prevention and Management of Pressure Ulcers, Bryant, RA, Nix DP (2007), Acute and Chronic Wounds: Current Management Concepts St. Louis: Mosby Year Book, 3rd edition. Unstageable Wound: Considered full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further Description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heel serves as "the body's natural (biological) cover" and should not be removed. The staging system, as recommended by the Wound, Ostomy and Continence Nurses (WOCN) Society the National Pressure Ulcer Advisory Panel Staging System (NPUAP), does not include a stage for granulating pressure ulcers. Down staging of granulating pressure ulcers is not appropriate, since the full thickness repair process involves replacement of the lost normal tissue with granulation tissue. For example, a granulating stage IV pressure ulcer should not be down-staged to a Stage III, because a Stage III pressure ulcer, by definition, is one with exposed subcutaneous tissue. Therefore, a granulating Stage IV pressure ulcer is most appropriately classified as a granulating Stage IV or healing Stage IV. If the Stage IV pressure ulcer is completely healed, it can be classified as a healed Stage IV, which conveys the pressure ulcer is now filled with granulation tissue and resurfaced with epithelium. B. Facility Policies On 6/25/12 at 3:00 p.m., the facility's policies and procedures addressing pressure ulcers were requested from the Director of Nursing (DON). The facility provided two documents. 1. One document was a "Wound/Skin Healing Record," which should be used for each wound separately and required at least a weekly assessment. If skin integrity is impaired or open area is present (i.e., pressure ulcer), the recommendation was to document on this record every treatment observation. 2. The other document was a "Pressure Ulcer Prevention Policy and Procedure" which read in pertinent part: "The purpose of this policy is to establish protocols for care of residents who are at risk of developing pressure ulcers to ensure that the resident does not develop a pressure ulcer unless clinically unavoidable. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to underlying tissue(s)." -Overview: "A pressure ulcer can occur wherever pressure has impaired circulation to the tissue." -"Critical steps in pressure ulcer prevention and healing: identifying and evaluating the risk factors (that) can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underling risk factors, monitoring the impact of interventions, and modifying the interventions as appropriate. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure." Point #8 in the above policy read: "The comprehensive assessment, which includes Resident Assessment Instrument (RAI), evaluates the resident's [MEDICATION NAME] risks, the resident's skin condition, other factors (including casual factors) which place the resident at risk for developing pressure ulcers/or experiencing delayed healing and the nature of the pressure to which the resident may be subject." C. Resident Failures 1. Resident #66 Resident #66, age 63, was admitted to facility on 2/24/12 with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS), a significant change assessment dated [DATE], documented the resident received a Brief Interview for Mental Status (BIMS) score of 3/15 (severely cognitively impaired) and required the limited assistance of one staff member with dressing, eating, toilet use and personal hygiene. He was totally dependent on staff for bathing. The MDS identified that the resident was at risk for developing pressure ulcers, and he was coded with two stage II pressure ulcers. a. Status on Admission Braden Risk Assessment Scale (predicting pressure sore risk) was done for resident #66 on admission (2/25/12) and the score was 21 points, which indicated the resident was at very low risk for developing pressure ulcers. The Nursing Data Collection Tool completed on admission read in pertinent part: "Feet and toes without open areas or pressure." The Admission MDS dated [DATE], did not specify any pressure sores on admission. b. Development of Pressure Sores (1) Discovery of skin breakdown on left heel - Facility response - Facility Failures Record review revealed a form titled "Skin Condition Record for non-pressure ulcer skin conditions" dated 3/6/12. It noted an initial observation on 3/6/12 of the following: "Left heel, resident had a blister that popped and the skin has come off; 2.5 cm x 2 cm from increasing walking and pacing, new shoes." (sic) The same page had a space for reassessment frequency - the frequency was noted "everyday." Further record review revealed another form titled "Wound/Skin Healing Record" which was utilized for pressure ulcers. This form included a note, dated 3/6/12, with the same information as above. On this form, the area on the resident's left heel was assessed as a stage II pressure wound. The note was signed by Licensed Practical Nurse (LPN). Review of nurses' notes (NNs) from 3/6/12 to 3/13/12 revealed no documentation regarding the change in the resident's skin condition. However, a NN dated 3/14/12, eight days after the wound was first observed read, "covered left heel with bandage to cover blister." Record review revealed no care plan to address the resident's skin breakdown from 3/6/12 to 5/25/12. There were no instructions to staff on the presence of the resident's left heel wound or on the treatment plan, including interventions to ensure pressure relief to the resident's heels. Review of the resident's Treatment Administration Records (TARs) for March 2012 revealed that the blister to the left heel was monitored and covered with a bandage until 4/11/12. Review of Physician's Telephone Orders (TO) dated 4/10/12, revealed the facility requested a wound clinic visit to treat left heel wound. The documentation from wound clinic (WC) was requested and reviewed on 6/21/12. -Original consultation and treatment to left medial heel was initiated by RN (Registered Nurse) on 4/12/12. The RN recommended heel protector while resident in bed. The resident visited the WC every week and the wound was healing well. However (see above and below), the resident did not have a care plan for pressure areas/skin until 5/24/12; therefore, the WC recommendation for heel protectors in bed was not placed on the care plan to ensure staff implemented the recommendation. (2) New open areas right and left heel - Facility Response - Facility Failures A Plan of Care reflecting pressure areas/skin was dated 5/25/12. The problem identified was "returned from pass with family and noted to have new blister left heel 3cm x 3cm x 0.3cm depth." One of the approaches listed and dated 5/18/12 was "monitor shoes for proper fit." There was no note or assessment in NN on 5/18 (date of approach) or 5/25/12 (date of care plan) regarding the resident's new areas of skin breakdown. However: -On 5/23/12, documentation from the WC revealed there was a new 0.2 cm opening on the right heel. The order was to apply collagen gel and monitor the wound, keeping it padded and preventing it from rubbing. There was no other documentation in medical record or WC notes that described the open area on the right heel, except for an Acute Care Plan, dated 6/8/12, identified a problem as: "Right foot/heel wounds, right outer wound 3 cm long x 3.2 cm wide," with an approach to "continue to apply collagen hydrogel to right inner heel wound and cover, until healed." -On 5/28/12, the facility initiated a Wound Skin Healing Record that documented: Stage III pressure ulcer to left outer ankle which measured 2.8 cm x 3.7 cm x 0.2 cm with moderate odor and moderate exudate amount. This note was signed by the LPN. -On 5/29/12, a NN documented a new blister was noted. The location (right or left heel) was not identified. -On 6/1/12, a consultation report from the WC read, "wound at medial aspect heel is nearly closed, now 0.2 cm x 0.8cm x 0.05 cm. Patient now has blood/fluid filled blister 2.8 cm x 3.7 cm on lateral left heel; wound unstageable. New tissue damage to lateral left heel, likely from friction/shear from footwear." -On 6/8/12 the pressure ulcer report by LPN read: stage III, size 3 cm x 3 cm x 0.3 cm depth. The box specified exudate type was checked - serosanguineous with moderate odor and moderate exudate amount. Wound bed was assessed as [MEDICATION