Every finding on record at Wellsprings Care Center

Based on record review and interviews, the facility failed to ensure two (#7 and #2) of five residents were kept free from physical abuse out of seven sample residents.Specifically, the facility failed to:-Protect Resident #7 from physical abuse by Resident #3 on 5/11/26; and,-Protect Resident #2 from physical abuse by Resident #3 on 6/20/26.Findings include:I. Facility policy and procedureThe Abuse policy and procedure, dated May 2023, was provided by the nursing home administrator (NHA) on 8/5/26 at 8:50 a.m. It revealed in pertinent part, Communities do 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 representative, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Each facility assesses each potential resident prior to admission. This assessment includes a behavior history. Persons with a significant history or high risk of violent behavior are carefully screened and assessed for appropriateness of admission. If a resident experiences a behavior change resulting in aggression toward other residents, the community will implement interventions for protection of the alleged assailant and other residents. The facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization, can then be implemented. When another resident jeopardizes the safety of one resident, alternative placement may be considered for that resident. If a cognitively intact resident willfully and knowingly abuses another resident, the abused resident and the responsible party may file criminal charges against that resident.II. Incident of physical abuse by Resident #3 towards Resident #7 on 5/11/26A. Facility investigationThe 5/11/26 facility investigation documented Resident #7 suffered physical abuse when Resident #3 hit Resident #7, after Resident #7 made rude comments to Resident #3. Resident #3 became upset and swung his arm backward and struck Resident #7 on the right side of his nose. Both residents were separated; the facility staff started 15-minute checks, and Resident #3 moved to a separate room. The local police department was notified; both residents, witnesses, and random residents were interviewed. After the incident, Resident #7 required a staff member at all times and became a supervised smoker. The investigation did not identify if the facility substantiated or unsubstantiated the abuse allegation.-However, abuse occurred as Resident #3 intentionally swung his arm at Resident #7 and hit Resident #7 in the face.B. Resident #3 (assailant) 1. Resident statusResident #3, age less than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included schizophrenia, epilepsy, and sequelae of intracranial injury with loss of consciousness.The 5/8/26 staff assessment for mental status revealed short-term and long-term memory problems. Resident #3 required setup assistance with showers, and supervision with transfers. The MDS assessment indicated that the resident did not have physical or verbal behaviors towards others during the assessment look-back period.2. Record reviewThe trauma care plan, initiated 5/30/24, documented Resident #3 had a history of trauma that resulted in difficulty connecting and trusting others. Behaviors included being resistive to care and poor interpersonal interactions. Interventions included assessing the resident's need for additional services and therapeutic support from specialists, and offering referrals periodically and as needed.The physical behavior care plan, initiated 2/24/25, documented Resident #3 had the potential to be physically aggressive and had a history of physical aggression toward others. The resident had been involved in resident-to-resident altercations in August 2025 and December 2025. Interventions included assessing and anticipating the resident's needs, such as food, thirst, toileting, comfort level, body positioning, and pain; monitoring and documenting observed behaviors and attempted interventions every shift and as needed; when the resident became agitated, intervening before the agitation escalated; guiding the resident away from the source of distress; and engaging the resident calmly in a conversation and if the response was aggressive, staff were to walk calmly away and approach the resident later.The verbal behavior care plan revised 8/12/25, documented Resident #3 could be verbally aggressive and use racially derogatory slurs. Resident #3 tended to decline to participate in the MDS assessments. Interventions included allowing the resident to make decisions about his treatment regimen to provide the resident with a sense of control, educating the resident about the possible outcomes of not complying with treatment or care, and praising the resident when his behavior was appropriate. The 5/11/26 progress note documented Resident #7 was calling Resident #3 names. Resident #3 was unable to wheel himself away from the area as he was blocked in by a second resident who refused to move out of the way. Resident #3 proceeded to hit Resident #7 in the nose. Both residents were immediately separated and placed on 15-minute checks. Resident #3 was educated to call out for help and not hit others. C. Resident #7 (victim)1. Resident statusResident #7, age less than 65, was admitted on [DATE], and re-admitted on [DATE]. According to the July 2026 CPO, diagnoses included dementia, history of cerebral infarction, schizophrenia, bipolar disorder, panic disorder, and obsessive-compulsive disorder.The 5/16/26 MDS assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. He required substantial assistance to move between surfaces.The MDS assessment indicated the resident exhibited verbal behaviors toward others on four to six days a week during the assessment look-back period.2. Record reviewThe behavior care plan, initiated 5/2/25, documented Resident #7's diagnoses included bipolar disorder, panic disorder, and dementia. Interventions included behavior monitoring; documenting if the resident was verbalizing depression, sleeping too much or too little, showing rage or talking about seeking, revenge, extreme mood swings, and withdrawal or isolation; offering and documenting non-pharmacological interventions as needed; offering massage, relaxation and breathing techniques, distraction techniques, re-positioning, aromatherapy, therapeutic touch, and offering a snack. Additional interventions included redirecting the resident to an activity, offering independent activity supplies, offering to call a loved one, assisting the resident outside, sitting with the resident as needed, offering a shower or a bath, and active listening and validation; administering medications as ordered, and monitoring for side effects and effectiveness; encouraging the resident to express feelings appropriately. The behavior and incidents care plan, initiated 5/12/26, documented Resident #7, who lived on the first floor was involved in an altercation with Resident #3, who lived on the second floor. Resident #7 was hit in the nose by Resident #3. Interventions included encouraging the resident to stay on the first floor as much as possible, monitoring and documenting observed behaviors and attempted interventions every shift, and supervising the resident when he was going to the second floor.The 5/11/26 behavior progress note documented Resident #7 was involved in an altercation with another resident while on the second floor patio. Resident #7 was punched in the face, resulting in a nosebleed. The resident reported feeling well and denied pain. The director of nursing (DON) and the resident's representative were notified. Resident #7's access to the patio would now be supervised, and 15-minute checks of the resident were initiated for 72 hours.III. Incident of physical abuse by Resident #3 towards Resident #2 on 6/20/26A. Facility investigationThe 6/20/26 facility investigation documented Resident #3 was coming out of the patio door and knocked Resident #2's cane out of her hands. Resident #3 then hit Resident #2 on the face to get away.The facility staff initiated 15-minute checks for 24 hours with the assailant (Resident #3). Both residents were assessed and interviewed, the police were notified, witnesses were interviewed, and random resident interviews were completed.The staff removed Resident #3's access to Resident #2 to prevent further abuse. There was no evidence of injury. During the post-incident interview, Resident #3 said Resident #2 hit him.The facility offered Resident #2 the opportunity to move to a different room, but she refused.The facility substantiated the incident.B. Resident #3 (assailant)1. Record reviewThe 6/20/26 behavior note documented Resident #3 hit Resident #2 in the face. A staff member asked Resident #3 what happened, but he refused to answer. Resident #2 said she was coming into the activity room. She opened the door, Resident #3 started making his way out and knocked Resident #2's cane down. Resident #2 reacted by pushing Resident #3 back to get him away from her; Resident #3 turned and hit her in the face. Both residents were separated; no injuries were observed during the initial evaluation; 15-minute checks were initiated; and all pertinent parties, including the local police department, were notified. C. Resident #2 (victim)1. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side, type 2 diabetes, depressive disorder, displaced fracture of the surgical neck of the right humerus, and age-related nuclear cataract, bilateral.The 6/21/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision for transfers, and required set up assistance with dressing.2. Resident interviewResident #2 was interviewed on 8/5/26 at 12:42 p.m. Resident #2 said she pushed the patio door open while Resident #3 was coming in the opposite direction. Resident #2 said she told Resident #3 to move away, and then he grabbed her cane, threw it away, turned around, and hit her in the face. Resident #2 said she left after the incident. She said the staff recommendation was for her to stay away from Resident #3. Resident #2 said the staff members did not do anything after the incident, and they said Resident #3 was not cognitive. Resident #2 said the staff asked her to move to a different floor, but she did not accept it. She said she was angry that Resident #3 hit her and she was frustrated that the facility asked her to move rooms instead of Resident #3.3. Record reviewThe psychosocial care plan, revised 2/28/26, documented that Resident #2 was at risk for psychosocial well-being related to loss of family in the community, frustration with life circumstances, and depression. Interventions included activities and positively interacting with others, encouraging socializing with peers in the facility through activity participation, communal dining, independent leisure pursuits in common areas as the resident permitted, meeting with the psychologist to work through feelings and identify strategies to improve thoughts and overall mood, and utilizing reframing techniques to assist the resident to look at things differently.The 6/20/26 nursing progress notes documented Resident #2 was assaulted by Resident #3. A nurse immediately intervened and removed Resident #2 from the area. Resident #2 was assessed with no bleeding noted at that time. As needed Tylenol was administered to the resident prophylactically for pain. The nurse assisted Resident #2 in contacting the police to report the incident, and the DON was notified. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 8/5/26 at 4:14 p.m. CNA #1 said he had not heard about the incident between Resident #2 and Resident #3. He said he had seen Resident #3 insulting staff members several times. CNA #1 said in order to avoid incidents, a staff member was always present when Resident #3 went to smoke, and sometimes staff received indications to check on him every 15 minutes. CNA #1 said when Resident #3 approached another resident, the staff were to take one of the residents away. CNA #2 was interviewed on 8/5/26 at 4:18 p.m. CNA #2 said she saw Resident #3 insulting staff members or being verbally aggressive, but never physically aggressive. CNA #2 said in order to avoid incidents, the facility implemented 15-minute checks on Resident #3.CNA #3 was interviewed on 8/5/26 at 6:27 p.m. CNA #3 said the only incident that involved Resident #2 was the incident with Resident #3. CNA #3 said after the incident, Resident #2 did not ask to go upstairs anymore.--However, Resident #3 was the assailant in an incident with Resident #7 prior to the incident with Resident #2 (see incident above). Licensed practical nurse (LPN) #1 was interviewed on 8/5/26 at 4:33 p.m. LPN #1 said during the incident between Resident #2 and Resident #3, the staff heard somebody screaming and went to check on the residents. LPN #1 said Resident #2 had already left, and Resident #3 told the staff what happened. LPN #1 said there were no bruises or signs of injury for Resident #2.LPN #1 said the staff reported the incident immediately and the police came to the facility. LPN #1 said the incident was the only incident between both residents.LPN #1 said Resident #3 had medication for behaviors and received mental health services, and he did not have behaviors daily. LPN #1 said staff protected Resident #3 by not letting him go to the first floor because they were aware of the incident with Resident #7, but they did not know the details.The DON was interviewed on 8/5/26 at 6:11 p.m. The DON said Resident #3 had had several surgeries to his head since childhood. She said other residents called him retarded, and he would not talk to anyone unless he knew the person.The DON said Resident #2 was bossy, had a mean-girl attitude, was judgmental toward others, and said Resident #3 was crazy and made derogatory comments toward him as well. The DON said the staff was educated to tell Resident #2 that that was inappropriate. She said Resident #3 ignored the comments, but if a specific person repeated it, then he could react. The DON said since Resident #3 had been put in his own private room, his reactive behaviors had decreased. The DON said Resident #7 spoke negatively about Resident #3, so he was not allowed on the second floor without staff supervision. She said Resident #7 said he wanted to kill Resident #3, so the staff assessed him and asked some questions, but then he said he was just kidding. The DON said she did not see Resident #3 as the aggressor because he retaliated if he felt targeted or threatened. The NHA was interviewed on 8/5/26 at 4:36 p.m. The NHA said the facility identified several residents were bullying Resident #3. The NHA said Resident #3 came across as annoying to other residents, so he became a supervised smoker, had plenty of cigarettes, and had had a private room since January 2026. The NHA said when Resident #7 went upstairs to smoke, staff were with him to prevent an altercation between residents. However, the NHA said Resident #7 did not want to be around Resident #3.

Based on observations, record review and interviews, the facility failed to protect three (#3, #5 and #7) out of three residents from physical abuse out of 11 sample residents. Specifically, the facility failed to:-Protect Resident #3 from physical abuse by Resident #6; -Protect Resident #5 from physical abuse by Resident #6; and, -Protect Resident #7 from physical abuse by Resident #5.Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 1/6/25 at approximately 5:00 p.m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's medical symptoms. II. Incidents of physical abuse by Resident #6 toward Resident #3 on 12/12/25 and 12/14/25 A. Facility investigations The facility investigation, dated 12/12/25, documented Resident #3 was backing through the doorway in her wheelchair when Resident #7 guided her chair through the doorway, then Resident #6 proceeded to hit her (Resident #3) with an open hand on her upper back. The investigation documented the residents were separated. The investigation documented there were no physical or psychosocial injuries noted. The investigation documented Resident #6 was put on 15-minute checks for 24 hours following this event, and his behavioral care plan was updated to include his supervision when he was in the smoking area. The facility investigation substantiated abuse. The investigation documented as of 12/12/25 Resident #6 had five other documented instances of physical aggression in the past year. The facility investigation, dated 12/14/25, documented Resident #3 was backing through the doorway in her wheelchair when Resident #7 guided her chair through the doorway, then Resident #6 proceeded to hit her (Resident #3) in the head. The investigation documented a small bump was found on Resident #3's head. There were no other physical or psychosocial injuries noted. The investigation documented Resident #6 was once again put on 15-minute checks for 24 hours following this event. The facility investigation substantiated abuse. B. Resident #3 (victim) 1. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician's orders (CPO), diagnoses include chronic obstructive pulmonary disease and peripheral vascular disease. According to the 11/26/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. 2. Resident interview Resident #3 was interviewed on 1/6/26 at 1:14 p.m. Resident #3 said she had two recent incidents with Resident #6. Resident #3 said she had no pre-existing relationship or arguments with Resident #6. She said both times he hit her for no apparent reason. She said during both of the incidents she was in the common areas and the staff were able to separate them quickly. She said she said she still felt nervous when he (Resident #6) was in the same room as her. C. Resident #6 (assailant) 1. Resident status Resident #6, age less than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses include schizophrenia (mental illness), nicotine dependence and unspecified head injury. According to the 11/6/25 MDS assessment the resident had short and long and short term memory problems and severe cognitive impairment per staff assessment. 2. Resident interview and observations Resident #6 was interviewed on 1/6/26 at 12:05 p.m. Resident #6 said he got along great with everyone in the facility and he could not recall any altercations with other residents. On 1/7/26 at 9:13 a.m. Resident #6 was yelling derogatory comments at staff because he wanted a cigarette. The staff were able to calm the resident down by redirecting him and giving him a cigarette. 3. Record review Resident #6's behavior care plan, initiated, 2/24/25, revealed the resident had the potential to display physical aggression and has a history for several peer to peer altercations. Pertinent interventions included administering medications as ordered, anticipating the residents needs, intervening when the resident becomes agitated and engaging in calm conversation, withdrawing if the response to this is aggressive and attempting to approach again later. The care plan indicated the resident was also placed on 15-minute checks and made a supervised smoker in response to an altercation on 12/12/25. III. Incident of physical abuse by Resident #5 towards Resident #7 on 12/22/25 A. Facility investigation The facility investigation, dated 12/22/25, documented Resident #5 got into a verbal altercation with her roommate, Resident #7. Resident #7 was allegedly wearing Resident #5's shirt. Resident #5 took notice of this and attempted to remove the shirt from Resident #7. Resident #5 was unsuccessful at removing this shirt and proceeded to throw juice in Resident #7's face. This was witnessed by Resident #5 and Resident #7's roommate of both residents, who called for help after the incident occurred. The investigation documented no physical injuries or psychosocial harm were sustained to Resident #7. Resident #7 was noted to be incapable of dressing herself,and would have been unable to put on Resident #5's shirt without assistance. The investigation documented Resident #5 was put on 15-minute checks for 24 hours and was moved to another room following the incident.The investigation documented Resident #5 and Resident #7 were interviewed during the facility investigation. Resident #5 said Resident #7 previously took another one of her shirts and ruined it and she did not want it to keep happening. Resident #7 said Resident #5 accused Resident #7 of wearing her shirt. Resident #7 said Resident #5 hit her chin and poured juice on her. B. Resident #5 (assailant) 1. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses include heart failure, opioid abuse, and bipolar disorder. According to the 12/4/25 MDS assessment the resident was cognitively intact with a BIMS score of 14 out of 15. 2. Resident interview and observation Resident #5 was interviewed on 1/7/26 at 9:01 a.m. Resident #5 said she threw kool-aid on previous roommate's face (Resident #3) because she took her shirt. Resident #5 said she was upset about being moved to another room following this incident with Resident #3. On 1/6/26 at 11:15 a.m. Resident #5 was observed getting agitated with staff over cigarettes. Staff was able to calm Resident #5 by telling her she would get more tomorrow.3. Record review Resident #5's Preadmission Screening and Resident Review (PASSR), effective 8/8/24, recommended individual therapy for Resident #5's mental illness. Resident #5's behavior care plan, initiated on 4/15/25 and revised 10/6/25, revealed the resident had the potential to display verbally aggressive behaviors, often involving cigarettes and money. Pertinent interventions included de-escalating the resident by redirection and reassurance, intervening before agitation escalates, engaging calmly in conversation, and calmly walking away if aggressive response is received, and monitoring interactions between resident and roommate, separating them if altercations arise. Resident #5's nurse progress notes, dated 10/5/25 at 6:00 p.m., documented Resident #5 was verbally aggressive towards her roommate (Resident #7). Resident #5 said she hoped Resident #7 would choke on her own blood. Resident #5 also made hostile and profane remarks to staff members at this time. C. Resident #7 (victim) 1. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included brain tumor, obesity and repeated falls. According to the 12/4/25 MDS assessment the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. 2. Record review Resident #7 nursing care plan, initiated on 8/27/25, said Resident #7 required assistance with dressing herself. IV. Incident of physical abuse between Resident #5 and Resident #6 on 1/2/26 A. Facility investigation The facility investigation, dated 1/2/26, documented Resident #6 was going to bed at around 10:30 p.m., when she accidentally bumped into Resident #5 with her wheelchair while wheeling backwards. Resident #5 proceeded to hit resident #6 in the head. Resident #7 then hit Resident #5 back in retaliation. The investigation documented both residents being put on 15 minute checks for 24 hours. The nursing assessment after the incident revealed neither resident sustained any physical injuries and did not appear afraid. Resident #5 and Resident #6 were both interviewed as a part of the facility investigation. Resident #5 denied hitting Resident #6 in retaliation. Resident #6 did not recall hitting nor being hit on 1/2/26. B. Resident #5 (victim) 1. Resident interview Resident #5 was interviewed on 1/7/26 at 9:01 a.m. Resident #5 said she has had two incidents with Resident #6, one of them being recent. Resident #5 said during the most recent incident she accidentally bumped into Resident #6 and he hit her in the face. Resident #5 denied hitting him back. She said the staff did not separate the residents and laughed at her when she was hit. She said she felt helpless since the staff did little to address the incident and she did not feel like there was anything she could do to prevent it from happening again. VII. Staff interviews Licenced practical nurse (LPN) #2 was interviewed on 1/6/26 at 2:54 p.m. LPN #2 said physical abuse occurred if there was physical contact made. LPN #2 said all staff received training on combatting abuse and she felt confident in their CNA's ability to manage behaviors. Certified nurse aide(CNA) #1 was interviewed on 1/6/26 at 2:56 p.m. CNA #1 said any kind of unwanted hitting or touching was generally considered abuse. CNA #1 said she she worked with Resident #5 and Resident #6 often and she paid close attention to them. CNA #1 said if it seemed like either of them were getting agitated she would try to de-escalate them and talk them down. She said if this was ineffective she would then try to give them space to calm down. CNA #1 said these strategies generally proved effective at preventing any incidents. LPN #1 was interviewed on 1/6/26 at 3:05 p.m. LPN #1 said abuse could occur in many forms. She said she was unsure exactly what line needed to be crossed for it to constitute abuse. LPN #1 said she did not see any abuse in the facility. She said if a resident was getting agitated she would try to calm them down and de-escate them, as well as continue to monitor them frequently. The maintenance director was interviewed on 1/7/26 at 9:50 a.m. The maintenance director said he was a CNA. He said the facility generally responded to physical abuse by keeping relevant residents separated and moving them to separate floors. The maintenance director said clothing was generally labeled and distributed by room. The maintenance director said CNA's should be double checking labels to ensure the resident was getting their correct clothing if they were assisting a resident in getting dressed. LPN #4 was interviewed on 1/7/26 at 10:01 a.m. LPN #4 said any hitting or nonconsensual touching was generally considered abuse. LPN #4 said if she were to witness any abuse she would do her best to separate the residents and then immediately report it to administration members for full investigation. The nursing home administrator (NHA) was interviewed on 1/7/26 at 12:01 p.m. The NHA said the facility was working really hard to prevent Resident #6's behaviors. She said there were some medication changes. She said they were trying to be cautious with the medication changes, so it did not make things worse. She said she thought some other residents would antagonize him by bumping into him. The NHA said she thought the cause of the incident between Resident #5 and Resident #7 was a simple clothing mix-up, although she was unsure if the shirt was actually labeled for Resident #5. The NHA said she thought the situation was solved since they moved Resident #5 to a different room.

Based on record review and interviews, the facility failed to ensure one (#9) of three residents reviewed for accident hazards received adequate supervision out of 11 sample residents. Specifically, the facility failed to assess, educate, and initiate care plan interventions for Resident #9.Findings include: I. Facility policy and procedure The Fall Management policy, 2/29/24, was provided by the nursing home administrator (NHA) on 1/6/26 at 4:14 p.m. It read in pertinent part, A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Research has shown that a structured fall reduction program can substantially reduce the rate of falls and related injuries in nursing facilities; however, falls may likely occur. Identifying risk factors, followed by timely and appropriate interventions, is the key to a successful program. Risk factors that are internal to the resident include the resident's physical health and functional status. External risk factors include medication side effects, the use of appliances, and environmental conditions. Each resident will be reevaluated quarterly, annually and when a significant change occurs. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Please note interventions are to be re-evaluated when a resident falls for efficacy. Falls review will include the following: review the Risk Management Incident to ensure complete and appropriate parties have been notified regarding the incident; review the IDT (interdisciplinary team) Risk Management to ensure complete and appropriate interventions have been implemented; review that a care plan has been initiated and provide revisions to the plan of care as necessary after falls. The facility will review all falls daily (Monday through Friday) during the morning quality assurance process improvement (QAPI) meeting. II. Record review Review of facility training documentation revealed two in-service trainings on fall prevention on 7/31/25 and 10/8/25. The reports documented 100 percent of staff completed both trainings. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician's orders (CPO), pertinent diagnoses included bipolar disorder, underweight, muscle weakness, fatigue and reduced mobility. The 10/26/25 minimum data set (MDS) assessment revealed the resident was not cognitively intact, with a brief interview for mental status (BIMS) score of six out of 15. The MDS assessment documented Resident #9 needed set-up assistance with his activities of daily living. The MDS assessment indicated the resident had sustained a fall. B. Record review Review of Resident #9's comprehensive care plan, dated 11/4/25, revealed no care plan focus or fall interventions. Multiple nursing progress notes documented on 10/19/25 revealed Resident #9 had gone to the hospital after he had fallen while out in the community. The notes documented Resident #9 had broken his elbow, reported bodily pain and had abrasions (cuts or scrapes) on his knees and palms. The IDT risk management note, dated 10/20/25, said Resident #9 had lost his balance and fallen on 10/19/25 while out in the community. The physician's follow-up note, from 10/21/25, revealed Resident #9 had sustained a left radial fracture and left knee pain as a result of his fall on 10/19/25. The physician's note documented that Resident #9 had significant difficulties ambulating (walking) since the fall. Review of the 10/24/25 nursing fall risk assessment revealed Resident #9 was a high fall risk. No nursing fall risk assessments have been completed since then. Review of occupational therapy notes from 10/21/25 to 11/25/25 revealed Resident #9 was on fall risk precautions. Review of Resident #9's electronic medical record (EMR) did not reveal the facility assessed the resident's ability to safely leave the facility independently or provide the resident with education on safety in the community. C. Observations On 1/7/26 at 8:50 a.m. Resident #9 was walking in the hallway. He used one hand to push a front-wheeled walker at an angle and used his other hand to prevent his pants from falling. Halfway down the hallway, he stopped and adjusted his pants from falling using a rubber glove to tie two belt loops together. D. Resident #9 interview Resident #9 was interviewed on 1/7/26 at 8:55 a.m. Resident #9 said he had been using a walker for mobility since his fall in October 2025. He said he continues to have pain in his left arm and left leg as a result of the fall. He said he used a walker for mobility because he was afraid he might fall again. He said he went out into the community alone daily. E. Staff interviews Licensed practical nurse (LPN) #2 and LPN #3 were interviewed on 1/6/26 at 11:30 a.m. LPN #3 said she was Resident #9's nurse for the day. LPN #3 and LPN #2 said they did not have any residents at risk of falls currently. LPN #3 said if a resident fell, the interdisciplinary team would decide if the resident was a fall risk and developed a care plan for falls accordingly. The physician was interviewed on 1/6/26 at 2:00 p.m. The physician said Resident #9 had diagnoses of reduced mobility and muscle weakness, which could contribute to being a fall risk. The physician said that having a fall in the past six months was predictive of a resident falling again. The physician said Resident #9 had many factors to consider when determining his fall risk status, including his age. The physician said these factors could indicate Resident #9 was at risk of falls. The director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 1/6/26 at 2:00 p.m. The NHA said Resident #9 left the facility every day and walked around the community. The NHA said sometimes he visited his family member, who lived nearby. The DON said Resident #9 fell in the community while on his daily outing. The DON said Resident #9 did not have a fall risk care plan and the facility would only write care plans for factors that could be controlled within the facility. The physical therapist (PT) was interviewed on 1/7/26 at 11:16 a.m. The PT said he considered Resident #9 a fall risk based on the occupational therapist's assessment of Resident #9 (see record review) and the fall on 10/19/25. The PT said Resident #9 preferred to use a front wheel walker. The PT said ideally the resident would be using a four-wheeled walker, because it would provide Resident #9 with more stability as he was walking around the community.

Based on record review and interviews, the facility failed to protect one (#1) of three residents from misappropriation of property out of three sample residents.Specifically, the facility failed to protect Resident #1 from misappropriation of property and exploitation by a facility employee.Findings include:I. Facility policy and procedureThe Abuse policy and procedure, dated May 2023, was provided by the nursing home administrator (NHA) on 11/5/25 at 4:10 p.m. It revealed in pertinent part, Purpose: The facility 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 representative, sponsors, friends, or any other individuals. Intent: Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Employees have a unique position of trust with vulnerable residents. This facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. Identification of abuse shall be the responsibility of every employee. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Misappropriation includes, but is not limited to theft, fraud, and financial exploitation. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting can be completed verbally or in writing.II. Incident of misappropriation of property and exploitation of Resident #1 by activity assistant (AA) #1A. Facility investigationThe 9/11/25 facility occurrence and investigation revealed that on 9/11/25 at 4:00 p.m., the social services director (SSD) overheard Resident #1 speaking on the phone with someone about having the title of his vehicle signed over to the person on the phone. After some questions to Resident #1, the SSD found out the person speaking with the resident was a facility employee, AA #1. AA #1 begged the SSD not to mention anything to the NHA. Resident #1 stated that he had his friend sign his (Resident #1's) van over to AA #1 because she had been taking him to different places. Additionally, Resident #1 said that in the past, AA #1 took him to the bank, and he withdrew approximately $1000.00 and gave the money to her to get insurance and pay for the van's registration.The facility performed an immediate assessment of Resident #1, evaluated whether Resident #1 felt safe, took immediate steps to protect the resident, suspended the AA #1's access to the resident and started interventions to prevent further potential abuse, misappropriation of property and exploitation.After additional investigation, the facility found out AA #1 had been abusing Resident #1 financially since May 2025.On 9/11/25, the NHA interviewed AA #1. The NHA asked AA #1 whether she had Resident #1's friend sign his van title over to her. AA #1 first denied it, then said the title was in the friend's name and that the victim had nothing to do with it. The NHA asked her whether the resident had paid for the license and registration and AA #1 responded no.The NHA reported the incident to adult protection services (APS), to the ombudsman and to the police department. The 11/27/23 background screening report documented that the AA #1 had no reportable records found, and she was not substantiated as a perpetrator in an APS case. On 9/12/25, Resident #1 was interviewed and stated that AA #1 told him it would be cheaper for him to get an apartment because she would be his caregiver. The resident said he thought she would have to transport him to his hemodialysis appointments and other places, so he had his personal friend sign the van title over to her. Resident #1 stated that he believed AA #1 had his credit card information, as there were strange charges on it after AA #1 used the card to fill the van with gas. B. Resident #1 1. Resident statusResident #1, age less than 65, was admitted on [DATE] and readmitted [DATE]. According to the November 2025 computerized physician orders (CPO), diagnoses included chronic pulmonary obstructive diseases (COPD), major depressive disorder, anxiety disorder, type 2 diabetes mellitus and end stage renal disease. The 9/18/15 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15, but demonstrated disorganized thinking in the cognitive patterns evaluation. He required stand-by to moderate assistance with transfers and minimal assistance with showers. Resident #1 was dependent on renal dialysis.2. Resident interviewResident #1 was interviewed on 11/5/25 at 1:35 p.m. Resident #1 said AA #1 was his friend and that she told him she could take care of him outside the facility. Resident #1 said he had his van at his friend's house and AA #1 wanted to drive the resident to different places. The resident said he asked his friend to put the resident's van under her name on the registration and car title. Resident #1 said that AA #1 asked him to give her money for the registration and insurance. Resident #1 said AA #1 got his credit number after she went to put gas in his van. He said after that day she got gas, he saw some charges, including a $400.00 insurance charge on his credit card statement. Resident #1 said he gave AA #1 $1100.00 dollars in advance for future caregiving services and he has not received any money back so far.Resident #1 said that currently, AA #1 had the van, and in the past, she said she would bring it back, but she never did. Resident #1 said AA #1 secretly drove the van with him present and without him, and the facility did not know anything about it. Resident #1 said AA #1 charged him for her services. 3. Record reviewThe 10/1/25 care plan documented Resident #1 was a victim of financial exploitation in the past and because of this, he had attorneys, a banker, and a private helper who assisted him with financial needs. Interventions included allowing visits to the resident's counselors to discuss anxiety surrounding the incident, and reassuring the resident when he presented with anxiety surrounding this incident.The care plan reviewed on 2/10/23 documented Resident #1 had a mood problem related to his anxiety disorder, as well as his physical condition and life circumstances. Interventions included behavioral health consults as needed, observing for signs and symptoms of mania or hypomania, racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep, agitation or hyperactivity, observing and reporting any risk for harm to self (suicidal plan, stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harming or trying to harm self, refusing to eat or drink, refusing medication or therapies or displaying a sense of hopelessness or helplessness, impaired judgment or safety awareness.III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 11/5/25 at 2:17 p.m. CNA #1 said staff members were not allowed to accept gifts or money from residents or to make transactions on the residents' bank accounts. CNA #1 said staff members received abuse training in the facility. She said she was unaware of the incident with Resident #1.Registered nurse (RN) #1 was interviewed on 11/5/25 at 2:20 p.m. RN #1 said staff members were not allowed to accept gifts or money from residents and all staff received abuse training, which helped protect the residents. RN #1 said employees should not have access to residents' credit card numbers or bank accounts.The SSD was interviewed on 11/5/25 at 4:25 p.m. The SSD said she found out about the incident when Resident #1 spoke with AA #1 on the phone. The SSD said Resident #1 reported past purchases made by AA #1 credit card.The SSD said AA #1 said she would bring the van back, but she did not return it to Resident #1. The SSD said the police opened a case, which was still open; the facility was still working on the case and AA #1 was terminated.The NHA was interviewed on 11/5/25 at 4:50 p.m. The NHA said the facility's management team were not aware of the deal between Resident #1 and AA #1. The NHA said the incident with Resident #1 occurred after AA #1 crashed her personal vehicle. The NHA said all staff members received training on misappropriation of property and exploitation after the incident with Resident #1.