NAME] tissue; surrounding skin color was pink and indicated that the resident was started on an antibiotic, [MEDICATION NAME] 750 mg by mouth every other day times 5 doses, ordered on [DATE] (telephone order) due to wound infection. Record review revealed no documentation the resident's footwear was assessed even though footwear had been identified as a possible cause of the resident's heel breakdown in the "Skin Condition Record for non-pressure ulcer skin conditions" dated 3/6/12, in the update to the resident's care plan dated 5/18/12, and again in the WC report 6/1/12. Record review further revealed no orders in May 2012 MARs/TARs to identify and treat the new, third pressure area. c. Skin Assessments Weekly nursing documentation included skin assessment which included coccyx and heels areas. The resident's skin condition and weekly assessments were requested from DON on 6/13, 6/18 and 6/25. The DON was not able to provide any documentation regarding preventive measures, and monitoring of the resident's skin condition upon return from outings. (The resident frequently left the facility with family; however, the facility was unable to provide documentation of the dates the resident left the facility). d. Staff Interview The facility wound nurse LPN and director of nursing (DON) were interviewed on 6/19/12 at 2:15 p.m. -The LPN stated the resident continued wound care in the WC. She said she checked the resident's wound once a week, and the nurses performed daily dressings change following WC recommendations. She said the two wounds are almost closed/scabbed and the third wound was healing. -The DON said that she did not attend the weekly wound rounds every time; however, the other RN did. She said the LPN should not be staging wounds and confirmed documentation on the resident's wounds was very confused and unclear. The DON said the resident's tennis shoes were removed by a family member, but she wasn't sure when. The WC RNs (two RNs) were interviewed on 6/21/12 at 10:30 a.m. The RNs confirmed that the resident had scheduled visits every week and that his wound was improving after the recent oral antibiotic. They said all recommended supplies were provided by WC and the facility staff was responsible to monitor the daily maintenance and protective devices, a multipodus boot when walking and soft boot while in bed. They also verified that resident came to the clinic wearing the same shoes until two weeks ago, when a black protective boot was applied. The RN added that was her recommendation from 6/4/12, visit to provide a protective heel boot while patient is walking. However, the protective boot was not included to the TARs and there was no TO in the medical record. On 6/21/12 at 3:40 p.m., the Staff Development Coordinator was interviewed and stated she ordered the protective boot which arrived to the facility on [DATE], and she delivered the boot to the resident's room. She said the nurses should include the multipodus boot on the TARs and care plan. e. Family Interview On 6/21/12 at 9:25 a.m., resident #66's family member was interviewed by phone. The resident's daughter stated she took her father out on pass on 5/30/12 for a ride. She stated the resident was already dressed and ready to go and he was wearing tennis shoes. She added the resident walked from the parking lot to the restaurant and back which was not a long distance. After this trip, the facility notified the resident's power of attorney about new sore and asked the family to replace his footwear. She indicated there was no discussion about the resident's footwear prior to this. She stated the old shoes were disposed recently, in past two weeks. f. Observations The resident's heels were observed on 6/18/12 at 1:45 p.m. during dressing change. The observation revealed that the resident had a large wound on his/her left heel. The skin around the wound was macerated. A moderate amount of drainage with some odor was noticed. The bandage was wet and according to TAR, the dressing was to be changed daily. In summary, the facility failed to properly assess the integrity of resident #66's skin, failed to timely assess the resident's risk factors and identify and address his footwear (tennis shoes) as the cause of recurrent pressure ulcers. In a period of three months, the resident developed two stage II and one stage III pressure wound. 2. Resident #15 Resident #15 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 2/27/12 MDS documented the resident was at risk for developing pressure sores, though did not have one at the time of the assessment. Treatments listed included pressure reducing device for bed and chair, and received applications of ointments/medications. The comprehensive care plan updated 5/24/12 identified the resident was occasionally incontinent of bowel and required extensive assistance with bed mobility. The goal was for the resident to have no pressure areas or impaired skin integrity. Approaches listed included: -Staff to assist with bed mobility as needed, -CNA to report any skin issues noted during routine care, -Weekly skin assessments, -Pericare after each incontinence episode, -any skin issues will be reviewed in weekly skin meeting until healed, -pressure reduction mattress on bed, -Braden (risk assessment) to be done quarterly, -Catheter care daily, -Notify MD of any skin issues, -On 5/1/12, "resident refuses to be repositioned in bed. She is up in wheelchair or in bed on her back, staff encourage her to reposition, was added. Review of the Braden Risk assessment scale, dated 2/20/12 documented the resident was scored at 18. A score of 16 or less indicated risk for developing pressure ulcers. However, according to the assessment, there was a potential problem with friction and shearing. No updated Braden assessment was found, even though the 2/27/12 MDS identified the resident was at risk for pressure ulcers. Review of the weekly assessments dated 4/24/12 and 4/30/12 showed the resident's skin was warm dry and intact with no redness or open areas. The 5/6/12, 5/13/12 and 5/20/12 assessments documented the resident's coccyx was red, open or slightly open. The 5/29/12, 6/7/12 and 6/18/12 weekly assessments documented the coccyx was red, slightly open, peri area excoriated, barrier cream used after peri care, buttocks red, moisture barrier applied, small red area, right upper buttock. Review of the Skin Condition Record form revealed two entries, one dated 3/12/12 and one dated 3/20/12. Both entries documented the resident had an open area to her left inner buttock, due to shearing. The area measured 0.5 x 0.3 with 0.1 depth in centimeters (cm). No additional entries were found. On 6/14/12 at 7:00 a.m., the resident was observed seated in a wheelchair out on the patio area. There was a cushion in the seat of the chair. During an interview with the resident at the time, she said she had a sore on her bottom and she requested the surveyor look at it. At 7:12 a.m., a certified nurse aide (CNA) assisted the resident to her bathroom where the resident's buttocks were observed. The skin was excoriated around her coccyx with a visible small open area present. The CNA said the resident had been "battling" with that area on and off for some time. The resident stated she wanted zinc oxide to her bottom, however the staff used A and D instead. The resident stated she felt the area was getting worse and said, "When they take me to the bathroom they never wipe my seat or rear end off." Review of the 5/20/12 and 6/20/12 treatment records revealed on 5/14/12, "Good Skin Care, apply moisture barrier to buttocks every shift." A treatment order dated 6/15/12, was added, "Assess reddened area on left buttock, apply barrier cream prn (as needed)." A nurse's note dated 6/18/12 at 11:00 a.m., documented that on 6/15/12, after the survey findings, "MD notified of continued problems of redness on buttock. Resident encouraged to spend time out of the wheelchair to relieve pressure to buttocks. Assessment today reveals a blanchable area on left buttock, dermaseptin ointment applied. Discussed waffle cushion with wound clinic RN, she will be sending information on these products. Also discussed this with resident's physician on 6/15/12." On 6/20/12 at 11:13 a.m., the nurse assigned to care for the resident was interviewed. The nurse stated, regarding the area on the resident's left buttock, "She won't get out of chair and when she's in it, she slouches." The resident was at risk for shearing injury, had a history of [REDACTED]. However, the facility failed to adequately follow up until after the survey findings.