Based on observations and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure:-Perishable foods were discarded after the date of expiration; and, -Perishable foods were labeled and dated.Findings include:I. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (effective 3/16/24) retrieved 9/16/25A date marking system that meets the criteria using a method approved by the Department for refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is frequently re-wrapped, such as lunch meat or a roast. Marking the date or day of preparation with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Marking the date or day the original container is opened in a food establishment with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Using calendar dates, days of the week, color coded marks or other effective marking methods. (Chapter 3-29)II. ObservationsThe initial kitchen tour was conducted on 9/7/25 at 7:12 a.m. The following was observed in the walk-in refrigerator;-A bag of romaine romaine lettuce that was brown and was labeled with a discard date of 8/25/25;-A bag of parsley with a discard date of 8/1/25;-A pan labeled watermelon with a discard date of 8/26/25.-An uncovered, unlabeled pan with three patties resembling sausage;-An unlabeled pan, dated 9/6/25, with five hard boiled eggs;-An unlabeled pan, dated 8/2/25, with what resembled beans inside;-An unlabeled pan, with a black substance that resembled beans; and,-A pan with five wrapped, unlabeled blocks of sliced cheese.III. Staff interviewsDietary aide (DA) #1 was interviewed on 9/7/25 at 7:30 a.m. DA #1 said that all the items in the walk-in refrigerator should be dated as soon as opened and if in a manufacturer's bag. She said the kitchen staff utilized the discard dated that was printed on the package by the manufacturer. DA #1 said all food items in the walk-in refrigerator should be labeled. She said the romaine lettuce, parsley and watermelon should have been discarded. DA #1 said she was unable to identify the unlabeled pans with the food items resembling beans. The dietary supervisor (DS) was interviewed on 9/9/25 at 11:30 a.m. The DS said he had worked at the facility for almost a year. He said his expectation was for the kitchen staff to check the walk-in refrigerator every evening before leaving and then again when the opening staff came in the morning to ensure food was discarded timely. The DS said all food items needed to be labeled and all the food needed a discard date. He said if items were not labeled or dated, the residents could be at risk of being provided food items that are contaminated and spoiled.

Based on observations and interviews, the facility failed to ensure residents were not responsible to purchase items or services for which payment was made under Medicaid or Medicare. Specifically, the facility failed to ensure routine hygiene items such as hand soap in the resident rooms were provided at no cost to the residents.I. Facility admission agreementThe facility's admission agreement, dated 2018, was received from the nursing home administrator (NHA) on 9/8/25 at 10:41 a.m. It read in pertinent part,Services (items) covered under Medicaid/Medicare: Routine personal hygiene items and services, as needed, to meet your needs, including, but not limited to: hygiene supplies, comb, brush, soap, and disinfecting soaps or specialized cleansing agents when indicated to treat special skin.II. ObservationsOn 9/9/25 at 10:03 a.m. room [ROOM NUMBER] was observed. There was no bar soap or liquid hand soap in the resident bathroom. On 9/09/25 at 10:05 a.m. room [ROOM NUMBER] was observed. There was no bar soap or liquid hand soap in the resident bathroom.On 9/9/25 at 10:33 a.m. room [ROOM NUMBER] was observed. There was no bar soap or liquid hand soap in the resident bathroom. On 9/9/25 at 10:36 a.m. room [ROOM NUMBER] was observed. There was no bar soap or liquid hand soap in the resident bathroom.On 9/9/25 at 12:45 p.m. room [ROOM NUMBER] was observed. There was bar soap but no liquid hand soap in the resident bathroom.On 9/9/25 at 12:48 p.m. room [ROOM NUMBER] was observed. There was no bar soap or liquid hand soap in the resident bathroom.On 9/10/25 at 10:50 a.m. room [ROOM NUMBER] was observed. There was no bar soap or liquid hand soap in the resident bathroom.III. Resident group interviewA group interview was conducted on 9/9/25 at 2:42 p.m. with five residents (#20, #30, #39, #47 and #55) who were determined to be interviewable, per the facility and assessment. Resident #30 and Resident #47 said the residents were told they had to purchase their own toiletries, to include soap for their bathrooms, razors, mouthwash and deodorant. IV. Additional resident interviewsResident #4 was interviewed on 9/9/25 at 10:03 a.m. Resident #4 said the facility did not provide him with hand soap and he had to provide his own soap. Resident #16 was interviewed on 9/9/25 at 2:10 p.m. Resident #16 said he and his roommate had to purchase their own hand soap for the bathroom. Resident #12 was interviewed on 9/9/25 at 2:36 p.m. Resident #12 said the bar soap in his bathroom belonged to his roommate, who purchased it himself. Resident #12 said when he told the staff he was out of hand soap in his room, the nurses told him he could purchase soap from the store or the activities department. Resident #55 was interviewed on 9/10/25 at 10:50 a.m. Resident #55 said the nurses told the residents they had to provide their own personal hygiene items, to include hand soap in the bathrooms. Resident #55 said if residents attended activities, they could win points and use the points to purchase personal hygiene items from the activities department. V. Staff interviewsThe activities director (AD) was interviewed on 9/9/25 at 10:55 a.m. The AD said the facility's previous AD used a ticket system where residents could earn tickets for coming to activities and use the tickets to purchase items in the resident store. The AD said she used a punch card system for the residents, instead of tickets, but the concept was the same. During the interview, the resident store was observed with the AD. The store contained personal items, such as deodorant, body wash and bar soap that the residents could purchase with their points. Licensed practical nurse (LPN) #1 was interviewed on 9/9/25 at 11:40 a.m. LPN #1 said the housekeepers were responsible for filling the soap dispensers in the residents' rooms. Certified nursing aide (CNA) #2 was interviewed on 9/9/25 at 11:45 a.m. CNA #2 said the housekeepers and the maintenance department were responsible for filling the soap dispensers in the residents' rooms. Housekeeper (HK) #1 was interviewed on 9/10/25 at 9:20 a.m. HK #1 said she did not know who filled the soap dispensers in the residents' rooms, but she thought it might be the CNAs.-However, observations of seven residents' rooms revealed there was no liquid hand soap in the residents' bathrooms and multiple residents' interviewed said they had to purchase their own soap (see observations and interviews above).The NHA was interviewed on 9/10/25 at 1:00 p.m. She said the facility provided standard personal hygiene items and liquid soap in the hand soap dispensers in the residents' rooms free of charge to the residents. The NHA said the facility did not expect the residents to use their personal funds to pay for hand soap or personal hygiene items.-However, resident interviews revealed they were told they had to purchase their own soap and the AD said residents could use their punch card points to purchase personal hygiene items, such as soap (see resident interviews and the AD's interview above).

Based on observations, record review and interviews, the facility failed to provide a clean, comfortable and homelike environment for residents in two of four hallways and two of four shower rooms.Specifically, the facility failed to:-Ensure Resident #4's window blinds and walls were cleaned and maintained and the resident's bed was in good condition;-Ensure bath towels were available for resident use in shower rooms; and,-Ensure residents' rooms were free from debris and odors and appropriate personal hygiene items were available. Findings include: I. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the nursing home administrator (NHA) on 9/11/25 at 1:20 p.m. It read in pertinent part, Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur and when these surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis and when surfaces are visibly soiled. Manufacturer's instructions will be followed for proper use of disinfecting (or detergent) products. Walls, blinds and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Floor mopping solutions will be replaced every three residents' rooms, or changed no less often than at 60-minute intervals. Personnel should remain alert for evidence of rodent activity (droppings) and report such findings to the environmental services directly. Clean personal use items (lights, phones, call bells, and bedrails) with disinfectant solution at least twice weekly. Clean curtains, window blinds and walls when they are visibly soiled or dusty. II. Failed to ensure Resident #4's window blinds and walls were cleaned and maintained and the resident's bed was in good condition A. Resident observation and interview Resident #4's room was observed on 9/8/25 at 12:46 p.m. Resident #4's horizontal blinds in the window were covered with a layer of dust. The footboard of Resident #4's bed was secured to the bed on only one side and the other side of the footboard was loosened from the bed with an approximately six-inch long crack. Resident #4 had a bed cane (assistive device) on the left at the head of his bed. The bed cane had multiple brown and gray soiled spots. The wall next to the resident's window had multiple brown spots splattered on the wall and dried drip splatters that ran down the wall. Resident 4 said when housekeeping came to clean his room, they would change the trash bags and empty the trash but they did not clean under the bed or clean his window blinds. Resident #4 said the footboard of his bed was broken. Resident #4's room was observed a second time on 9/9/25 at 10:03 a.m. The resident's horizontal window blinds, footboard of the bed and the walls had not been cleaned or repaired and were in the same condition as on 9/8/25 (see observation above). Resident #4 said facility staff hid supplies and would not provide him with cleaning wipes to clean his bed cane. He said he had filed multiple grievances about his room being cleaned and he said only one housekeeper would clean the horizontal blinds. During a continuous observation on 9/9/25 from 11:34 a.m. to 11:47 a.m. an unidentified housekeeping staff member was observed cleaning Resident #4's room. The housekeeping staff member did not clean Resident #4's window blinds or the bed cane. B. Record review The Environmental Checklist for Monitoring Terminal Cleaning was provided by the NHA on 9/10/25 at approximately 12:00 p.m. The checklist documented staff were to evaluate the following priority sites in each residents' room: bed rails/controls, cubicle and/or window curtains, walls if soiled and floors. C. Staff interviews The regional clinical resource (RCR), the NHA and the regional director of operations were interviewed together on 9/11/25 at 3:00 p.m. The RCR said the facility reached out to the regional maintenance director for assistance (during the survey). The RCR said the regional maintenance director assisted the facility in updating their housekeeping cleaning checklists to Spanish (during the survey) as much of their housekeeping staff spoke Spanish. The NHA said residents' rooms should be deep cleaned periodically and when deep cleaned, the staff should clean under the resident's beds. The regional director of operations said the regional maintenance director helped (during the survey) realign the housekeeping tasks so the deep cleaning in residents' rooms was completed on a better rotating basis to include the horizontal window blinds and the walls. The regional director of operations said a room deep clean could not be done every day but should be rotated in a way that was efficient to ensure that the items in the room were cleaned on a rotating schedule instead of not at all. III. Failed to ensure bath towels were available for resident use in shower rooms A. Observations On 9/9/25 at 11:40 a.m. the second floor shower room nearest to resident room [ROOM NUMBER] was observed to have a linen rack containing sheets and fifteen wash cloths on it. There were no bath towels for residents on the linen rack or visible in the shower room. On 9/9/25 at 12:00 p.m. a male resident was observed being wheeled out of the shower room on a shower bed by an unidentified certified nurse aide (CNA). The unidentified CNA pushed the shower bed into the resident's room. The resident had a sheet covering his body and no visible bath towels for drying the resident. On 9/9/25 at 12:10 p.m. the first floor shower room nearest to resident room [ROOM NUMBER] was observed to have a linen rack containing sheets and five wash cloths on it. There were no bath towels for residents on the linen rack or visible in the shower room. B. Resident interviews Resident #4 was interviewed on 9/8/25 at 12:31 p.m. Resident #4 said there were rarely bath towels in the shower room and this affected his ability to take a shower. Resident #4 said sometimes he tries to take a shower and the facility did not have any bath towels available so he had to wait a day or two to take a shower. Resident #4 said the facility did not give him a reason as to why they were out of towels when this occurred. He said he thought the facility's laundry department was ineffective. Resident #4 said on the first weekend of September 2025, he was told by facility staff that the bath towels were wet in the dryer and no one had run the dryer so the residents did not have bath towels to use that weekend. C. Staff interviews CNA #2 was interviewed on 9/9/25 at 11:45 a.m. CNA #2 said that all the linens, including bedding and bath towels, were kept on a rack in the shower rooms. -However, observations revealed there were no bath towels in two of the shower rooms (see observations above). Licensed practical nurse (LPN) #2 was interviewed on 9/9/25 at 11:50 p.m. LPN #2 said that all the linens, including bedding and bath towels, were kept on a rack in the shower rooms. LPN #2 said she did not know what the residents used to dry off when the facility was out of bath towels. The maintenance director (MTD) was interviewed on 9/10/25 at 12:09 p.m. The MTD said he was the maintenance director and the supervisor of the housekeeping department. He said the housekeepers were to clean linens daily and keep the shower rooms stocked with bath towels every day. The MTD said he did not have a written schedule for when the housekeepers checked the shower rooms for linens and would expect the CNAs to let him know if they were out of bath towels. IV. Failed to ensure residents' rooms were free from debris and odors and appropriate personal hygiene items were available. A. Observations A tour of the facility's second floor was conducted on 9/8/25 at 7:30 a.m. and again at 3:00 p.m. The following was observed: Resident rooms #215, #218 and #219 were missing hand soap, towels and the paper towel dispensers were empty in each bathroom. The hand sanitizer dispensers additionally were empty in each room. Resident room [ROOM NUMBER] had a clogged toilet. Resident room [ROOM NUMBER] had a strong urine odor. There was brown liquid between the beds which had a strong urine smell and seeped between the floor tiles when pressure was applied to the floor. Resident room [ROOM NUMBER] had four meal trays full of plates, food, drinks and utensils on the floor of the room, along with cigarette butts, food crumbs and soiled clothing. The bathroom sink had black spots. There was a strong smell of urine, body odor and smoked cigarettes in the room. On 9/9/25 at 9:30 a.m. and again at 2:30 p.m. the following was observed: Resident rooms #215, #218 and #219 were missing soap, towels and paper towels in their bathrooms. The hand sanitizer dispensers were additionally empty in each room. On 9/9/25 at 9:30 a.m. according to the residents in room [ROOM NUMBER], their toilet had been unclogged. -However, the toilet had been clogged since 9/6/25 (see resident interview below). On 9/9/25 at 11:45 a.m. the maintenance director (MTD) was observed in resident room [ROOM NUMBER] with a work cart and floor tiles. He removed seven tiles from the floor. On 9/9/25 at 11:52 a.m. housekeeper (HK) #2 was observed pouring blue liquid from an unlabeled bottle onto the floor in room [ROOM NUMBER] to try to cover the urine odor. HK #2 said the blue liquid was disinfectant. On 9/10/25 at 9:30 a.m. and again at 2:30 p.m. the following was observed: Resident rooms #215, #218, and #219 were missing soap, towels and paper towels in their bathrooms. The hand sanitizer dispensers were additionally empty in each room. On 9/10/25 at 2:30 p.m. the MTD had removed the remaining loose tiles from the floor in room [ROOM NUMBER], disinfected the floor and replaced the tiles. On 9/11/25 at 8:20 a.m. and at 2:15 p.m. the following was observed: Resident rooms #215, #218, and #219 were missing soap, towels and paper towels in their bathrooms. The hand sanitizer dispensers were additionally empty in each room. B. Resident interviews The two residents who resided in room [ROOM NUMBER] were interviewed together on 9/8/25 at 7:30 a.m. The residents said their bathroom rarely had soap or towels. They said they would tell the staff, but the soap and towels did not get replaced. They said they had notified nursing staff that the toilet had been clogged for the past two days (since 9/6/25) and nothing had been done about it. The residents said they did not know how the staff washed their hands if there was no soap in the bathrooms and the hand sanitizer dispenser in their room seemed to be always empty. The residents said their room was not cleaned everyday. The resident who resided in room [ROOM NUMBER] was interviewed on 9/9/25 at 1:30 p.m. She said she did not have soap or towels in her bathroom. She said she did not feel these items were replaced timely. C. Staff interviews The MTD was interviewed on 9/8/25 at 12:28 p.m. The MTD said he was not aware of the floor issue in room [ROOM NUMBER] until it was brought to his attention during the survey. He said the loose tiles and brown liquid could be from mopping the floors and the water settled in between the tiles and became rusty. He said the brown fluid could have been there for quite awhile. The MTD said the floor was an easy fix and he would replace the tiles. The MTD said the residents' rooms were cleaned daily with the floors being mopped, bathrooms cleaned and wiping down of surface areas. He said the rooms were scheduled for monthly deep cleans, which had a more in-depth cleaning checklist. The floor technician was interviewed on 9/9/25 at 11:52 a.m. The floor technician said the smell coming from the floor in resident room [ROOM NUMBER] was urine seeping from under the tiles. The NHA was interviewed on 9/10/25 at 1:00 p.m. The NHA said the liquid under the tiles was not rusted water but urine. She said the residents should have been moved out of the room until all the affected areas in the room were cleaned and treated. She said she would have them moved to complete the maintenance on the floor properly. HK #2 was interviewed on 9/11/25 at 9:30 a.m. She requested for another staff member, the social services assistance (SSA), to interpret because she read and spoke very little English. HK #2 said she did not have a cleaning checklist on her cart. She said there was a checklist for rooms that received a deep clean. She said the checklist was filled out after the shift. She said the checklists were kept in a binder in the MTD's office. HK #2 said the checklist and the cleaning bottles on her cart were written in English.

Based on observations, record review and interviews, the facility failed to ensure the environment was free of accidents and hazards for three (#48, #68 and #5) of four residents reviewed for accidents/hazards out of 39 sample residents. Specifically, the facility failed to: -Ensure Resident #48 and Resident #68 were re-assessed to determine if they were safe to smoke independently; -Ensure staff were consistently implementing the care planned fall interventions for Resident #5; and, -Ensure Resident #5's fall care plan was updated with all fall interventions.Findings include:I. Resident #48A. Resident statusResident #48, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included schizophrenia and a traumatic brain injury (TBI). The 6/4/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments and was unable to participate in the brief interview for mental status (BIMS) assessment. A staff assessment for mental status revealed the resident had short and long term memory impairments, disorganized thinking, difficulty with following what was said and he had moderate impairments to his daily decision-making skills.B. ObservationsOn 9/8/25 at 9:50 a.m. Resident #48 was propelling himself (in his wheelchair) in circles in the activity room. He was wearing a shirt with two cigarette burns on the lower part of his shirt closest to his waist. He continued to propel himself in and out of the activities room, while watching the designated smoking patio. At 10:04 a.m., he propelled himself outside to the smoking patio and picked up a still lit cigarette butt he found on the floor, and then used the lit butt to light other cigarette butts he found on the floor in the smoking patio. At 10:24 a.m., he found a partially smoked cigarette on the floor in the smoking patio, but could not find a lit butt so he started asking other residents for a lighter. On 9/8/25 at 1:31 p.m. Resident #48 was in the designated smoking patio picking up still lit cigarette butts he found on the floor, smoking the lit butt and using it to light other cigarette butts he found on the ground. The smoking patio was directly next to the activities room and could be observed from inside the activity room through the glass windows. Several staff members walked back and forth in the activities room and did not check on Resident #48. C. Record reviewResident #48's smoking care plan, revised 5/5/25, revealed the resident was an independent smoker and the staff held his cigarettes and lighter for him. Interventions included to monitor the resident for unsafe smoking practices and burn holes in his clothing and re-evaluate the resident on a quarterly and as needed basis (initiated 9/3/25). A review of Resident #48's electronic medical record (EMR) failed to reveal documentation to indicate the resident was being monitored for unsafe smoking behaviors for Resident #48.A smoking/vaping risk assessment, dated 8/19/25, revealed Resident #48 was identified as an independent smoker with supervision for impulsiveness.-Review of Resident #48's EMR revealed there was no updated smoking assessment to determine if the resident was safe to continue as an independent smoker after he was involved in a physical altercation with another resident while trying to smoke cigarette butts off the ground on 8/9/25.Cross reference F600 for failure to keep residents free from abuse.II. Resident #68A. Resident statusResident #68, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, diagnoses included diabetes. The 6/6/25 MDS assessment revealed the resident had mild cognitive impairments with a BIMS score of 12 out of 15. B. Resident observationsOn 9/8/25 at 9:56 a.m. Resident #68 was observed outside in the designated smoking patio sitting in a patio chair. When Resident #68 finished his cigarette, he dropped the lit cigarette on the ground and went back inside. On 9/8/25 at 1:34 p.m. Resident #68 was observed outside in the designated smoking patio sitting in a patio chair. When Resident #68 finished his cigarette, he flicked the lit ash on to the ground and then put out his cigarette butt on the arm of the metal chair he was sitting in. C. Record reviewResident #68's smoking care plan, revised 6/17/25, revealed the resident was an independent smoker. Interventions included to monitor the resident for unsafe smoking practices and burn holes in his clothing and re-evaluate the resident on a quarterly and as needed basis (revised 6/17/25). A review of Resident #68's EMR failed to reveal documentation to indicate the resident was being monitored for unsafe smoking behaviors.A smoking/vaping risk assessment, dated 9/2/25, revealed Resident #68 was identified as an independent smoker.III. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, diagnoses included metabolic encephalopathy, schizoaffective disorder, dementia, hallucinations and artificial right hip. The 7/26/25 MDS assessment revealed the resident had mild cognitive impairments with a BIMS score of 12 out of 15. The MDS assessment documented the resident had limited range of motion in his lower extremities, shortness of breath when lying down, used a walker and wheelchair for mobility, and required two person total assistance with toileting, bathing, putting on shoes, bed mobility and transfers. The MDS assessment indicated the resident had had two falls since the prior assessment. B. Resident observationsOn 9/8/25 at 10:02 a.m. Resident #5 was sleeping in his bed in his room without the bed in the lowest position. On 9/10/25 at 1:50 p.m. Resident #5 was lying in his bed in his room without the bed in the lowest position. C. Record reviewResident #5's fall care plan, revised 8/18/25, revealed the resident was at risk for falls related to a history of falls and impaired mobility. Interventions included ensuring his bed was in the low position while in bed (initiated 1/8/25), ensuring the resident was wearing appropriate footwear when mobilizing in his wheelchair (initiated 1/8/25), ensuring the call light was within reach (initiated 6/24/25), physical therapy evaluate and treat (initiated 6/24/25), reviewing information on past falls and attempting to determine the cause of falls (initiated 6/24/25), ensuring a floor mat was next to the left side of bed (initiated 7/4/25), keeping his bed in lowest position at all times when in bed (initiated 7/8/25) and ensuring the resident's personal items, including water, snacks and the call light were within reach (initiated 7/17/25). -The intervention of ensuring the resident's bed was in the lowest position was added to the care plan on 1/8/24 and was added again on 7/8/25.-There were no new interventions added to the care plan for the resident's falls on 8/11/25 or 8/22/25 (see falls below), and there was no documentation to indicate the care plan had been reviewed to determine if the interventions were effective or if new interventions were needed. A review of Resident #5's EMR from 7/4/25 to 9/9/25 revealed the following progress notes:A nursing note, dated 7/4/25, revealed Resident #5 was found on the floor in his room. He was lying on his left side with complaints of pain in his right shoulder. The resident told the staff he had been trying to reach an item from his bedside table and rolled out of his bed onto the floor. A fall mat was ordered. A risk management review note, dated 7/7/25, revealed the root cause analysis of the fall on 7/4/25 was confused, unsteady gait with an intervention of a fall mat on the left side of the resident's bed. A nursing note, dated 7/7/25, revealed Resident #5 reported he had rolled out of his bed when trying to reach for his bed control. He rolled onto the fall mat on his floor. A risk management review note, dated 7/8/25, revealed the root cause analysis of the fall on 7/7/25 was unsteady gait, weakness with an intervention of keeping the bed in the lowest position.A nursing note, dated 7/17/25, revealed a nurse and nursing student entered Resident #5's room to find the resident lying on his stomach on the fall mat. The resident's bed was in the lowest position. The resident reported he had rolled out of bed when he attempted to reach for his water pitcher. A nursing note, dated 8/9/25, revealed a certified nurse aide (CNA) reported that she found Resident #5 on the floor mat in his room. He told the CNA he had been reaching for a book and had slid out of his bed. The resident's bed had been in the lowest position.A risk management review note, dated 8/11/25, revealed the root cause analysis of the fall on 8/9/25 was balance impairments with an intervention of keeping the call light placed within reach, ensuring personal items were placed within reach and changing out the resident's air mattress with a pressure-reducing mattress.-However, the resident's care plan was not updated with the intervention of switching to a pressure-reducing mattress.A nursing note, dated 8/22/25, revealed the resident had activated the call light and was found lying on his floor. The fall mat was in place. -The note failed to indicate if the resident was found on the floor or on his fall mat on the floor, or if the bed had been in the lowest position. -There was no risk management review note documented for the falls on 8/11/25 on 8/22/25. A fall intervention implementation timeline was provided by the NHA on 9/11/25 at 11:12 a.m. The timeline revealed the following;On 6/24/25 the interventions to anticipate and meet Resident #5's needs, ensure his call light was within reach, review past falls to determine the root cause, educate the staff and resident on possible causes and respond promptly to requests for assistance were added to his EMR.On 7/4/25 the new intervention post 7/4/25 fall was to ensure a floor mat was next to the left side of Resident #5's bed.On 7/8/25, the new intervention post fall on 7/7/25 was to keep the resident's bed in the lowest position at all times when the resident was in bed.On 7/17/25 the new interventions post fall on 7/17/25 were to ensure the resident's personal items including water, snacks and call light were within reach.On 8/18/225 the new intervention post fall on 8/11/25 was frequent rounds.-However, the care plan was not updated with the frequent round intervention (see care plan above). -The timeline provided failed to reveal new interventions for the falls on 8/9/25 or 8/22/25 or documentation that the falls were reviewed to determine if new interventions were needed.IV. Staff interviewsLicensed practical nurse (LPN #1) was interviewed on 9/9/25 at 11:40 a.m. LPN #1 said Resident #48 and Resident #68 were both independent smokers and kept their own smoking materials. She said Resident #5 was a fall risk and the fall interventions for him were to use a fall mat when he was laying in bed. -LPN #1 did not indicate if the resident's bed should be in the lowest position when the resident was in bed (see observations and care plan above).CNA #2 was interviewed on 9/9/25 at 11:47 a.m. CNA #2 said Resident #48 was an independent smoker and kept his own cigarettes and lighter. She said he did not have any behaviors regarding smoking. CNA #2 said Resident #68 was an independent smoker and kept his own cigarettes and lighter. She said he did not have any behaviors regarding smoking. CNA #2 said the fall interventions for Resident #5 were to keep the fall mat on his floor and to keep his bed in the lowest position when he was lying in bed. CNA #2 said when the nurse managers puts new fall interventions into the resident's EMR, they communicated the new interventions to the staff verbally and she said she did not know where to find the fall interventions in Resident #5's EMR. The activities director (AD) was interviewed on 9/9/25 at 10:55 a.m. The AD said she kept the lighter that Resident #48 used and the nurses kept his cigarettes. She said throwing cigarettes on the ground instead of the ashtray was not an uncommon behavior for Resident #68. The AD said he was hard to redirect and had been educated on putting cigarettes in the ashtray. The regional clinical resource (RCR) was interviewed on 9/11/25 at 9:54 a.m. The RCR said the process post-fall was for a registered nurse (RN) to assess the resident. The RCR said the RN would attempt to determine the root cause of the fall and talk to the resident. She said the clinical interdisciplinary team (IDT) reviewed falls in the morning meeting and tried to determine the root cause of the falls and establish fall interventions. The RCR said the IDT would review the prior interventions, why those interventions were not effective and look at adding new interventions. She said staff were provided education on fall interventions and how to find the interventions in the resident's care plan.-However, CNA #2 said she did not know where to find fall intervention for residents (see interview above). The nursing home administrator (NHA) was interviewed on 9/11/25 at 12:11 p.m. The NHA said that after each fall, the IDT evaluated the root cause, interventions used, whether the interventions were effective or not and new interventions to try. The NHA said Resident #5's care plan should have been updated after the facility initiated new interventions and she acknowledged the care plan should have been updated after Resident #5's August 2025 falls and the staff should know where to find the interventions. The NHA said even residents who are independent smokers, should be periodically observed for safe smoking practices. She was unaware of Resident #48 and #68's smoking issues.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on three of four hallways.Specifically, the facility failed to:-Ensure enhanced barrier precautions (EBP) were followed during a transfer for Resident #49, who had an indwelling medical device (Foley catheter); -Ensure enhanced barrier precautions (EBP) were followed during resident care for Resident #47, who had an indwelling medical device (enteral feeding tube); and,-Ensure staff performed hand hygiene consistently during medication administration for Resident #31, Resident #14 and Resident #24.Findings include: I. Facility policy and procedure The Infection Control and Surveillance policy, July 2023, was provided by the nursing home administrator (NHA) on 9/8/25 at 1:53 p.m. It read in pertinent part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program is developed to address the facility-specific infection control needs, requirements identified in the facility assessment and the infection control risk assessment. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Important facets of infection prevention include: educating staff and ensuring that they adhere to proper techniques and procedures; instituting measures to avoid complications or dissemination; and educating staff and ensuring that they adhere to proper techniques and procedures. II. EBP failure during a transfer with Resident #49 A. Professional reference Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), April 2024, was retrieved on 9/15/25. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Standard precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. Examples of high-contact resident care activities requiring gown and glove use for Enhanced barrier precautions include: Dressing Bathing/showering, transferring, providing hygiene changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator wound care; or any skin opening requiring a dressing. B. Observations On 9/8/25 at 3:25 p.m. Resident #49 was observed lying in bed. Resident #49 had an indwelling catheter. Two unidentified staff members were in Resident #49's room. Certified nurse aide (CNA) #4 wheeled the shower table into Resident #49's room. One of the unidentified staff members, while wearing gloves, picked up Resident #49's Foley catheter bag and moved it from one side of the bed to the other, and then lifted the resident's right upper body and placed a mechanical lift sling underneath the resident's right side. CNA #4 and the other unidentified staff member each placed an offloading boot on Resident #49's lower legs. The unidentified staff member who placed the resident's offloading boot lifted the resident's left upper body while holding the resident's shoulder with one hand and the resident's waist with the other. CNA #4 moved the remaining half of the sling half of the sling underneath Resident #49's left side. CNA #4 placed a sheet between straps near Resident #49's legs, then placed the sling straps on the mechanical lift. The two unidentified staff members supported each of the resident's legs with their hands as the resident was lifted off the bed with the mechanical lift and then lowered onto the shower table. After the sling was disconnected from the mechanical lift, CNA #4 moved Resident #49's Foley catheter bag to the edge of the shower table. One of the unidentified staff members covered the resident with a blanket and then opened the resident's drawers to get toiletries while wearing the same gloves she wore to assist the resident during the transfer. Resident #49 was then taken to the shower room by the unidentified staff member who placed the resident's offloading boot. CNA #4 removed the sheets and blankets from Resident #49's bed. The maintenance director (MTD) entered Resident #49's room and wheeled the mechanical lift out of Resident #49's room. -CNA #4 and the two unidentified staff members did not don (put on) gowns while assisting Resident #49 with a transfer, or while providing care and changing the resident's sheets. The MTD did not sanitize his hands upon entering Resident #49's room. C. Staff interviews The regional clinical resource (RCR) and the NHA were interviewed together on 9/11/25 at 2:30 p.m. The RCR said when a resident was admitted to the facility and needed EBP, the facility would enter physician's orders for EBP into the resident's medical record. The RCR said when Resident #49 moved rooms, the facility did not move the EBP sign to her new room. The RCR said the nurses knew when to use EBP, but she would have to follow up with the CNAs and have to do more EBP education with the CNAs. The RCR said EBP use was on the facility's clinical audit and the facility reviewed all of the residents who should have EBP orders. The RCR said resident room moves were part of the facility's clinical audit. The RCR said if a resident developed a condition that warranted use of EBP after admission, that would be reviewed in the facility's daily meeting and the resident would have EBP orders updated. The RCR said EBP training was ongoing at the facility and was part of the staff competencies. The NHA said EBP training was part of the facility's skills clinic. III. EBP failure during resident care for Resident #47 A. Observations On 9/8/25 at 7:30 a.m. an EBP sign was observed posted on Resident #47's door. The sign read in pertinent part, Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care including feeding tubes. -Resident #47 had an enteral feeding tube, however, there were no EBP supplies observed inside or outside of the resident's room. There was a small plastic bin with gloves and trash bags observed three doors down from Resident #47's room. On 9/8/25 at 12:30 p.m. CNA #3 and an unidentified CNA entered Resident #47's room to provide personal hygiene care. -The CNAs did not perform hand hygiene prior to putting on gloves. -The CNAs did not wear gowns while providing care for Resident #47. On 9/8/25 at 2:25 p.m. CNA #3 and an unidentified CNA entered Resident #47's room to provide activities of daily living (ADL) care for the resident. The resident had requested to get dressed and get out of bed. -The CNAs did not perform hand hygiene prior to putting on gloves. -The CNAs did not wear gowns while they provided dressing assistance or when they transferred the resident using a mechanical lift into the wheelchair. On 9/9/25 at 5:50 p.m. two unidentified CNAs entered Resident #47's room to provide ADL care for the resident. -The CNAs transferred the resident to her bed using a mechanical lift, provided incontinence care and changed the resident's clothes without performing hand hygiene prior to putting on gloves. -The CNA did not wear gowns while providing care. On 9/10/25 at 10:49 a.m. CNA #1 entered Resident #47's room to provide incontinence care for the resident. -CNA #1 did not perform hand hygiene prior to putting on gloves -CNA #1 did not wear a gown while providing incontinence care. B. Resident interview Resident #47 said she was not aware that the staff were to wear gowns while providing her personal care or for transfers in and out of bed. She said the staff did wear gloves but they did not wear gowns. C. Staff interview Registered nurse (RN) #1 was interviewed on 9/11/25 at 1:00 p.m. RN #1 said that staff should be wearing gloves, gowns and sometimes a mask for residents who may have a feeding tube, wounds or a Foley catheter. She said signs were posted on the doors to notify staff of who required the extra PPE. RN #1 said PPE supplies were provided inside or outside of the resident's room for staff to put on when providing care. IV. Failure to ensure nursing staff performed hand hygiene during medication administration A. Facility policy and procedure The Hand Hygiene policy, undated, was provided by the NHA on 9/10/25 at 10:02 a.m. It read in pertinent part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The Medication Administration policy, dated 8/4/25, was provided by the NHA on 9/10/25 at 10:02 a.m. It read in pertinent part, Follow sanitary practices. Wash hands or use hand sanitizer prior to medication preparation for each medication pass. If direct resident contact is made, the nurse must wash hands. Use sanitary technique to place medications into a soufflé or medication cup. Do not touch oral medications, topical medications, ointments or creams with bare hands. Use safety syringes and needles for all injections. B. Observations and interviews During a continuous observation on 9/10/25, beginning at 9:22 a.m. and ending at approximately 9:30 a.m., registered nurse (RN) #2 was observed administering medications to residents on the first floor north unit. The following was observed: At 9:22 a.m., Resident #31 was sitting down on the seat of her four-wheeled walker near the medication cart. RN #2 performed hand hygiene. RN #2 grabbed a plastic cup from a stack of cups located on the left side of the medication cart. RN #2 poured water from a pitcher sitting on top of the medication cart into the plastic cup. RN #2 placed the cup of water on top of the medication cart, holding the cup from the sides. RN #2 grabbed a pair a gloves from a box located on top of the medication cart and donned them. -RN #2 did not perform hand hygiene prior to donning the gloves. A certified nurse aide (CNA) handed an electronic wrist blood pressure cuff to RN #2 from behind the nurses' station. RN #2 attached the blood pressure cuff to Resident #31's left wrist. After the resident's blood pressure reading was obtained, RN #2 removed the blood pressure cuff from Resident #31's wrist and placed it on top of the medication cart. RN #2 removed her gloves and threw them away. RN #2 grabbed the cup of water and the medication cup containing Resident #31's medications and handed them to the resident to take. RN #2 observed the resident take her medications and then performed hand hygiene at the medication cart. -RN #2 did not perform hand hygiene after she removed her gloves and before giving Resident #31 her medications and a cup of water. At 9:26 a.m., RN #2 said Resident #14 requested pain medication. The door to Resident #14's room was closed. RN #2 knocked on the door, opened it with her left hand, and stood in the doorway with her right hand resting on the inner doorframe. RN #2 assessed Resident #14's pain and said she would get his pain medication. RN #2 closed the door with her left hand and walked back to the medication cart. RN #2 unlocked the medication cart, grabbed a medication cup from the stack of cups located on the left of the medication cart and placed the medication cup on top of the cart. RN #2 unlocked and opened the narcotic medication drawer and removed the blister pack containing Resident #14's medication. RN #2 picked up the medication cup and popped one tablet from the blister pack into the medication cup. RN #2 placed the medication cup on top of the medication cart and returned the blister pack to the narcotic medication drawer. RN #2 picked up a pen, opened the narcotic medication log, and logged the medication. RN #2 grabbed a plastic cup from the left side of the medication cart and filled it with the water pitcher. RN #2 picked up the medication cup and the cup of water and walked to Resident #14's room. RN #2 held the medication cup and the cup of water by the bottom in her right hand and used her left hand to knock on and open Resident #14's room. RN #2 walked into Resident #14's room and handed him the medication cup and the cup of water. RN #2 observed Resident #14 take his medication and then exited the resident's room. -RN #2 did not perform hand hygiene after preparing medication and before walking into Resident #14's room and administering the medication to the resident. During a continuous observation on 9/10/25, beginning at 12:42 p.m. and ending at 12:50 p.m., licensed practical nurse (LPN) #3 was observed during medication administration. The following was observed: LPN #3 performed hand hygiene at the medication cart. She unlocked the medication cart and began preparing medications for Resident #24. LPN #3 obtained a medication cup from a stack of cups located on the left side of the medication cart. LPN #3 opened a bottle of medication and poured it into the medication cup. LPN #3 opened a medication drawer, obtained a resident labeled blister pack of medication, and popped one tablet into the medication cup. LPN #3 unlocked the narcotic medication drawer and obtained a resident labeled blister pack of medication. LPN #3 popped a half tablet of medication into the medication cup. LPN #3 closed the narcotic medication drawer and grabbed and opened the narcotic medication binder, on top of the medication cart and logged the medication. LPN #3 grabbed a water cup from a stack of cups located on the left side of the medication cart. LPN #3 poured water into the cup from a water pitcher sitting on top of the medication cart. LPN #3 picked up the cup of water and the medication cup containing Resident #24's medications and walked toward the resident's room. Upon entering Resident #24's room, LPN #3 handed him the medication cup and the cup of water. LPN #3 verified Resident #24 took his medication. LPN #3 threw the cup of water and the medication cup away and exited Resident #24's room. -LPN #3 did not perform hand hygiene during the preparation of Resident #24's medication, upon entering the resident's room or upon exiting the resident's room. C. Staff interviews RN #2 was interviewed on 9/10/25 at 9:31 a.m. RN #2 said hand hygiene should be performed before, during and after medication preparation. She said hand hygiene should also be performed before and after medications were administered to a resident. RN #2 said hand hygiene should be performed to decrease the risk of transmitting organisms and help reduce the risk of infection. LPN #3 was interviewed on 9/10/25 at 1:17 p.m. LPN #3 said hand hygiene should be performed before and after all resident care. LPN #3 said hand hygiene was important because it helped decrease the risk of infection. The RCR was interviewed on 9/11/25 at 2:30 p.m. The RCR said facility staff were supposed to perform hand hygiene when going in and out of a resident room and also between glove use. The RCR said proper hand hygiene was important to help prevent the transmission of organisms.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to:-Ensure the first floor north shower gurney pad was smooth, cleanable, in good repair, and cleaned according to manufacturing instructions; and, -Ensure the residents' shower rooms were maintained in a safe, sanitary and working conditions. Findings include: I. Failure to ensure the shower gurney pad was maintained and cleaned per instructions A. Facility policy and procedure The Manual Cleaning Shower Bed policy and procedure, undated, was provided by the nursing home administrator (NHA) on 9/10/25 at 10:02 a.m. It read in pertinent part, Usage recommendation: Recommended for showering people who are unable to stand or sit in a chair. Cleaning instructions: Clean cushion, pipe and fittings with in-house disinfectant after each use. Wipe down casters after each use. Avoid using solvent based or abrasive cleaners. B. Observations and interviews A continuous observation on 9/9/25, beginning at 12:22 p.m. and ending at 12:51 p.m., revealed the following: At 12:22 p.m. certified nurse aide (CNA) #5 wheeled the shower gurney out of room [ROOM NUMBER] and into the shower room located on the first floor north unit. The gurney had a blue pad made of foam on top of it. The headrest of the pad had approximately eight to ten cracks in it, exposing the material's inner foam. The body of the pad had approximately 20 to 25 cracks in it, exposing the material's inner foam. CNA #5 wheeled the shower gurney into an open shower located straight forward upon entering the shower room. At approximately 12:27 p.m. CNA #5 was interviewed. CNA #5 said the shower bed was cleaned using a cleansing spray located in the shower room. CNA #5 went to the cabinet and retrieved an unlabeled spray bottle that contained a yellow liquid. CNA #5 said she did not know what chemical the liquid was. CNA #5 said the fluid was mixed by housekeeping. CNA #5 said the shower gurney and pad should be cleansed between residents. CNA #5 said the shower gurney and pad should be sprayed with the yellow liquid. CNA #5 said the mixture should be left for three minutes and then rinsed off with warm water. CNA #5 said the inner exposed foam was kept dry by using a towel on top of the foam and underneath the resident. CNA #5 said she was going to clean the shower gurney and pad. CNA #5 donned gloves, she grabbed a blanket and one washcloth from the linen cart and placed them on top of the shower gurney pad. CNA #5 turned on the shower. CNA #5 wet the washcloth then pumped three pumps of Total Bath Skin and Hair Cleanser onto the washcloth. CNA #5 wiped the top of the shower gurney pad with the washcloth, including over all of the exposed cracks in the foam. CNA #5 rinsed the washcloth under the water and reapplied more of the cleanser. She then used the washcloth to wipe down the frame of the shower gurney. CNA #5 rinsed out the washcloth and placed it in the dirty linen. CNA #5 disconnected the shower head from the wall of the shower. At 12:32 p.m. CNA #5 grabbed the shower head from the wall. Used water from the shower head to rinse off the shower gurney and pad. CNA #5 sprayed water directly over spots in the pad where the exposed foam was located. Water was flowing into multiple open spots of the exposed inner foam padding. CNA #5 rinsed off the frame of the shower gurney and reconnected the shower head to the wall. At 12:34 p.m. CNA #5 turned the water off and used the blanket to wipe down the shower gurney pad and frame. At 12:36 p.m. CNA #5 retrieved the unlabeled spray bottle containing the unknown chemical and sprayed it onto the shower gurney pad and frame. At 12:39 p.m. CNA #5 said the chemical spray needed to sit for three minutes. CNA #5 left the shower room. At 12:42 p.m. CNA #5 returned to the shower room and donned a pair of gloves. Obtained a blanket from the linen cart. CNA #5 used the blanket to wipe down the shower gurney pad and frame. CNA #5 placed the blanket in a bag for dirty linen, removed her gloves and threw them away. At 12:45 p.m. CNA #5 said the shower gurney was ready for the next resident to use. CNA #5 said she should report any issues with resident care equipment to maintenance. CNA #5 said the potential risks associated with the wet, exposed inner foam of the shower pad included growth and spread of organisms. CNA #5 said she would report the shower issue to the maintenance director (MTD). At 12:51 p.m. CNA #5 spoke with the MTD. The MTD said he would look at the shower gurney pad. The MTD said the director of nursing (DON) was responsible for ordering the shower gurney pad. On 9/9/25 at 3:18 p.m. the shower gurney and pad were observed The shower gurney pad's inner foam was exposed. The exposed foam was wet to the touch and water trickled and pooled when pressure was applied to the pad. II. Failure to ensure the shower rooms were maintained in safe, sanitary, and working condition A. Observations On 9/7/25 at 7:28 a.m. during the initial walk through of the shower rooms, the following was observed: The second floor shower room, nearest to resident room [ROOM NUMBER], revealed the drain in the shower had an unsecure drain cover that did not stay in place over the hole in the shower floor, broken pieces of a body wash bottle were on the floor of the shower and an unlabeled spray bottle of yellow liquid in an unlocked cupboard. The second floor shower room, nearest to resident room [ROOM NUMBER], revealed four wet towels on the floor and one wet towel on the shower chair, an approximate 10 inches wide by 2 inches high section of wall with missing caulking on the baseboard and a black substance in the place of the missing caulking. The first floor tub and shower shower room, nearest to the business office, revealed the tub had a bin and broken plastic inside of it with an approximate six inches wide by eight inches long yellow and brown stain in the tub around the drain. On two of the four sides of the shower area, an unidentified grayish black discoloration in circular shapes that had spread up the wall approximately four inches high from the baseboard was observed and the shower head was dripping. On 9/9/25 at 11:35 a.m. the following was observed: The second floor shower room, nearest to resident room [ROOM NUMBER], revealed the drain in the shower has an unsecure drain cover that did not stay in place over the hole in the shower floor and an unlabeled spray bottle of yellow liquid in an unlocked cupboard. The second floor shower room, nearest to resident room [ROOM NUMBER], revealed an approximate 10 inches wide by two inches high section of wall with missing caulking on the baseboard and a black substance in the place of the missing caulking. The first floor combined tub and shower shower room nearest to the business office, revealed the tub had an approximate six inches wide by eight inches long yellow and brown stain in the tub around the drain. On two of the four sides of the shower area, an unidentified grayish black discoloration in circular shapes that had spread up the wall approximately four inches high from the baseboard was observed. The shower head was dripping and had a trash can underneath it to catch the water. B. Staff interviews Licensed practical nurse (LPN #1) was interviewed on 9/9/25 at 11:40 a.m. She said the housekeepers were to clean the shower rooms everyday and the certified nurse aides (CNA) were to clean the shower rooms after every resident. CNA #2 and CNA #3 were interviewed together on 9/9/25 at 11:47 a.m. Both CNA #2 and #3 said the housekeepers were to clean the shower rooms everyday and the CNAs were to clean the shower rooms after every resident. The MTD was interviewed on 9/10/25 at 12:09 p.m. He said he oversaw the maintenance and housekeeping departments. He said the reason the 2nd floor shower room (nearest to resident room [ROOM NUMBER]) had an unsecure drain cover so the staff could pull hair out of the drain. The MTD said the housekeepers were to clean the shower rooms everyday and the CNAs were to clean the shower rooms after every resident. He said he did do random, spot checks of the housekeepers work, however, he did not document those checks. The MTD also said there wasn't a written daily cleaning schedule for the housekeepers or a sign off of work completed, because he knows what they do and do not do. He said he did not have a work order for the dripping shower head, and could not explain why the CNAs and housekeepers had not advised him. The NHA was interviewed on 9/10/25 at 1:15 p.m. She said the broken drain cover should be replaced and if there was an issue with hair, a new drain cover that would collect hair should be installed. Housekeeper (HK) #1 was interviewed on 9/11/25 at 9:20 a.m. She said the black substance on the wall in the first floor shower room (nearest to the business office) was very old and she had tried to scrub it. HK #1 said it had faded some, but would not completely go away. She said she had worked at the facility for six months, and the substance on the wall had been there since she was hired. HK #1 said the shower head had always leaked since she was hired, and that was the reason the staff put a trash can under it to catch the water. The NHA and the regional maintenance director were interviewed together on 9/11/25 at 11:30 a.m. while touring the shower rooms. The NHA and the regional maintenance director could not identify the black substance on the wall in the first floor shower room (nearest to the business office) or the black substance in the second floor shower room (nearest to resident room [ROOM NUMBER]) in the place of the missing caulking. The regional maintenance director said the black substance in both shower rooms should have been inspected and tested for possible mold. The NHA said it was her expectation that a work order would be written for a leaking shower head to prevent water damage from prolonged dripping and that any suspicious black substance in the shower rooms would be tested for identification and treatment.