Based on observations record review and staff interviews, the facility failed to ensure four residents of 49 sample residents (#20, #54, #44 and #22) received adequate supervision and assistive devices to prevent accidents. Specifically: - Resident #20: The facility failed to ensure adequate supervision and assessment of resident #20's safety needs. The resident fell daily over a period of four days (,[DATE] - [DATE]) after re-admission from the hospital. The resident died a few hours after the final fall on [DATE]. - Resident #54: The facility failed to thoroughly investigate the cause of his fall and to identify proper approaches for further fall prevention. - Resident #44: The facility failed to ensure appropriate interventions were considered, implemented, and evaluated in a timely manner and in accordance with facility policy. The resident had 11 falls over a 3-month period. - Resident #22: The facility failed to ensure adequate supervision was provided for a resident whose ill-fitted wheelchair put him at risk for sliding out of his chair and injuring himself. The findings include: 1. Resident #20 (closed record) Resident #20, age 61, was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged from the facility to the hospital on [DATE], for a scheduled procedure (placement of a colostomy). The resident was readmitted to the facility from the hospital following the procedure on [DATE]. The resident died at the facility on [DATE]. a. Resident Status ,[DATE] The [DATE] Minimum Data Set (MDS) revealed: -The resident usually understood others and others usually understood the resident. The resident scored 12 on the Brief Interview for Mental Status (BIMS), an indication that the resident was cognitively intact. The resident had delusions and no behavioral symptoms. -The resident was ambulatory and was independent with all activities of daily living (ADLs). The resident was steady with balancing during transition and walking. The resident was without limitations to all four extremities. -The resident was frequently incontinent of urine and continent of bowel. -The MDS indicated no fall history from admission. The MDS indicated that the resident received no therapies. Although the [DATE] MDS indicated no fall history, the resident was care planned ([DATE]) to have a history of falls related to (r/t) poor safety awareness and responding to internal stimuli due to mental illness. The care plan also indicated that the resident had a history of [REDACTED]. -The care plan indicated the resident was independent with ambulation and gait and was usually steady with his gait. -The goals were that the resident would have no falls with serious injuries. -The approaches included quarterly assessments; all falls were to be reviewed in fall meeting for any recommendations for safety measures. b. Falls Nurses' notes, dated [DATE], read in pertinent part: "Received call from a (name of neighborhood store) stating (store staff stated) that resident fell and was sent to ER (by store staff). Notified (facility staff notified) MD, POA (Medical Power of Attorney) appropriately. Nurses' notes, dated [DATE], read in pertinent part: "returned from ER (emergency room ) ambulatory independently. The notes indicated that the resident was on antibiotics (abx) for urinary tract infection (UTI). Nurses' notes, dated [DATE] at 8:08 a.m., indicated that the resident was overheard as he called for help. Nurses' notes read in pertinent part: "Heard calls for help at 200 (2:00 a.m.) this morning. Found (resident #20) on floor lying flat on floor on his back. (Resident #20) stated (he) was returning to his bed from the bathroom, when his foot slipped from under him and he fell . No indication of injuries from head to toe assessment. Neuro (neurological checks) within normal limits ....fell @ (name of local convenience store) twelve days ago." The MD and Medical Power of Attorney (MPOA) were notified. The resident was ambulatory to DR (dining room) on this date. c. Facility and Resident Response to Fall [DATE] Facility Response: In an interview with the Nursing Home Administrator (NHA) on [DATE] at 3:30 p.m., she stated that for each documented fall, an incident report and a post fall assessment/investigation (PFA) were to be completed. The Incident Report and (IR) and Post Fall Assessment Report (PFA) dated [DATE], indicated the following: -The IR indicated that the nurse heard calls for help at 2:00 a.m. that morning. The nurse responded and found resident #20 on floor, lying flat on his back. The IR indicated that resident #20 stated that as he was returning to his bed from the bathroom, his foot slipped from under him and he fell . -The IR indicated no injuries from head to toe assessment. The IR report indicated the resident's condition before incident/accident as, "sedated ...Drug ...Ativan ...2mg ...Time (time last given) 2208 (10:08 p.m.)." -The IR indicated further steps to prevent recurrence as: the resident was instructed to use call light so that standby assist could be provided for the resident prior to going to the bathroom. The IR indicated that the resident verbalized understanding. There was no PFA report attached to the IR, as expected per NHA (see above). During the [DATE] interview, the NHA stated, "There was no follow-up on that incident ...I did not see one completed ...there should be follow up on each fall" for appropriate implementation of prevention measures to avoid or prevent similar falls. Although no PFA was attached, on [DATE] a care plan was developed for "actual fall." -The goals for this care plan indicated that the resident would experience no further falls that week. -The approaches read in pertinent part: assessment for injuries, physician (MD) notification. On [DATE], the [DATE] care plan was updated to include PT/OT (physical therapy/occupational therapy) evaluation as needed, encourage the resident to call for assistance to toilet at night. Resident Response: Although the resident was ambulatory at baseline (see nurses' note above), a subsequent nurses' note dated [DATE] at 12:50 p.m. indicated that the resident, who was ambulatory at 8:08 a.m., was using a wheelchair for locomotion by 12:50 p.m. Nurses' notes at 12:50 p.m. read in pertinent part, "Alert, pleasant & cooperative. Requested (resident requested) use of WC (wheelchair) ...When in DR (dining room) observed by staff to get out of WC and kneel on floor ...Directed back into WC and to Rm (taken to room). C/O back pain. Rx (pain medications) given." Nurses' notes, dated [DATE] at 10:00 p.m., again indicated that the resident, who was ambulatory at baseline, used a WC for locomotion. The note read in pertinent part, "Did use WC to wheel around ...Gait steady when walking." Nurses' notes, on [DATE] at 9:00 p.m., indicated that the resident propelled around facility in WC. Facility Failures: -Review of the care plan (see [DATE] plan above) indicated no use of wheelchair by the resident. -Review further revealed there was no documentation that PT/OT screened or evaluated the resident until after a fall [DATE] (see below). On [DATE] at 12:30 p.m., during an interview with the Consultant PT/OT Manager (CPTOT), she confirmed that the resident received no screening after his fall [DATE]. The CPTOT said that according to the consultant service provider policy, screening or evaluations were to be completed within 24 hours of the request. -The CPTOT presented a form titled "Therapy Department." That form was dated [DATE], and indicated in pertinent part: "Resident (resident #20) has had increased falls." That form further showed that the request for PT services was initiated by a Registered Nurse (RN). -The form was left blank or unmarked in the following subtitle areas: "Therapy recommendations ....Evaluate and Treat ...Orders." -The CPTOT stated that she was not sure when the PT/OT department received the form. The CPTOT further stated that there was no indication that there was follow-up as the resident received no screening in regards to the [DATE] fall as requested. -The CPTOTM stated that the screening was not provided timely or in a manner consistent with facility policy after that