Based on record review and interviews, the facility failed to ensure two (#27 and #43) of six residents reviewed for abuse out of 39 sample residents were kept free from abuse. Specially, the facility failed to protect Resident #27 and Resident #43 from physical abuse by Resident #48.Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was received from the nursing home administrator (NHA) on 9/8/25 at 10:41 a.m. It read in pertinent part, If a resident experiences a behavior change resulting in aggression toward other residents, the community will implement interventions for protection of the alleged assailant and other residents. The facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization, can then be implemented. II. Incident of physical abuse of Resident #27 by Resident #48 on 8/9/25 A. Facility investigation The 8/9/25 facility investigation documented an unwitnessed physical altercation between Resident #48 and Resident #27. Another resident had thrown a partially smoked cigarette on the ground on the designated smoking patio. Resident #27 went to reach for it, and Resident #48 then pushed her and scratched her arm in order to retrieve the cigarette for himself. Resident #27 reported the incident to the nurse and contacted the police herself. The two residents were separated by staff and assessed for injuries and no injuries were noted. When interviewed by facility staff, Resident #27 denied feeling fearful. Resident #48 denied the incident occurred. Resident #27 and Resident #48 were both placed on 15-minute checks for 24 hours and the resident's responsible parties and the physician were notified. The investigation documented that the facility unsubstantiated abuse. -However, abuse occurred due to Resident #48 making willful physical contact with Resident #27. B. Resident #48 (assailant) 1. Resident status Resident #48, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included schizophrenia and a traumatic brain injury (TBI). The 6/4/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments and was unable to participate in the brief interview for mental status (BIMS) assessment. A staff assessment for mental status revealed the resident had short and long term memory impairments, disorganized thinking, difficulty with following what was said and he had moderate impairments to his daily decision-making skills. The MDS assessment indicated the resident had behaviors of physical and verbal aggression towards others, rejection of care and experienced delusions and hallucinations. 2. Record review Resident #48's trauma care plan, initiated 5/30/24, revealed the resident had a history of trauma, difficulty connecting and trusting others. His behaviors included being resistive to care and poor interpersonal skills. Interventions, initiated 5/30/24, included assessing his need for additional services and therapeutic support or specialists from the community, offering him referrals periodically and as needed, and providing consistent care providers whenever possible. Resident #48's behavior care plan, revised 2/24/25, revealed the resident had the potential to be physically aggressive related to a history of physical aggression towards others. Interventions, initiated 2/24/25, included administering medication as ordered, assessing the resident's needs, monitoring and documenting behaviors and interventions tried, intervening before agitation escalated, guiding the resident away from sources of distress, engaging the resident calmly in conversation and if the resident's responses were aggressive, staff was to walk calmly away and reapproach later. -The care plan failed to identify the episodes of physical aggression on 8/9/25 (with Resident #27 - see facility investigation above) and 8/19/25 (with Resident #43 - see facility investigation below) and the interventions implemented to prevent further abuse incidents. A review of Resident #48's electronic medical record (EMR), from 5/6/25 to 8/20/25, revealed the following; A behavior note, dated 5/6/25, revealed Resident #48 propelled himself (in his wheelchair) past another resident and attempted to strike the other resident. The two residents were separated without contact. A behavior note, dated 5/28/25, revealed Resident #48 had thrown his coffee in the face of the nurse, kicked, pulled hair, and punched the nurse. To resolve the incident, another staff member had to come and remove the resident. A behavior note, dated 7/2/25, revealed Resident #48 had attempted to swing at a staff member and the social worker was notified. A nurse progress note, dated 8/9/25, revealed Resident #48 was on 15-minute checks after an altercation with another resident (Resident #27). A behavior note dated, 8/10/25, revealed Resident #48 had a verbal altercation with another resident and was placed on 15-minute checks for observation. -A review of Resident #48's EMR failed to reveal the behavior interventions that were attempted for the resident's behaviors and what precipitating factors were analyzed to prevent recurrence. -A review of the resident's behavior progress notes from 8/9/25 failed to reveal specific documentation of the physical altercation Resident #48 was involved in with Resident #27. C. Resident #27 (victim) 1. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, diagnoses included chronic obstructive pulmonary disease. The 8/29/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment indicated the resident did not have any behaviors. 2. Record review Resident #27's behavior care plan, initiated 6/3/25, revealed the resident could be resistive or refuse personal care such as showers. Interventions, initiated 6/3/25, included praising the resident and allowing the resident to make decisions about her treatment. -Resident #27's care plan failed to address the incident with Resident #48 on 8/9/25. A review of Resident #27's EMR, from 8/1/25 to 8/9/25, revealed the following; A nursing progress note, dated 8/9/25, revealed Resident #27 had reported to the nurse that she was scratched on the arm by another resident (Resident #48). The two residents were on the designated smoking patio and Resident #48 pushed and scratched Resident #27 after trying to take a cigarette from her that she had picked up from the ground. III. Incident of physical abuse of Resident #43 by Resident #48 on 8/19/25 A. Facility investigation The 8/20/25 facility investigation documented that on 8/19/25, Resident #43 called Resident #48 names and was yelling at him. Resident #48 picked up a step stool and threw the stool at Resident #43 and caused a skin tear on Resident #43's eyebrow. Immediate interventions put in place by the facility included asking both residents to stay on their separate floors through the night, both residents were placed on 15-minute checks and the police were notified. Witness statements were taken and additional facility residents were interviewed. The investigation documented Resident #43 was an at-risk adult and had a history of behaviors with the potential to be verbally aggressive and use derogatory names and racial slurs related to poor impulse control. The resident was involved in a previous altercation. Resident #48 was documented as having a history of physical behaviors and refusals and the resident had a care plan for his behaviors. He had been involved in three other occurrences of physical aggression. The investigation documented Resident #43 was assessed by the director of nursing (DON) immediately after the incident and had a small cut above his left eyebrow. The cut was cleaned with a wound cleanser, pressure was applied and the bleeding stopped. The investigation interview with Resident #43 on 8/20/25 documented Resident #43 approached the NHA and stated look what that guy did to me. Resident #43 said, That guy threw a stool at me. Resident #43 stated he called Resident #48 an derogatory word. Resident #43 declined further attempts to discuss the incident on 8/21/25 and 8/22/25. Resident #48 was interviewed during the investigation on 8/20/25 and Resident #48 said he did not remember throwing a step stool, calling other residents names or getting in an argument. The investigation documented that the facility substantiated the allegation. B. Resident #48 (assailant) 1. Record review A behavior note, dated 8/20/25, revealed Resident #48 continued on 15- minute checks due to a reported altercation (with Resident #43). -A review of Resident #48's EMR failed to reveal the behavior interventions that were attempted for the resident's behaviors and what precipitating factors were analyzed to prevent recurrence. -A review of progress behavior notes, from 8/19/25 failed to reveal specific documentation related the physical altercation Resident #48 was involved in with Resident #43. C. Resident #43 (victim) 1. Resident status Resident #43, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included discitis (chronic infection of the spinal discs), chronic respiratory failure, end stage renal disease and dependence on dialysis. The 8/13/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. He was independent with activities of daily living (ADL). The assessment documented the resident did not have physical or verbal behaviors toward others. 2. Record review Resident #43's behavior care plan, revised 8/21/25, documented he had the potential to be verbally aggressive and use derogatory names and racial slurs due to poor impulse control. The resident was involved in a peer-to-peer altercation in which he verbally caused issues and the peer reacted with physical aggression. Pertinent interventions included to assess the resident's understanding of the situation; allow time for the resident to express himself and feelings towards the situation and provide positive feedback for good behavior; emphasize the positive aspects of compliance and when the resident became agitated, intervene before the agitation escalated, initiated 1/12/24 and educate the resident on healthy and appropriate interactions with peers, initiated 8/21/25. An 8/20/25 nursing note, documented at 6:03 a.m., revealed that Resident #43 sustained a small laceration above his left eyebrow, and the area was severely bruised. All parties were notified. An 8/20/25 nursing note, documented at 6:12 a.m., revealed that Resident #43 refused neurological signs and symptoms checks and refused to speak to police. An 8/21/25 nursing note, documented at 5:15 p.m., revealed that Resident #43 was being monitored following an altercation with another resident Resident #48). The resident was not cooperative for a full neurological assessment. The resident denied having pain. Bruising with a small laceration was noted to the resident's left eye brow area and a bandage in place was clean, dry and intact. No signs of infection were noted. IV. Staff interviews The NHA was interviewed on 9/11/25 at 12:00 p.m. The NHA said the facility's procedure after an incident of resident-to-resident physical abuse was to separate the residents, assess the residents for any physical or psychosocial harm and contact the NHA for notification and further direction. The NHA went over a timeline of what the facility had done for Resident #48 after the 8/9/25 incident with Resident #27. The NHA said the facility provided Resident #48 with education to not hit other residents and he was placed on 15-minute checks on 8/9/25. She said the physician's assistant reviewed Resident #48's medications on 8/10/25 with no changes made. She said the social services consultant reviewed Resident #48's EMR on 8/14/25 and recommended contacting the physician for psychoactive medication changes and initiating a positive incentive program for Resident #48. The NHA said Resident #48 was placed on 15-minute checks again on 8/19/25 (following the incident with Resident #43). She said the resident's medications were reviewed by the physician's assistant again on 8/20/25. The NHA said the social services consultant's recommendations on 8/14/25 (see above) were not put into place because she (the NHA) believed the social worker had followed up, but the NHA had not verified whether or not she had followed up on the recommendations. The NHA said she did not know why the residents' care plans had not been updated after the incidents. The NHA acknowledged, due to Resident #48's complex medical conditions (schizophrenia and a TBI), the facility should have followed the recommendations of the social services consultant on 8/14/25, as well as including a psychiatrist to review the resident's EMR for medication and behavior modification recommendations. She said the facility would get a referral for a psychiatrist to review Resident #48.