initial fall. C. Falls after re-admission ,[DATE], ,[DATE], ,[DATE] and [DATE] On [DATE], the resident was discharged from the facility to a hospital for a scheduled colostomy placement surgery. The resident was discharged from the hospital and readmitted to the facility on [DATE], post-operation (post-op) colostomy placement. (No date of the colostomy placement procedure was provided by the facility despite multiple requests, and no further records were sent after exit [DATE]). Fall [DATE]: Nurses' notes, dated [DATE] at 10:30 p.m., read that the resident had a witnessed fall in the tub room. The notes read in pertinent part: -"Pt (patient/resident) was in the bath tub and attempted to stand up to get out. When he stood up ...the CNA noted that he was unsteady... (CNA) tried to stop pt from falling. CNA let pt down to floor and prevented him from hitting his head. -This nurse found pt lying on (L) left side. Pt would not verbally respond. Pt moved eyebrows when spoken to. PROM (passive range of motion) to extremities per baseline. Pt sat up bleeding was noted from (L) ear. Pt assisted by 2 assist to stand. Pt WB (weight bearing) per baseline and turned self to sit in w/c. Pt told this nurse that he "felt dizzy" before he fell ." -"PERRL (pupils round reactive to light). Pressure to (L) ear laceration...with cold wet washcloth. Bleeding stopped + band aid applied. Orthostatic BP (standing)..XXX,[DATE]." The notes indicated that the Pt's abdominal incision was intact and dry. Although the CNA stated that she prevented the resident from falling and hitting his head, the resident stated to the nurse that he fell and that he was dizzy before he fell . Review of the PFA report revealed no clarification or investigation how the resident sustained [REDACTED]. The [DATE] fall IR and PFA report were reviewed with NHA on [DATE]. The IR indicated that the accident occurred at 9:20 p.m. and documented "Condition before incident ...Normal." -Under the subtitle: "describe exactly what happened; why it happened; what the causes were ...state part of body injured," documentation read in pertinent part: "Pt attempted to get himself out of the Bath tub, when he stood up he said he 'felt dizzy,' CNA tried to stop pt from falling & kept pt from hitting head ...type of injury ...(L) ear ...LEVEL OF CONSCIOUSNESS ...Pt won't respond at first, but then began talking per baseline, PERRL." -The IR further read in pertinent part: "Pt noted to have orthostatic hypotension ...will address with (MD name)." The PFA report dated [DATE] was reviewed with the NHA on [DATE]. -The PFA report indicated a fall in the tub room that the floor was wet, that the resident experienced dizziness, and the resident was identified as a high risk for falls. The PFA report identified that the resident experienced a change of condition secondary to surgery that the resident medication changes in the last 72 hours were antibiotics and the fall was witnessed by the CNA. -Actions Plan had one area marked in pertinent part: "Other ...MD notified of orthostatic hypotension." Facility Failures: -Record review revealed no evidence the physician was notified that the resident had a brief period of unresponsiveness or that the resident had blood from his left ear laceration. -Review of the IR and PFA revealed no investigation of the inconsistences between the resident and CNA statements in the nurses' note and IR to determine the cause of the left ear laceration, if the resident had not fallen but had been "let down to the floor" by the CNA. During that review of the resident's falls with the NHA on [DATE] at 3:30 p.m., the NHA clarified the facility policy and stated, "There is no proper description as to whether the resident fell or not in the nursing notes or incident report ...there is no investigation as to how the resident sustained [REDACTED]. -The resident's care plan "actual fall" was updated [DATE] and read in pertinent part: "Will contact MD R/T (related to) orthostatic BP (blood pressure)." However, there were no instructions to staff on monitoring or resident safety related to orthostatic BP included in the care plan update. Fall [DATE]: Nurses' notes, dated [DATE] at 5:15 p.m., read in pertinent part, "fell ...Resident found on floor in hallway outside of room. WC is facing...and resident is lying with head towards the east...with feet towards the west behind the WC...lying prone... (with) face on hands ...palms down ... (no) injuries noted upon assessment...Denies pain." The MD and MPOA were notified. The IR and PFA report were reviewed with NHA on [DATE] at 3:30 p.m. -The IR dated [DATE] indicated that the resident fell in the hallway. The IR read in pertinent part, "Resident found on floor lying ...on back ...face down (on belly) ...0 (no) injuries ...anticipate needs." -The PFA report dated [DATE], indicated no shoes or slippers in place and the floor was dry. The PFA report indicated that the resident had no fall risk, although the resident was receiving PT/OT related to his fall risk as indicated by PT services notes dated [DATE] and in the note was identified as a fall risk. Specifically, review of the PT treatment encounter notes (TEN) dated [DATE] read in pertinent part, "Current status ...PRECAUTIONS: Behaviors risk, Constant Supervision d/t (due to) Cognition and Fall risk ....Skilled Services ...interventions this reporting period include: Therapeutic Activities adjusting of center of mass over base of standing ...Activities ...for training in safe performance of correct technique for transfer training ...Patient/caregiver instruction: Instructed patient and primary caregiver (nursing staff) in transfer, gait ...safety, mechanics, stability and endurance with inconsistent return demonstration and carry over requiring ...need for further instruction and assessment." -The PFA report further read in pertinent part, "Action Plan ..." Physical Therapy Screen for W/C use ...Educate/reorient resident to call light. The resident's "actual fall" care plan was updated again on [DATE] for another actual fall on that date. -The goal as previously was for no further falls that week. -The approaches were updated to include allowing the resident to rise slowly from sitting to standing position, asking the resident if he felt dizzy and checking vital signs (VS) when the resident was dizzy. The resident was to be encouraged to use the call light, staff was to anticipate the resident's need for standby assist when he got up to use bathroom (BR) at night. His call light was to be kept in reach and a urinal was to be used at the bedside. Failure: -There was no documentation in the care plan update regarding increasing resident supervision, even though the PT TEN note read, "Constant supervision d/t cognition and fall risk." Fall [DATE]: Nurses' notes, on [DATE] at 12:30 p.m., read in pertinent part: "Resident found on floor in bathroom ...(no) witness, Denies injuries noted....States, 'I was getting water' when asked what happened. Neuros re-started...Alert and able to make needs known. Denies nausea or dizziness." MD and MPOA notified. Review of the IR and PFA report dated [DATE] at 12:30 p.m., revealed the IR read in pertinent part, "Found on floor in bathroom on (R) right side with head under valve control of toilet bowl, feet by sink - states 'getting some water' ...Alert & able to make needs known ...(with) behavioral disturbances ...no witness ...Additional comments..Steps taken to prevent recurrence ...Q (every) 15 minutes checks, anticipate needs, monitor often." Although PT notes dated [DATE] recommended "constant Supervision d/t cognitive and fall risk," the care plan did not indicate constant supervision until [DATE], after the resident's third fall since re-admission [DATE]. (Record review revealed 15 minute visualization/supervision was initiated after the resident fell again on [DATE].) The PFA report for [DATE], indicated that no shoes or slippers for resident who was under constant supervision. No assistive devices were in use, the call light was in reach, and was on. Although the resident placed his call light on as instructed, the resident ambulated from his bed to the bathroom without assistance. The resident's "actual fall" care plan was updated again on [DATE] identifying another actual fall on [DATE]. -The goals indicated that the resident would experience no further falls that week. -The new approach was to check on the resident every 15 minutes (no time limit was set). Failure: Review of the facility records revealed no investigation as to why staff failed to timely respond to the resident's call light after the resident had been re-educated to use the call light to obtain assistance. First Fall [DATE]: Nurses' note, on [DATE] at 4:50 p.m., read in pertinent part, "In dining room...sitting at table through (threw)...ice tea on floor, then flung hi(m)self on to floor no c/o (complaint of ) pain ..Assisted him up into WC." MD and MPOA were notified. The IR dated [DATE] at 4:50 p.m., read in pertinent part, "resident was in dining room @ table... ready for supper. Through (threw) ice tea on floor, and then he was on the floor." The IR indicated that the resident was alert. There was no documentation whether the resident hit his head or not and whether the fall was witnessed by staff. The incident report read in pertinent part, "Check for safety ...reassures to call for help if needed." The PFA report indicated no further interventions. The resident's "actual fall" care plan was updated [DATE], identifying another actual fall on that date. -The goal was as above; the resident would experience no further falls that week. -The new approach, in pertinent part, was to monitor the resident frequently. Second Fall [DATE]: On [DATE] at 7:30 p.m., about 2.5 hours after the resident's fall in the dining room, the resident fell again. Nurses' notes read in pertinent part, "Resident was found on the floor in dining room by entry way at the TV room, res (resident) was assessed @ this time no c/o pain or discomfort was asking for something for agitation. Helped him to bed...VS & neuros started per protocol...Will continue to monitor." The IR dated [DATE] at 7:50 p.m., read in pertinent part, "resident was in WC, then he was hollering and was found lying on floor next to WC in DR ...LEVEL OF CONSCIOUSNESS ...confused ...O2 sats (oxygen saturation blood level) 70@ R/A on room air ...Behaviors, he is ok and keep safe." The PFA report dated [DATE] at 7:50 p.m. indicated that a WC was in use when the resident fell , the resident had socks in place, had no shoes on, there was no indication if the resident was at risk for falls. Although the IR indicated that the resident was confused by the time of this fall, the PFA report indicated no change in mental status as that section was left undocumented. The report indicated that fall was unwitnessed. No further investigations were done. Failure: -There was no indication the resident was being supervised in the dining room at the time of his second fall, although he was to be monitored closely. There was no indication whether his low O2 saturation level was addressed. -The facility failed to comprehensively monitor the resident's status after his second fall on [DATE], and the resident's physical status declined. Cross reference F309. Review of the GLASCOW COMA SCALE/PUPIL RESPONSE EVALUATION (GCS/PR) dated [DATE], indicated that an evaluation was to be done every 15 minutes four times after the initial evaluation, then every 30 minutes six times then, 4 times every hour. The GCS/PR dated [DATE] and initiated at 7:30 p.m., was incomplete. The GCS/PR revealed no indication that the resident's pupil reaction to light (PERL) was checked between 7:30 p.m. and 11:00 p.m. when the resident was documented with decreased responsiveness and the According to nurses notes dated [DATE] at 1200 a.m., indicated that Medical Response Services (MRS)(??) documented the resident without VS on [DATE] between 11:10 and 11:30 (No clarification of specific times was provided by the facility, no MRS report was provided by the facility despite multiple requests) See nurses notes on [DATE] at 12:00 a.m., below. Nurses' notes dated [DATE] at 12:00 a.m., read in pertinent; "Res (resident #20's) Rm (room) as they were attempting to obtain V/S (vital signs). Resident had decreased responsiveness....writer attempted vigorous sterna rub to obtain response - non-responsive. At 2310 (11:10 p.m.) writer called on call MD... then returned to resident...VS...Resident remained unresponsive. Resp (respirations) were agonal and writer called 911...Amb (ambulance) arrived & attempted V/S on resident & run cardiac strip. Amb attendant determined that per their protocol no attempt would be made to resuscitate resident....Rs (resident) was not able to be resuscitated." e. Staff Interviews The facility Consultant and Consultant RN #2 (CRN #2) were interviewed together on [DATE] at 12:26 p.m. -The CRN #2 stated, "PT/OT is a consideration but was not one of the intervention considered" following the fall of [DATE]. The CRN #2 clarified that PT/OT was indicated on the care plan on an as need (PRN) basis and was not indicated on [DATE]. -Regarding the fall of [DATE] with injuries to ear, the Consultant stated, "I don't know how he sustained injury to the ear ..." -Regarding the fall of [DATE] at 7:50 p.m., the Consultant acknowledged that the resident pupil reaction to light (PERL) was not assessed on that date, as indicated on the GCS/PR evaluation scale. She stated the GCS/PR scale should be completed. CRN #2 disagreed, and stated, "They were monitoring other VS and other indications, I disagree, other VS were okay." 2. Resident #54 Resident #54, age 82, was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. a. Resident Status The resident's most recent MDS dated [DATE], indicated: -The resident usually understood others and others usually understood the resident. The resident had clear speech. The resident had short-t and long-term memory problems. The resident had symptoms of delirium including inattention, disorganized thinking, altered level of consciousness, and psychomotor retardation. The resident's exhibited verbal behavioral symptoms. -The resident needed extensive assistance of two staff for bed mobility, dressing and toilet use. The resident needed extensive assistance of one staff for walking, locomotion, eating, personal hygiene and bathing. The resident needed limited assistance of one staff with transfer. The resident's balance during walking and transitions indicated that resident was not steady, but able to stabilize with staff assistance when moving from seat to standing position, walking, turning around, surface to surface transfer, moving on and off of toilet. The resident utilized a cane/crutch and wheelchair for mobility devices. -The resident received restorative therapy for passive range of motion. A fall risk evaluation dated [DATE] indicated that the resident was at high risk for falls. The fall care plan was initiated on [DATE] and was last updated on [DATE]. The care plan indicated that the resident had a history of [REDACTED]. The care plan indicated a problem of (L) sided hemiparesis & the resident used a cane for ambulation. The care plan also indicated that the resident had a bed cane that helped the resident for going from lying to sitting position related to (L) side hemiplagia and weakness. -The goal for the care plan indicated that the resident would not suffer injuries related to falls until [DATE]. -The approaches indicated to follow facility protocols. PT/OT evaluation for the resident for gait and balance. A non-skid strip was in place at the resident's bedside. A bed cane for bed positioning. The resident was reminded to use his cane while ambulating. Staff was to remind resident to sit in a chair with arms. b. Fall [DATE] and Facility Response Nurses' notes, dated [DATE] at 8:30 p.m., read in pertinent part, "Resident found on floor in room ... (with) bottom ? of body under bed. Lying on his back. No injuries noted ....Resident replied, 'I know I need to get up,' when asked what happened. Unable to determine what resident was doing when this happened. 