Based on record review and interviews, the facility failed to notify the state mental health agency promptly after a significant change in the resident's mental condition for one (#7) of four residents out of 39 sample residents. Specifically, the facility failed to notify the state mental health agency authority of Resident #7's necessity for inpatient psychiatric hospitalization.Findings include:I. Facility Policy and ProcedureThe Pre-admission Screen and Resident Review (PASRR) policy, dated 9/26/23, was provided by the nursing home administrator (NHA) on 9/11/25 at 9:15 a.m. It revealed in pertinent part, If a resident's psychiatric status changes after admission. The social services staff are responsible for contacting Omnibus Budget Reconciliation Act (OBRA - state mental health agency) coordinator via completion and submission of a PASRR level I screen and indicate the reason for referral as a change in mental health status or psychiatric diagnosis. Notification of changes are to be made within 10 business days of identifying the change. Status change Level I screens should be submitted in the following circumstances:-If there is a change in psychiatric diagnosis,-Significant deterioration in mental health condition; significant increase in psychiatric symptoms, or-Psychiatric hospitalization, regardless of whether there is a change in diagnosis or medication.II. Resident #7A. Resident statusResident #7, age [AGE], was admitted to the facility on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included schizoaffective disorder, demoralization and apathy, delusional disorder and unspecified mood.The 7/30/25 minimum date set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #7 was independent with all of his activities of daily living (ADL).B. Record reviewThe comprehensive care plan, initiated 3/18/22 and revised 8/15/22, revealed Resident #7 had a PASRR level II related to schizoaffective disorder, bipolar type and history of probable neurocognitive disorder due to traumatic brain injury (TBI) with past behavior disturbances. -On 9/10/25 (during survey) the resident's comprehensive care plan was updated to include a suicidal ideation care plan focus. The care plan documented the resident was at risk for feelings of hopelessness and suicidal ideation. Resident #7 had a history of making statements of wanting to die. Review of Resident #7's electronic medical record (EMR), from 6/9/25 through 9/7/25, revealed the following progress notes:A progress note, dated 6/10/25 at 6:46 a.m., documented Resident #7 walked to the nurses' station and started to smash computers to the floor. The nurse phoned 911 and the resident was handcuffed and escorted out. A progress note, dated 6/19/25 at 11:55 a.m., documented Resident #7 returned to the facility. A progress note, dated 6/23/25 at 3:59 p.m., documented Resident #7 had a follow up with his physician following a psychiatric hospital stay. A progress note, dated 6/26/25 at 6:25 p.m., documented Resident #7 was seen by the physician due to Resident #7 refusing to take his medications. A progress note, dated 6/27/25 at 5:50 p.m., documented the facility received a call from a hospital stating Resident #7 had been found intoxicated and taken to the emergency room by the police. Resident #7 was being admitted for psychosis. The note documented that the resident had signed himself out on an independent pass.A progress note, dated 7/28/25 at 8:23 p.m., documented Resident #7 was readmitted from a behavioral health transition of care hospital. A progress note, dated 7/29/25 at 9:30 a.m., documented Resident #7 was seen by his physician for readmission to the long-term care facility following a recent hospitalization with decompensation. Resident #7 was reported to have suicidal ideations with a plan. The resident returned with new medication orders for clozapine (an antipsychotic medication) and haloperidol (an antipsychotic medication).A progress note, dated 7/31/25 at 4:47 p.m., documented Resident #7 said he wanted to die. He denied having any plan to harm himself and frequent checks were initiated. -Review of Resident #7's EMR, from 6/9/25 through 9/7/25, revealed there was no social services documentation related to the resident's two psychiatric hospitalizations, the new psychotropic medications or the suicidal ideations. -Review of Resident #7's EMR revealed there was no documentation to indicate that the OBRA coordinator was notified of the resident's decline in behavior, medication changes and psychiatric hospitalizations. Resident #7's level II PASRR evaluation was dated 6/18/2020. Resident #7's Colorado PASRR level II Notice of Determination for Mental Illness was dated 6/24/2020.C. Staff interviewsThe social services director (SSD) and the social services consultant (SSC) were interviewed together on 9/10/25 at 1:27 p.m. The SSD said a status change PASRR level I should be submitted when there was a change in a resident's diagnosis or a significant change in the resident's mood or behavior. She said when a resident was decompensating, the facility should notify the mental health agency, the physician and update the resident's care plan of the changes.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%).Specifically, the facility had a medication error rate of 8%, or two errors out of 25 total opportunities for error.Findings include:I. Facility policy and procedureThe Medication Administration policy, dated 8/4/25, was provided by the nursing home administrator (NHA) on 9/10/25 at 10:02 a.m. It read in pertinent part, Resident medications are administered in an accurate, safe, timely, and sanitary manner. Verify the medication label against the medication administration record (MAR) for accuracy of drug frequency, duration, strength, and route. The nurse is responsible to read and follow precautionary or instructions on prescription labels. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved. Never administer medications from an unmarked container.II. ObservationsOn 9/10/25 at 9:08 a.m., registered nurse (RN) #2 was dispensing medications to Resident #31. RN #2 dispensed one tablet of Aspirin (blood thinner) 81 milligrams (mg) enteric coated (EC - a polymer barrier applied to oral medication that prevents it from dissolving in the highly acidic stomach environment) into a medication cup. RN #2 poured a cup of water and handed the water and medication cup to Resident #31. Resident #31 took the medication.On 9/10/25 at 9:08 a.m. RN #2 was dispensing medication to Resident #59. RN #2 dispensed one tablet of Paliperidone (antipsychotic) EC 6 mg into a medication cup. RN #2 poured a cup of water, walked into Resident #59's room and handed him the cup of medication and water. Resident #59 took the medication.III. Record reviewReview of Resident #31's September 2025 computerized physician orders (CPO) revealed the resident had a physician's order for Aspirin 81 mg chewable tablets.-However, RN #2 administered an enteric coated Aspirin to Resident #31 instead of chewable aspirin (see observation above). Review of Resident #59's September 2025 CPO revealed the resident had a physician's order for Paliperidone EC 6 mg tablet. Take 2 tablets in the afternoon. -However, RN #2 dispensed one tablet of Paliperidone to Resident #59 during the morning administration pass (see observation above).IV. Staff interviewsThe regional clinical resource (RCR) was interviewed on 9/11/25 at 2:30 p.m. The RCR said a lower dose of an administered medication could lessen the effect of the medication. The RCR confirmed Resident #59's order for Paliperidone was for two tablets instead of one tablet. The RCR said Resident #31's physician's order for Aspirin read chewable tablets, however, she said the resident did not need a chewable table.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication carts.Specifically, the facility failed to:-Ensure residents' medications were labeled and dated appropriately with the resident's name, the date the medication was opened and the expiration date, as applicable; and,-Ensure over-the-counter (OTC) medications stored in medication carts were not expired.Findings include:I. ObservationsOn [DATE] at 10:48 a.m. medication cart #1 on the first floor was observed with licensed practical nurse (LPN) #1. The following items were found:-There was an albuterol sulfate 90 microgram (mcg) inhaler stored in an appropriately labeled medication box; however, the inhaler inside the box was not labelled with the resident's name for Resident #2.-Resident #2's albuterol sulfate inhaler was labeled with a medication expiration date of [DATE].-There was a Breo ellipta 50/25 mcg inhaler stored in an appropriately labeled medication box; however, the inhaler inside the box was not labelled with the resident's name for Resident #31.-There was a [NAME] 160-4.5 mcg inhaler stored in an appropriately labeled medication box; however, the inhaler inside the box was not labelled with the resident's name, the date the medication was opened or the medication's date of expiration for Resident #52.On [DATE] at 11:15 a.m. the south medication cart on the second floor was observed with LPN #2. The following item was found:-There was a vitamin B-12 100 mcg tablet medication bottle with an expiration date of [DATE] in the OTC drawer of the medication cart.II. Staff interviewsLPN #1 was interviewed on [DATE] at 10:48 a.m. LPN #1 said the albuterol sulfate inhaler had expired after she noticed the expiration date when the medication was removed from the medication cart during the observation (see observations above). She said the medication should have been removed from medication cart #1 when it expired.LPN #2 was interviewed on [DATE] at 11:15 a.m. LPN #2 acknowledged the OTC medication on the south medication cart had expired. She said the expired medication did not belong in the medication cart.The regional clinical resource (RCR) was interviewed on [DATE] at 1:00 p.m. The RCR said the typical process for medication labelling was to label the individual medication bottles inside their respective medication boxes with the resident's name and the medication expiration date. She said she was not sure how to best label inhalers, as a Sharpie pen could rub off and the pharmacy would not want to open a medication box to apply a label to the medication bottle.