0 (no injuries noted upon full assessment ...denies drowsiness, dizziness or nausea - alert able to make needs known ...neuros initiated & WNL (within normal limits) ...will continue to monitor." The physician was notified. The care plan was updated on [DATE], after the resident fell on [DATE]. The updated care plan read in pertinent part, "(resident #54's) gait has become more unsteady and he is at increased risk for falls. He does not always ring the call light for staff assist with transfer and ambulation. Tab monitor (tab alarm) ordered to alert staff when attempting unsafe transfer or getting up without assist ...ambulates with a quad cane." -The goal for care plan indicated no injury related to use of tab monitor. The goals were dated [DATE]. -The approaches included the use of a tab alarm. Staff was to monitor the resident for signs and symptoms related to the use of tabs alarms. PT/OT was ordered. Nurses notes dated [DATE] indicated that guardian was notified on that date and agreed with the use of a tabs alarm for safety. The notes also indicated that the resident was receiving PT/OT at that time. Although nurses notes dated [DATE] indicated no injuries with the fall on that date, PT treatment notes dated [DATE], read in pertinent part, "Comments: Pt was found trying to get up by himself, with cut on (L) anterior mid shin, nursing staff notified." Review of nursing notes dated [DATE] though [DATE], revealed no indication that the resident sustained [REDACTED]. Furthermore, there was no indication that the cut was assessed or treated. Failure: -The Post Fall Assessment Report (PFAR) was reviewed and no Incident report (IR) was provided for the fall dated [DATE]. On [DATE] at 2:00 p.m., the NHA was interviewed and she stated, "There was no documentation of investigation of the fall." -The facility failed to accurately assess the resident after the fall on [DATE]. Although PT notes indicated that nursing staff was notified of that cut on [DATE], there was no documentation of an assessment of the cut or indication that the physician was notified of the cut. -Multiple observations of the resident sitting or lying on his bed on [DATE] at 9:00 a.m., [DATE] at 9:20 a.m., [DATE] at 11:30 a.m. and 11:50 a.m., revealed the facility identified intervention for resident safety (tab alarm) was not being implemented. On [DATE] at 9:30 a.m., the resident was observed in his room as he received restorative therapy from the Restorative Aide (RA). The RA was interviewed about the tabs alarm which was placed on the resident's bedside drawer top. The RA stated, I know him well ...He gets up and down his bed ...He is not supposed to have an alarm on bed." 3. Resident #44 (Closed Record) Resident #44 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. a. Resident Status on Admission The admission minimum data set (MDS) assessment, dated [DATE], indicated the resident was sometimes able to understand others and could sometimes make himself understood. The resident received a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS assessment further indicated the resident was independent with wheelchair mobility, but required supervision for transferring, limited assistance for dressing, eating, and personal hygiene, and extensive assistance for toileting. His vision was highly impaired. The resident's record contained an admission Nursing Data Collection Tool, dated [DATE], which included a Fall Risk Evaluation. The total fall risk score was based on scores given for eight clinical condition parameters: mental status; history of falls; ambulation/elimination status; vision status; gait/balance; systolic blood pressure; medications; and predisposing diseases. -According to the Fall Risk Evaluation, "If the total score is 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." -For the first parameter - mental status- the nurse wrote a score of 0, indicating the resident was "alert." However, the resident was not alert (see cognitive score above), and he should have received a score of at least 2. -For the parameter of vision status, the nurse gave a score of 0, indicating "adequate" vision. However, the resident should have received a score of 2, to accurately reflect his "poor" vision. -For gait/balance, the nurse wrote a score of 0, indicating "normal" gait. However, according to an Interdisciplinary Team (IDT) review on [DATE], the resident had "poor balance when he attempts to stand; has dementia and confusion - poor safety awareness.." The resident should have received a score of at least a 3 for that parameter. -The resident's total score computed by the nurse on the resident's Fall Risk Assessment, was 6, which indicated a low fall risk. The actual score should have been at least 11, which would indicate a high fall risk, and prevention protocols should have been put into place at that time. b. Falls - Facility Response Review of resident #44's record revealed the resident experienced 11 falls at the facility before expiring on [DATE]. -Review of resident #44's record revealed the resident experienced an unwitnessed fall on [DATE]. According to nurses notes, there was no injury noted. -The resident had another unwitnessed fall on [DATE], with no injuries noted. Nurses notes documented, "(Resident) was found on floor in hallway-said he 'just fell '-hit his head on wall. No injury noted.." -On [DATE], the resident had an unwitnessed fall. According to nurses notes, "Slipped and fell in bathroom, urine on the floor; unable to locate pain-says 'hurts all over.' No injuries noted at this time." A Falls care plan was initiated on [DATE], with the following documented Problem: "(Resident) is at risk of falls related to wandering in his w/c (wheelchair); he tries to stand unassisted and is not steady and he has had one fall since his admission. He also has a dx (diagnosis) of dementia and is oriented to person only. he has poor safety awareness. (Resident) has had back surgery and knee replacement." -Listed interventions were: 1) Fall risk evaluation done-completed on admission and will be done quarterly; 2) Staff to assist (resident) with transfers as he allows; 3) Staff will encourage (resident) to use his call light to ring for help when he needs it; 4) Any falls wil

Based on observation, record review, staff and resident interviews, the facility failed to ensure that the residents environment remained as free of accidents as possible; and each resident received adequate supervision and assistance devices to prevent accidents for two (#31 and #43) out of 22 sample residents. Specifically: -No interventions put into place to prevent further injuries for resident #31 and #43. The findings included: I. Resident #43 Resident #43 a [AGE] year old female, was admitted to the facility on [DATE]. According to the face sheet, the resident had the following diagnosis; schizoaffective disorder, constipation and sub acute dyskinesia. According to the most recent minimum data set assessment ((MDS) dated [DATE], the resident was coded to have short-term and long-term memory problems. She was coded as being moderately impaired for cognitive skills for daily decision making. The resident was coded as independent for bed mobility and transfers. She required supervision for toileting and personal hygiene. Review of an undated incident report, revealed documentation of an injury of unknown origin. The time of the injury was also documented as unknown. The documentation also read, "Resident normally confused and disoriented, the bed was adjustable and in the down position. The resident presented at the nurses' station with a large bruise (yellow around edges). The resident reported, 'I fell out of bed two evenings ago'. The resident denies pain. The doctor was here and notified". It was also noted on the report that the resident had a bruise to her left anticubital, which was documented with a circle on the diagram of a person. There was no written documentation found on the incident report, which stated the size of the bruise. In the section, additional comments and/or steps taken to prevent recurrence, the following was written, "Resident educated to use call light when getting out of bed to bathroom, and to notify staff of any falls". Although the form required the signature/title and date of the person preparing the report, director of nursing, medical director and administrator, only the nurse (completing the form) and director of nursing had signed the form and neither had dated it. It was not clear what date the investigation had been initiated or completed. Review of the resident witness interview summary, which was part of the facility investigation to determine the cause of the injury, dated 8/2/12, the nurse documented, "The resident stated, 'I fell out of bed two evenings ago'." It was noted that the resident did not recall bumping her arm, and she did not notify staff because she was not hurt and went back to bed. Review of the witness interview summary dated 8/3/12, 8:00 a.m., the resident's nurse documented, the resident had gone to the nurses' station and lifted up her arm. The nurse noted a large old looking bruise on her arm. The nurse asked the resident what had happened and the resident stated, "I don't know and never mind that." The resident stated that she was ok and that the bruise did not hurt. Review of the witness interview summary dated 8/2/12, the interim director of nursing (IDON) at 2:15 p.m., revealed that on 8/2/12, the resident was noted to have a bruise to her left inner elbow. The edges of the bruise were noted to be yellow in color, but the left arm had good range of motion. The resident denied pain upon palpation or during range of motion. The resident was ambulating throughout the facility with contact guard assistance per her normal. Interviews were conducted with the three additional resident's regarding whether or not they felt safe, if they were afraid and if they had ever been treated roughly. All three residents's stated that they felt safe, were not afraid and had never been treated roughly. Review of the nursing progress note dated 8/2/12, documented that the resident presented at the nurses' station with a "large bruise to her left inner elbow, appeared old and healing (yellowish/green) around edges." The resident stated that she slid out of bed two evenings ago and hit her elbow on the bed. The resident denied pain, her vital signs were within normal limits and the nurse would continue to monitor. Review of the medical record, medication administration record and treatment administration record, revealed after the residents reported fall, there was no evidence the facility attempted to determine the cause of the fall through fall risk assessments, medication review or other assessment tools. The residents care plan was also noted to not be updated with interventions to prevent further injury due to a fall. II. Resident #31 Resident #31, an [AGE] year old male, admitted to the facility on [DATE]. According to the face sheet, the resident had the following diagnosis; late effects of cerebrovascular disease, hypertension, gout and depressive disorder. According to the most MDS assessment dated [DATE], the resident was coded as scoring a 15/15 on the brief interview for mental status (BIMS), which indicated that the resident did not have cognitive impairment. The resident was coded as requiring limited assistance for bed mobility, transfers, toileting and personal hygiene. He was not steady, but was able to stabilize without human assistance when moving from seated to standing position and moving on/off the toilet. He required human stabilization for surface to surface transfers (transfers from bed to chair/wheelchair). Review of incident report dated 8/14/12, documented that the resident had a bruise on the top of his left foot. The incident had been unwitnessed. It documented that a certified nursing aid reported that the resident had a bruise on the top of his left foot, and that the resident reported he hit his foot on his wheelchair. The resident was alert and oriented, his physician was notified, and he was his own responsible party. The resident did not require first aid or hospitalization , or a physician's visit. In the section which documented if additional comments and/or steps were taken to prevent recurrence, the form documented, "none". The incident report did not document if the resident was asked if he had hit his head, or how long ago the injury took place. The incident report was also not dated by the person preparing the report, the director of nursing or the administrator, although the form required this information. Review of the resident witness interview summary dated 8/15/12, the nurse documented the resident stated, "I bumped it on my wheelchair." It was noted on the form that the resident did take 81 mg of aspirin a day. Additional information documented by another nurse stated, "Resident denies fear and he also states staff treat him well and he has never been treated roughly." There was no further information found on the form. There was no documentation on 8/14/12 or 8/15/12, in the nursing progress notes regarding the resident's bruise. Review of the treatment administration record (TAR) and medication administration record (MAR) on 8/21/12 at 4:20 p.m., revealed there was no acute care plan regarding the bruise or additional skin monitoring sheet. Review of a skin condition report dated 8/15/12, revealed that the injury was first discovered on 8/14/12. The form documented that the resident had a bruise to his left foot measuring 2 cm X 3 cm. It was yellowish in color. The resident stated he hit his foot on the arm of the wheelchair when swinging his leg around to get out of bed. It documented that the injury had improved; there was no additional treatment and no care plan update. There were no other entries regarding the condition of the resident's bruise. On 8/21/12 at 2:50 p.m., resident #31 was interviewed regarding the bruise to his foot. The resident stated he hit his foot on his wheelchair while getting out of bed. He also stated the staff did not give him any advice on how to prevent this from happening again, or add any measure to prevent it. He stated has tried to be more careful. On 8/21/12 at 4:20 p.m., the resident's nurse stated that an acute care plan was put into place when a resident had a bruise, skin tear, fall or injury. She discussed that the length of time an acute care plan was in place varied, but usually they were 15 days and if it was needed for a longer period it would be part of the permanent care plan. Further record review of the residents medical record, revealed after the resident hit his foot while transferring, a referral to therapy to evaluate his wheel chair for modification and his need for physical therapy was not completed. The residents care plan was also not updated to include interventions that might prevent further injury to the resident.

Based on observation, interviews and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for two of 32 sample residents (#60, #48). Specifically, the facility failed to ensure pain was controlled for a terminally ill resident (#60), which resulted in unnecessary pain for the resident; and failed to address #48's continuous complaints about pain after he bit his tongue. The findings include: 1. Resident #60, a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses, per the facility face sheet, of [MEDICAL CONDITION], dementia with behavioral disturbance, cardiovascular disease, lack of coordination and dysphagia. a. Record Review According to a faxed communication from the local hospice agency, the resident was admitted to hospice care on 12/8/10. The primary terminal [DIAGNOSES REDACTED]. -Allow patient to stay in place of residence -Provide support to patient and family -Provide optimal pain control/symptom management -Visits by interdisciplinary team as needed to meet patient goals, as specified in plan of care -May institute all collaborative practice orders. Review of the physician's orders [REDACTED]. -[MEDICATION NAME] 2 mg (milligrams) qam (every morning) - agitation -[MEDICATION NAME] 20 mg qd (every day) - depression -[MEDICATION NAME] 1 mg q 4hr (every four hours) prn (as needed) - agitation -[MEDICATION NAME] 40 mg qd - [MEDICAL CONDITION] -[MEDICATION NAME] 5 mg qid (four times a day) prn - pain -[MEDICATION NAME] 200 mg @hs (at hour of sleep) - agitation -[MEDICATION NAME] 12 gm powder 12 gm in 240 cc of water qd - constipation -[MEDICATION NAME] 5 mg q 4 hr prn - agitation -[MEDICATION NAME] 50 mg qid prn - pain -MOM liquid 30 ml qd - constipation Nursing services were to be provided by hospice 1 x wk & prn; family services (provided by hospice) 2 x mo & prn; hospice CNA (certified nurse aide) services were provided 3 x wk. Review of the Nursing Data Collection Tool, revealed a pain assessment was completed as part of a Nursing Data Collection Tool on 12/14/10. Documentation showed resident #60 was assessed using the PAINAD (Pain Assessment in Advanced Dementia). This scale was used for residents with dementia who were unable to verbalize pain. Visual signs assessed were breathing, negative vocalization, facial expression, body language, and consolability. Each of the five (5) categories is scored from 0-2, which results in a total score between 