Based on record review and interviews, the facility failed to ensure residents received the required therapy services which were ordered by the physician for one (#74) of three residents reviewed for therapy services out of 39 sample residents. Specifically, the facility failed to ensure Resident #74 received specialized rehabilitative services as ordered on admission to the facility, to maintain the resident's highest practicable level of physical, mental, functional and psycho-social well-being.Findings include:I. Professional referenceAccording to [NAME], D (2023) Tips for a Comprehensive Post-admission Medical Record Review, retrieved on on 9/18/25 from: https://www.aapacn.org/article/tips-for-a-comprehensive-post-admission-medical-record-review American Association of Post-Acute Care Nursing, Omissions and inaccuracies in the medical record can hinder resident quality of care. Omitting or incorrectly transcribing medications or treatments can lead to adverse outcomes due to incorrect dosage, missed medications or skipped treatments. II. Resident #74A. Resident statusResident, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included traumatic subarachnoid hemorrhage (brain bleed) with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter, nondisplaced fracture of navicular (bone in the foot) of left foot, subsequent encounter for fracture with routine healing, nondisplaced fracture of medial malleolus (bony bump on the inner side of the ankle) of left tibia (shinbone), subsequent encounter for closed fracture with routine healing, displaced fracture of neck and right talus (ankle bone), subsequent encounter for fracture with routine healing, other fracture of upper and lower end of right fibula (calf bone) , subsequent encourager for closed fracture with routine healing, nondisplaced fracture of cuboid bone (bone outer side of foot) of left foot, subsequent encounter for fracture with routine healing, nondisplaced fracture of anterior process of left calcaneus (heel bone), subsequent encounter for fracture with routine healing and unspecified multiple injuries, subsequent encounter. The 9/8/25 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The functional ability portion of the MDS assessment was still in progress at the time of the survey. According to the resident's activities of daily living (ADL) care plan (see record review below), the resident required staff assistance for ADLs and had limited physical mobility.B. Resident interviewResident #74 was interviewed on 9/8/25 at 10:00 a.m. Resident #74 said she was admitted to the facility in order to continue therapy services, but she said she had not been seen by a physical therapist (PT), an occupational therapist (OT) or a speech therapist (ST) yet. She said when she was discharged from the rehabilitation hospital, she was told she would continue her therapy at the facility. Resident #74 said she had been working with a walker at the previous facility but had not yet received a walker at this facility and she had been limited to the wheelchair. Resident #74 said she had asked different staff members about the therapy services but she had not received an answer from anyone.C. Record reviewResident #74's admission physician's orders, dated 8/22/25, revealed the resident was to be discharged to a long-term care facility (LTC) for PT, OT and ST.-Review of Resident #74's September 2025 CPO revealed there were no referral physician's orders for PT, OT or ST to evaluate and treat the resident. Review of the activities of daily living (ADL) functional abilities care plan, initiated 9/8/25 and revised 9/9/25, revealed Resident #74 required assistance with bed mobility, dressing and transfers. Review of the mobility care plan, initiated 9/9/25 (during the survey), documented Resident #74 had limited physical mobility related to recent polytrauma (multiple injuries at once) resulting in multiple fractures. Pertinent interventions included providing supportive care, assistance with mobility as needed, PT, OT referrals as ordered and PRN (as needed).III. Staff interviewsThe regional clinical resource (RCR) was interviewed on 9/10/25 at 12:45 p.m. The RCR said the admitting nurse input and reconciled the physician's orders in the resident's electronic medical record (EMR). The RCR said she was not aware Resident #74 did not have physician's orders for therapy to evaluate and treat. She said the orders were missed being input into the resident's EMR by the admitting nurse on 9/3/25. IV. Facility follow upOn 9/10/25 Resident #74's September 2025 CPO revealed a physician's order for PT, OT, ST evaluation and treatment, ordered 9/10/25 (during the survey). -However, the physician's order was not entered into the resident's EMR until seven days after Resident #74's admission to the facility on 9/3/25.

Based on observations and interviews, the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation for two out of four shower rooms. Specifically, the facility failed to ensure ventilation fan covers were kept clean and operational in the resident shower rooms. Findings include:A. Professional referenceAccording to the U.S. Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021 retrieved on 9/19/25 from: https://docs.nrel.gov/docs/fy21osti/79150.pdf., Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and wellbeing of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety and quality of life for their residents. B. Observations On 9/7/25 at 7:28 a.m. during the initial walk through of the shower rooms, the following was observed:The first floor tub and shower room, nearest to the business office, revealed there was no air flow coming from the ventilation fan in the shower room. The ventilation fan wall cover was covered with a thick layer of what resembled gray dust. The first floor shower room, nearest to resident room [ROOM NUMBER], revealed there was no air flow coming from the ventilation fan in the shower room.On 9/9/25 at 11:35 a.m. the following was observed:The first floor tub and shower room, nearest to the business office, revealed there was no air flow coming from the ventilation fan in the shower room. The ventilation fan wall cover was covered with a thick layer of what resembled gray dust. The first floor shower room, nearest to resident room [ROOM NUMBER], revealed there was no air flow coming from the ventilation fan in the shower room.C. Staff interviewsThe regional maintenance director was interviewed on 9/11/25 at 11:30 a.m. while touring the shower rooms. The regional maintenance director said the facility used a mechanical ventilation system. He said the ventilation system prevented condensation risks by pulling moisture laden air out of the room. The regional maintenance director said if a ventilation system was not operational in a humid environment, it could contribute to the growth of mold. He said to ensure the ventilation system was working properly in the rooms and shower rooms, a piece of paper could be put up to the vent and if there was proper air flow, the paper would be pulled to the vent. The regional maintenance director said the ventilation fan and cover should be cleaned every six months. After inspecting the first floor tub and shower room ventilation cover, the regional maintenance director acknowledged there was not any air flow and the ventilation cover had not been cleaned within the last six months. After inspecting the first floor shower room ventilation cover, the regional maintenance director acknowledged there was not any air flow.

Based on record review and interviews, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care were delivered by individuals who have the skills, experience and knowledge to do a particular task or activity for four (#2, #4, #6 and #7) of seven residents out of 11 sample residents. Specifically, the facility failed to: -Ensure Resident #2, Resident #5, Resident #6 and Resident #7's post fall assessments were completed timely by a qualified person and documented in the residents medical record. Findings include: I. Facility policy and procedure The Fall Management policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/24/25 at 4:00 p.m. It read in pertinent part, All fall risk evaluation will be completed within the first 24 hours of admission and a baseline care plan will be initiated for residents to be at risk. If a resident experiences a fall with a head injury, the fall is unwitnessed, or the resident self-reports a fall, neurological checks will be initiated. The facility will review all falls daily during the morning QAPI meeting. Falls review will include the following: review the risk management incident to ensure complete and appropriate parties have been notified regarding the incident, review the interdisciplinary team (IDT) risk management to ensure complete and appropriate interventions have been implemented, review that a care plan has been initiated, and provided revisions to the plan of care as necessary after falls. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included hepatic encephalopathy (brain dysfunction resulting from liver disease), left arm fracture, schizophrenia (mental disorder), type 1 diabetes mellitus, chronic obstructive pulmonary disease (COPD), cirrhosis of the liver (build up of scar tissue on the liver) and alcohol abuse. The 5/25/25 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required staff supervision for showering including tub/shower transferring and was independent with all other activities of daily living (ADL). B. Record review A 5/30/25 nursing progress note documented at 8:19 p.m. revealed Resident #2 reported to licensed practical nurse (LPN) #1 that he had an unwitnessed fall. The note documented Resident #2 was assessed by LPN #1 to have sustained an abrasion to the right eye and the right hand above the 2nd and 3rd fingers. The resident's neurological status was intact. -A review of Resident #2's electronic medical record (EMR) did not reveal documentation of Resident #2 being assessed by a registered nurse (RN). III. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included encephalopathy , aphasia (language disorder affecting the ability to communicate), schizophrenia, anoxic brain damage (oxygen deprivation), acute respiratory failure and category three blindness (severe vision impairment). The 6/8/25 MDS assessment indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was dependent on staff for assistance with all ADL. B. Record review The 5/2/25 fall investigation documented LPN #2 heard Resident #5's wife calling for help. Upon observation, the resident was on the floor between the toilet and the wall. The resident attempted to self transfer from the wheelchair to the toilet and fell. The 5/5/25 (three days after the fall) nursing progress note documented by the director of nursing (DON) revealed was noted on the floor in the bathroom and attempted to transfer himself. Resident #5 was assessed for injuries and range of motion was within normal limits. IV. Resident #6 A. Resident status Resident #6, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included multiple sclerosis, chronic obstructive pulmonary disease, schizophrenia, and history of falling. The 4/13/25 MDS assessment indicated the resident was severely cognitively impaired with a BIMS score of 6 out of 15. The resident required moderate staff assistance with bathing, supervision with hygiene and was independent with all other ADL. B. Record review A review of Resident #6's fall investigation and nursing progress notes documented by an LPN on 3/17/25 that Resident #6's roommate pressed the call button. A certified nurse aide (CNA) found the resident sitting on the floor. The resident was alert and oriented and not in distress with stable vital signs. The resident stated she fell asleep while using the bathroom and woke up on the floor. The resident was assessed by an LPN with no abnormal findings, vital signs were stable and the resident was assisted back to bed. Neurological checks were initiated. -A review of Resident #6's EMR and fall investigation did not reveal documentation of Resident #6 being assessed by a RN. V. Resident #7 A. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included neurofibromatosis (tumor growth on nerve tissues), malignant neoplasm (tumor) of the spinal cord, muscle weakness, need for assistance with personal care and cognitive communication deficit. The 4/17/25 MDS assessment indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The resident needed moderate staff assistance for bathing, set up for eating and moderate staff assistance for all other ADL. B. Record review The 5/2/25 fall investigation review documented it was reported to a LPN at approximately 2:00 p.m. that the resident slipped off the toilet. When the nurse arrived at the resident's bathroom the resident was already sitting up on the toilet seat. The resident was attempting to shift his weight while he was with an occupational therapist. The investigation documented the LPN assessed the resident for pain and vital signs, and notified the DON and physician. -A review of Resident #7's EMR did not reveal documentation of Resident #5 being assessed by a RN. A 6/23/25 progress note (written during the survey) by RN #1 documented she was notified on 3/19/25 at approximately 2:00 p.m. that this resident had a witnessed fall. The resident was assessed and no injuries were noted, the resident denied pain or hitting his head. The resident's vital signs were within normal limits. The DON and physician were notified of the resident's fall. VI. Staff interviews The quality mentor was interviewed on 6/24/25 at 9:30 a.m. The quality mentor said RN #1 received a report on 5/30/25 from the nurse on duty that Resident #2 had an unwitnessed fall. The quality mentor said RN #1 assessed Resident #2 at 10:00 p.m. when she arrived at the facility for the start of her shift. The quality mentor said RN #1's assessment did not result in different findings than LPN #1's (see above) so RN #1 did not document her assessment. The quality mentor said she provided education to RN #1 that when she assessed a resident the assessment should be documented in the resident's EMR. The quality mentor said RN #1 also failed to document her assessment for Resident #6 and Resident #7's fall because her assessments resulted in the same findings as the LPN's initial assessment. The NHA, the DON and the quality mentor were interviewed together on 6/24/25 at 2:30 p.m. The DON said she assessed Resident #5 after his fall on 5/2/25 but did not document her assessment until 5/5/25. The DON said she completed the assessment and it was in her list of papers and she forgot to enter the assessment timely. The DON said she asked RN #1 to document the results of her assessment of Resident #7 in the resident's EMR during the survey. The NHA said if an RN was not in the facility to assess a resident then the staff should notify the DON. The quality mentor said RN #1 was documenting her assessments by exception. The quality mentor said because RN #1's assessments resulted in the same results, RN #1 chose not to document the assessment but had since been educated on the correct process (see below). VII. Facility follow up The resident assessment education, dated 6/23/25 (during the survey), was provided by the quality mentor on 6/24/25 at 9:30 a.m. The education documented it was provided to LPN #1, RN #1 and the DON on 6/23/25 by the quality mentor. The education documented that upon assessment of fall, a progress note should be written at the time of the fall to ensure that the assessment was documented in the medical record and findings were addressed as necessary. The LPN should also document in the progress notes that an RN completed the assessment. An action plan for falls, dated 6/23/25 (during the survey), was provided by the quality mentor on 6/24/25 at 2:30 p.m. The action plan documented on 6/23/25 it was identified the fall system was not being properly carried out and complete re-education by the DON or other designee with licensed nursing staff would be completed. The education included that anytime a resident fell a post fall assessment was completed by the RN, the LPN should document that the RN completed the assessment and the RN should document the findings in the medical record.

Based on observations and interviews the facility failed to provide a safe, clean, sanitary and comfortable homelike environment throughout the facility in three out of four hallways. Specifically the facility failed to: -Ensure resident rooms were clean and odor free; -Ensure the residents had clean bed linens and privacy curtains; -Ensure the dining room and common areas were clean; and, -Ensure the facility was free from institutional odors. Findings include: I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 6/4/25 at 12:24 p.m. The policy read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included a clean, sanitary and orderly environment, clean bed and bath linens that are in good condition, and pleasant, neutral scents. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics included institutional odors. II. Observations Observations of the facility's second floor were conducted on 6/3/25 between 8:47 a.m. to 11:30 a.m. The following was observed: The second floor hallways had a strong smell of urine, cigarettes and body odor. The second floor dining room had food, cigarette butts and a hair tie filled with hair on the floor. The heating unit covers had cigarette butts, dirt and clumps of dust underneath. The window blinds were covered in dust and dirt with pieces broken off. The tables had dried paint splatter and food stains. The second floor dining room was observed again on 6/3/25 at 11:30 a.m., during lunch. The floor had not been cleaned and there were no tablecloths placed on the stained table. The second floor common area's heating unit was covered with dirt and dust, there were clumps of dust and dirt underneath the heating unit and the vending machines. The common area smelt of urine and cigarettes. Resident room [ROOM NUMBER] had broken blinds on the floor underneath the window, which left the window with no privacy covering to the front of the facility. The resident who resided in that room said the blind had been off for a week. Resident rooms #218 and #221 had broken closet doors. room [ROOM NUMBER]'s closet door was off the track and room [ROOM NUMBER]'s had missing closet hardware. Resident rooms #218, #219 and #221's privacy curtains had yellow and brown stains. Resident rooms #211, #219, #221 and #205 had a strong smell of urine and body odor. Resident room [ROOM NUMBER]'s toilet lid was broken off and placed near the toilet. The overhead light covering had dark yellow stains. Observations made of the facility's first floor were conducted on 6/3/25 at 1:30 p.m. The following was observed: Resident rooms #109 and #111 had brown stained sheets. The blanket on the made bed had brown color stains. Both rooms had a urine odor. Resident room [ROOM NUMBER] had a brown colored, dried sticky substance on the bathroom floor. There was a brown stain around the toilet floor. The window curtains had broken hooks and were partly hanging off the curtain rod. Resident room [ROOM NUMBER] had a urinal that was three quarters full of urine that was left on the bedside table. The urinal did not have a lid and was stained a dark yellow color and the outside of the urinal was soiled. An observation on 6/4/25 at 10:00 a.m. revealed the following: The second floor had food on the floor. The dirt and clumps of dust under the heating unit was still there. The hair tie and cigarette butts remained under the heating unit along the wall. The tables had no coverings and were stained with paint and food. The second floor had a smell of urine and body odor. III. Resident interviews The resident who resided in room [ROOM NUMBER] was interviewed on 6/3/25 11:30 a.m. He said the blinds had been broken off for at least a week. The resident said he told a staff member about the blinds, but did not remember who he told. The resident who resided in room [ROOM NUMBER] was interviewed on 6/3/25 at 11:15 a.m. The resident said her room was not cleaned daily. She said she had many personal items but she expected the bathroom to be cleaned everyday. She said if the bathroom was not cleaned, she cleaned it herself. The resident said she had to keep her door closed because the odor from the hallway had been so bad. IV. Staff interviews Housekeeper (HK) #1 was interviewed on 6/3/25 at 9:44 a.m. HK #1 said she cleaned the rooms daily. She said when completing a daily clean of a resident's room, she dusted, swept and mopped the floor, dusted around a resident's personal items, cleaned the bathrooms and took out the trash. She said the maintenance director (MTD) would tell her when a room needed a deep clean. She said if a resident had too many personal items or refused to have the room cleaned she would report it to her supervisor. HK #1 said she did not know how often the privacy curtains were cleaned. The NHA and the MTD interviewed together on 6/3/25 at 1:17 p.m. The MTD said the residents' rooms needed to be cleaned everyday. The MTD said daily cleaning consisted of sweeping and mopping the floors, cleaning high-touch areas (light switches, door knobs), bathrooms and removing trash. The MTD said one room a day got deep cleaned, which included wiping down the walls, beds and mattresses along with the daily cleaning schedule. He said he was working with the residents on decluttering rooms and providing plastic bins to pack up belongings, especially food items. The MTD said the privacy curtains were washed when they were soiled and if a privacy curtain had stains it would be replaced. He said that each room was scheduled to be repaired and painted within the next several weeks. The NHA said if the bed linens or privacy curtains needed to be replaced, she would order new ones. Licensed practical nurse (LPN) #1 was interviewed on 6/4/24 at 10:50 a.m. LPN #1 said the residents'sheets were changed on the resident's shower days, which were twice a week. She said if a resident refused the shower the certified nurse aide (CNA) would still change the sheets. LPN #1 said if a resident refused to have the sheets changed, the nurse kept a log that documented refusals of showers and bedding changes. CNA #1 was interviewed 6/4/25 at 11:00 a.m. CNA #1 said the CNAs were responsible for making the residents' beds everyday. He said the CNAs changed the sheets on shower days, which was twice a week and as needed. CNA #1 said if the bedding looked stained or had holes he would replace the bedding.