0 and 10, so pain could be identified on a 0 to 10 scale. The resident's acceptable level of pain was noted to be 0. Team progress notes, dated 12/15/10, were reviewed and revealed the following entries: "Pain assessment completed 12/11/10 = 4 out of 10. PAINAD used r/t (related to) nonverbal. Acceptable level of pain is 0. Dx (diagnosis) Alzheimer's dementia, disuse atrophy. On hospice, pain medication review, [MEDICATION NAME] severe pain, [MEDICATION NAME] for breakthrough. No non-pharm intervention used." A progress note, dated 12/30/10, stated, "(Resident #60) has received [MEDICATION NAME] 7 x (times) in last seven days for pain of 8 on PAINAD scale. [MEDICATION NAME] is effective." Review of the February 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's pain was identified as a 6 to 7 on a 0-10 scale on the night shift from 2/17/11-2/20/11, and from 2/23/11-2/28/11. He was administered prn (as needed) [MEDICATION NAME] 5 mg (for severe pain) on each occasion. Documentation indicated his pain was reduced to a 0 in each case. The March 2011 MAR indicated [REDACTED]. Observed behaviors included groaning, grimacing and rigidity. The results reflected a reduction in pain to 0 to 2 on the PAINAD scale. The April 2011 MAR indicated [REDACTED]. Care Plan A care plan for the problem area "Pain" was initiated on 12/1/10 and stated, "(Resident #60) may experience generalized pain AEB (as exhibited by) groaning or grimacing. PAINAD acceptable level 0." Additional notes stated: -3/14/11 Hospice in & adjusted pain meds, -3/31/11 [MEDICATION NAME] increased r/t freq prn use (2.5 mg), -4/5/11 [MEDICATION NAME] increased to 5mg q 12 hrs per hospice. The goals section stated, "AEB PAINAD scale utilized before and after intervention with relief evidenced by score." Interventions included: -Medication as ordered for pain -Monitor effectiveness of prn med -Encourage activity attendance -Rest after medication to facilitate relief -Utilize PAINAD scale and assess for pain q shift -12/8/10 Integrate all care with Hospice -3/3/11 Notify hospice if pain management (sic) -3/31/11 Per (PCP) document specific behaviors r/t pain An integrated plan of care was initiated on 12/8/10 and addressed in detail the facility's role and hospice's role in pain management, B & B program, skin integrity/wound care; physical mobility, pt & family coping and nutrition. The pain management section identified the plan as "report pain <3 on 1-10 scale or pain relieved by current med regime." The facility's role was noted as, "Assess pain, administer pain Rx as ordered. Notify hospice if pain is not managed." Hospice's role was stated as, "Assess pain at each visit, assess med regime; notify MD if pain is not managed." Physician's Telephone Orders (PTO) The resident's primary care physician (PCP) was notified by PTO on 3/9/11 for a request to schedule regular dosing of [MEDICATION NAME] twice a day, based on the frequent administration of PRN [MEDICATION NAME] on the night shift. The physician's response was to keep the [MEDICATION NAME] order as it was (5 mg at HS and QID PRN) BID (sic). On 3/13/11, the PRN [MEDICATION NAME] was increased to 5 mg q 2hrs for pain uncontrolled by qid doses. The order stated, "May use [MEDICATION NAME] as (illegible) alternate with [MEDICATION NAME]." On 3/14/11, the resident was prescribed [MEDICATION NAME] 5 mg tab 1/2 qhs in addition to the [MEDICATION NAME] previously ordered. A PTO, dated 3/31/11, stated, "Start [MEDICATION NAME] 2.5 mg BID (am & pm) 12 hours apart. Will trial this for 1 week if no change discontinue." A further notation stated the resident's PCP, "would like specific behaviors documented related to pain." A PTO, dated 4/5/11, stated, "Increase [MEDICATION NAME] to 5 mg q12 hours for pain." Staff Interviews On 3/31/11 at 9:55 a.m., an interview was conducted with the director of nursing (DON) and a registered nurse (RN) from hospice who provided cares for the resident. The RN stated that she had addressed pain concerns with the resident's primary care physician (PCP) following a care plan meeting at the facility at the end of February. The RN said she informed the PCP that the facility staff had administered PRN pain medication 13 times in February. She said the physician stated that meant there were 16 days the resident did not need it. The RN stated she had routinely checked the number of administrations of PRN [MEDICATION NAME] on the MARs when she visited the facility, but she was not aware of the section of nurse's notes on the MAR. These notes identified the resident's level of pain (6-8 of 10) and the specific times (usually 5 a.m.) the PRN medication had been administered in February. Therefore, that information had not been shared with the physician. A discussion of the pain scale used to assess pain for this resident revealed hospice used the FLACC scale while the facility used (name of consulting agency) Management's pain scale. Both of the scales were based on non-verbal indicators of pain. The RN provided a copy of the FLACC (Face, Legs, Activity, Cry, Consolably) scale. As with the tool used by the facility, the five categories were each rated 0 to 2 for a total pain score ranging from 0 to 10. The RN pointed out that the resident always exhibited rigidity and drawing up of knees, making it difficult to identify the presence of pain at times. The DON suggested that a pain scale needed to be developed specific to this resident's nonverbal expressions of pain. The DON stated the standardized scales did not allow for the disease process. The hospice RN stated the resident's pain always appeared to be controlled when she visited. The DON pointed out this was likely because the resident had been consistently receiving a PRN dose of [MEDICATION NAME] at about 5:00 a.m., prior to the RN's morning visits. Both the RN and the DON expressed that there were failures on the part of both hospice and the facility and that more effective communication was needed. The RN stated she failed to recognize the degree of the resident's pain and stated that a pain level of "6" was not acceptable. The DON stated the facility should have followed up more diligently with hospice and the physician regarding the frequent use of PRN meds to address such high levels of pain. The RN stated she had a call in to the resident's physician to provide additional information and request a medication change. She said if the physician was not responsive this time, she would contact hospice's medical director for guidance. The DON stated she planned to meet with the medical director to discuss concerns as well. Medical Director Interview The facility's medical director was interviewed on 4/4/11 at approximately 10:00 a.m. When asked to review and comment on the March 2011 MAR indicated [REDACTED]. 2. Sample resident #48 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His Minimum Data Set, dated dated [DATE], revealed short and long-term memory impairment, impaired cognition and independent for most activities of daily living. He was understood and could understand others. His care plan for potential for pain, dated 11/25/09 and updated 4/12/11, had a goal of having pain at an acceptable level. On 3/29/11 at approximately 12:00 p.m., the resident stated he had bitten his tongue and was experiencing pain. He stated he had told the certified nurse aides, however, they were not able to see any injury. On 3/30/11 at approximately 9:30 a.m., he was complaining of pain. The resident was given Tylenol 650 mg. At approximately 11:00 a.m., he was asked if the Tylenol had helped. The resident stated it had not helped. The resident continued to complain of pain throughout the survey. Review of the medical chart on 3/30/11 at 9:35 a.m. revealed there was a note to the physician on a physician progress notes [REDACTED]. It read, "He complains it hurts but I don't see anything. " The physician did see resident #48 on 4/2/11 and noted there was no injury visible on the resident's tongue. His order read, if the resident continues to complain of pain, try a [MEDICATION NAME] swish and swallow even though there is no obvious signs of thrush. There were no further notes from the physician by the end of survey. Further review of the resident's record revealed there was no change in the resident's current care plan or in the pain assessment scale, dated 11/25/09 and updated 4/12/11.