Based on record review and interviews, the facility failed to notify the resident representative when there was a significant change in the resident's condition for two (#7 and #8) of three residents reviewed out of 12 sample residents. Specifically, for Resident #7 and Resident #8, the facility failed to: -Keep the resident's current designated representative's name and contact information updated in the resident's record; and, -Make additional attempts or try alternative methods to contact the representative when the representative was not reachable. Findings include: I. Facility policy and procedure The Change of Condition policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/4/25 at 12:24 p.m. It read in pertinent part, The resident, attending physician and legal representative or interested family member are notified when changes in condition or certain events occur. Communication with the IDT (interdisciplinary team) and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status (a deterioration in health, mental, or psychosocial status in either life - threatening conditions or clinical or a decision to transfer or discharge the resident from the facility. II. Resident #7 A. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), atrial fibrillation (abnormal heartbeat), chronic respiratory failure, depression and type 2 diabetes mellitus with diabetic neuropathy. According to the 4/17/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interview Resident #7 was interviewed on 6/3/25 at 10:30 a.m. Resident #7 said the facility failed to notify his representative when he was sent out to the hospital and his representative had been worried when he was not able to contact him at the facility. He said it made him very upset that his representative did not know his whereabouts. Resident #7 said his representative only found out about his hospitalization when he called his representative to see if he was going to come to the hospital. Resident #7 said it was very important to him to have his representative involved in his care. He said he updated his representative`s phone number before the last two hospitalizations, so he was not sure why the facility was unable to notify his representative that he was hospitalized . Resident #7 did not remember who he informed about the change. He said he would inform the NHA to update his representative`s information when needed. C. Record review Resident #7`s clinical resident profile, in the electronic medical record (EMR), was reviewed on 6/3/25 at 12:15 p.m. with Resident #7. The phone number listed for the resident's representative was verified as the correct number by Resident #7. The Situation, Background, Appearance, Review and Notify (SBAR) communication form, dated 4/2/25, revealed that the facility made one attempt to call Resident #7`s representative and the alternative representative on that date (4/2/25). A progress note, dated 4/2/25, revealed licensed practical nurse ( LPN) #3 was not able to reach the resident's representatives and no message was left when the representatives were unreachable. -There was no documentation in Resident #7's EMR to indicate the facility attempted to notify the resident's representatives again after the initial attempt to notify them. III. Resident #8 A. Resident status Resident #8, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2025 CPO, diagnoses included chronic systolic heart failure, COPD, bipolar disorder and abnormalities of gait and mobility. According to the 4/28/25 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. B. Resident interview Resident #8 was interviewed on 6/3/25 at 1:30 p.m. She said the facility failed to notify her representative about her hospitalizations numerous times. She said her representative was only informed about her hospitalization when she came to visit her at the nursing home while she was hospitalized in April 2025. The contact information in the resident's EMR was reviewed with Resident #8 during the interview and she said the person listed on file as her representative was not correct. She said the person listed as her representative in the EMR had passed away last year and her EMR should have been updated to list her current representative contact. She said she did not know why her current representative's information was not on her clinical resident profile. She said the facility did not ask to verify her representative`s information during her stay or at any of her care conferences. She said she was unsure how to make sure the facility had up-to-date contact information for her representative`s phone number. C. Record review -Review of Resident #8`s current clinical profile information, reviewed on 6/3/25 at 1:30 p.m. with Resident #8, did not contain the correct name or contact information for the resident's current representative (see resident interview above). The SBAR communication form dated 4/21/25, revealed that Resident #8's representative was unreachable but there was no documentation of who the nurse attempted to contact. -However, the representative's information listed in Resident #8's EMR was for the resident's previous representative (see above). IV. Staff interview LPN #3 was interviewed on 6/3/25 at 11:40 a.m. LPN #3 said she would call the residents' representative`s number on the clinical resident profile when she needed to update them. She said she would attempt to call two to three times to reach the representative if she was not able to leave a voicemail. She said staff would request a call back without leaving a detailed message and would say whether the call was an emergency or not. She said there was no timeframe to reach the representative, but she said in the case of an emergency, staff would call right away. She said staff documented all calls in the progress notes. She said she would inform the director of nursing (DON) or the resident's physician about an unsuccessful representative notification. -However, there was no documentation to indicate LPN #3 attempted to contact Resident #7's representative more than one time (see record review above). LPN #3 was interviewed a second time on 6/4/25 at 7:45 a.m. LPN #3 said the nurses were able to update residents' representative contact information in the EMR. She said nurses could also forward the information to the social services department or the medical records department so the information could be corrected for other contact lists. She said she was unsure what to do if staff could not reach the resident's representative in an emergency situation, other than making a progress note. LPN #3 said she thought the DON would read progress notes daily and notice if there was an unsuccessful call to the resident's representative and take care of it. She said nurses were not able to send emails to the residents' representatives. The social services director (SSD) was interviewed on 6/4/25 at 10:30 a.m. The SSD said the facility used the hospital`s referral packet to obtain the residents' representative's contact information most of the time. She said residents were asked to verify information upon admission if they were able to verify the information. She said the facility would ask residents to verify current representative information during their care conferences. She said if the resident or the resident's representative needed to update the representative's contact information, they should notify the social services department, the medical record department or the nurses. The regional nurse consultant (RNC) was interviewed on 6/4/25 at 10:40 a.m. The RNC said there was no official procedure to update the residents' representative information. She said the nurses were able to update this information. She said nurses recorded all notifications to residents' representatives in the EMR progress notes. She said there were two ways the DON would be notified about an unsuccessful representative notification. She said the DON read all notes, including change of condition notes, each morning. She said the DON could also filter notes in the residents' EMRs for high risk notes or change of condition notes. She said it was the nurse`s responsibility to notify representatives about a hospitalization. The RNC said nurses should notify the DON if a representative's notification was unsuccessful. She said the facility expected nurses to reach out to the representatives a couple of times and record all attempts to call the representative in the progress notes. She said the facility should never rely on the hospital`s information. She said the facility should have a better system to keep representatives' information updated during the residents' stay at the facility. She said staff should indicate the representative`s name and number in the progress note. She said staff should attempt to reach the second emergency contact if needed. She said using email could be another way to notify representatives. She said the facility would educate the residents about how to update their representative`s contact information. The NHA was interviewed on 6/4/25 at 12:30 p.m. The NHA said nurses would document all resident representative notification attempts in the residents' progress notes. She said nurses would call the second contact if they could not reach the first representative. She said nurses would reach out to the facility`s management if no contact was able to be made with the representative. She said the facility updated the residents' representative information during quarterly care conference meetings. She said the facility should have updated Resident #3`s representative`s information once he returned from the hospital and all the previous attempts were unsuccessful. -However, there was no documentation to indicate the facility attempted to contact Resident #7's representative more than one time (see record review above). The NHA said she knew that Resident #8`s previous representative had passed away and said the resident's clinical resident profile should have been updated with the resident's current representative's name and contact information.

Based on record review and interviews, the facility failed to ensure three (#1, #2 and #5) of three residents reviewed for abuse out of 12 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #2 and Resident #5 were kept free from physical abuse from each other; and, -Ensure Resident #1 was kept free from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse policy and procedure, dated 5/3/23, was provided by the nursing home administrator (NHA) on 6/4/22 at 12:24 p.m. It revealed in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. If a resident experiences a behavior change resulting in aggression toward other residents, the facility will implement interventions for protection of the alleged assailant and other residents. The facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization, can then be implemented. Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Also, verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through use of technology. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. II. Incident of physical abuse between Resident #5 and Resident #2 on 4/20/25 A. Facility investigation The facility's abuse investigation, dated 4/20/25, documented that at 11:00 a.m. Resident #2 and Resident #5 were sitting outside on the second floor patio area. Resident #2 asked Resident #5 a question, and before Resident #5 could reply, Resident #2 punched Resident #5 in the face twice with a closed fist. Resident #12 witnessed the incident. Licensed practical nurse (LPN) #2 heard loud voices coming from the patio area. LPN #2 ran from the nurse's station to the patio and observed Resident #2 and Resident #5 arguing and in each other's faces. LPN #2 immediately got in the middle and separated the residents. Registered nurse (RN) #1 assessed Resident #5. Resident #5 said that his tooth was cracked. RN #1 assessed Resident #5 and found no dental injuries. RN #1 offered dental care but Resident #5 declined. LPN #2 completed an injury assessment on Resident #2 and observed an abrasion to Resident #2's forehead, however, the injury did not require more than first aid treatment. The investigation documented that Resident #2 had dementia with impaired cognitive function, resulting in poor impulse control and impaired thought processes. He had a history of behavioral issues, including refusal of medications and occasional verbal and physical aggression directed towards others. He exhibited impaired thought processes and was diagnosed with dementia. Resident #5 was interviewed by the social services director (SSD) on 4/20/25 at 11:30 a.m., following the incident. Resident #5 said that he was complaining about the food and Resident #2 responded by telling him, if you don't like it, there's the street. Resident #5 said he replied that he was capable of making his own decisions and then Resident #2 punched him in the face twice. Resident #5 said he stood up from his wheelchair and struck Resident #2 once in the face. Resident #5 said Resident #2 then made a comment accusing Resident #5 of faking his need for a wheelchair. Resident #2 was interviewed by the SSD on 4/20/25 at 11:40 a.m., following the incident. Resident #2 said that Resident #5 had been speaking negatively about the facility and staff, which upset him. Resident #2 said he told Resident #5 he could leave and then Resident #5 hit him. Resident #2 said he did not strike Resident #5. The investigation documented that Resident #12 provided a verbal witness statement. Resident #12 said he saw Resident #2 hit Resident #5 twice and Resident #5 hit Resident #2 back. Resident #12 said Resident #2 told Resident #5 There is the street and Resident #5 responded that he knew where the street was. The investigation documented the facility substantiated that the allegation of resident-to-resident physical abuse occurred. The interventions put into place after the incident for Resident #2 included 15-minute checks and increased notifications to the resident's family members, the NHA and the director of nursing (DON) if the resident refused medications. B. Resident #5 - victim and assailant 1. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included diabetes and a history of psychoactive substance use. The 4/23/25 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. He did not need assistance with the activities of daily living (ADL). The MDS assessment revealed the resident displayed verbal behavioral symptoms directed toward others. 2. Resident interview Resident #5 was interviewed on 6/3/25 at 1:25 p.m. Resident #5 said Resident #2 punched him twice because Resident #2 became upset when he spoke negatively about the facility. He said he felt it was wrong for Resident #2 to tell him to go on the street. He said he later apologized to Resident #2. Resident #5 said he did not hate Resident #2 and he felt safe at the facility. 3. Record review The behavioral care plan, initiated 4/29/25, documented Resident #5 could become loud or verbally aggressive when refusing care. It indicated the resident had mood and behavior challenges, including yelling or verbal aggression. Pertinent interventions included monitoring, documenting and reporting as needed for increased anger, agitation, or feeling threatened by others and consulting behavioral health as needed. The 4/20/25 nurse progress note revealed that Resident #5 was in a physical altercation with another resident and the altercation resulted in a cracked tooth. C. Resident #2 - assailant and victim 1. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included delusional disorders, alcohol dependence, restlessness and agitation. The 4/10/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required set-up assistance from one staff member to complete ADLs. The MDS assessment revealed the resident did not display physical behaviors directed towards others during the assessment period. 2. Resident interview Resident #2 was interviewed on 6/3/25 at 2:37 p.m. Resident #2 said he did not punch anyone because if he had, the police would have been notified and he would not still be at the facility. He said another resident called him a racial slur and although the comment upset him, he did not react. He said that if the incident had occurred on the street, it would have ended differently. 3. Record review The behavioral care plan, initiated 7/24/24 and revised 5/5/25, documented Resident #2 had a history of verbal and physical aggression toward others, with behaviors related to poor impulse control due to encephalopathy and a subdural hematoma. It indicated Resident #2 had impaired cognitive functioning and impaired thought processes related to dementia. Pertinent interventions included analyzing key times, places, circumstances and triggers that escalated his behavior; assessing his understanding of situations and allowing time for the resident to express himself and his feelings. The care plan documented that Resident #2 could become verbally aggressive when he perceived others as invading his space or when he felt disrespected. Staff were directed to intervene before agitation escalated, guide the resident away from the source of distress, and engage him calmly in conversation. If the resident responded aggressively, staff were instructed to walk away calmly and approach again later. His behavior was noted to de-escalate when he was given time alone. The 4/20/25 nurse progress note revealed that Resident #2 and Resident #5 argued with each other and that Resident #2 hit Resident #5. III. Incident of physical abuse between Resident #1 and Resident #2 on 4/28/25 A. Facility investigation The facility abuse investigation, dated 4/28/25, documented that at 7:30 a.m. Resident #1 made a derogatory racist comment to Resident #2 as Resident #2 was getting up from the table to leave the dining room. Resident #2 grabbed Resident #1's hair while passing by and pulled it. Certified nurse aide (CNA) #2 witnessed the incident and immediately intervened to remove Resident #2's hand from Resident #1's hair. Resident #9 witnessed the incident and provided a written witness statement. RN #1 attempted to assess Resident #1 for injury; however, Resident #1 refused assessment and no treatment was provided. The investigation documented Resident #1 had poor impulse control and the potential to become verbally aggressive, including the use of derogatory names and racial slurs directed towards other residents. Resident #2 was interviewed by the NHA on 4/29/25 regarding the incident that occurred on 4/28/25. Resident #2 initially denied doing anything. He then said, Maybe, but he is fine in reference to pulling Resident #1's hair. He continued by saying that everyone always said he did things he was not doing and added, Whatever, just get me out of this place. The NHA observed that Resident #2 became increasingly agitated and the interview was ended at that time. Resident #1 was interviewed by the NHA on 5/3/25 at 11:30 a.m. regarding the incident. Resident #1 initially refused to discuss the matter and said, it is done and over with. When the NHA brought up the resident's use of racial slurs directed towards Resident #2, Resident #1 admitted making the comment and said he would come up with something else to call Resident #2. Resident #1 was redirected and informed that further disruptive or disrespectful behavior could result in being removed from the dining room. Resident #1 responded dismissively and asked if the NHA was done talking to him. The investigation documented CNA #2 provided a written witness statement. CNA #2 said he observed Resident #2 holding onto Resident #1's hair so he grabbed Resident #2's hand to prevent him from pulling Resident #1's hair. The interventions put into place after the incident for Resident #2 included 15-minute checks, resident education on respect and appropriate peer interactions, encouraging both residents not to sit near each other and staff was educated on visual monitoring during mealtimes in the dining room. Interventions for Resident #1 included staff intervening before agitation escalated, guiding the resident away from the source of distress, engaging the resident in calm conversation, and, if the resident's response was aggressive, staff were to remain calm, walk away and approach later. The investigation concluded the abuse was substantiated. C. Resident #1 - victim 1. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the June 2025 CPO, diagnoses included encephalopathy (brain disorder) and acute kidney failure. The 5/13/25 MDS assessment revealed the resident had short-term memory impairment, per the staff assessment for mental status. He was independent with ADLs. The MDS assessment indicated the resident demonstrated rejection of care during the assessment look back period. 2. Record review The behavioral care plan, initiated 10/9/24 and revised 1/17/25, documented Resident #1 had poor impulse control and the potential to become verbally aggressive, including the use of derogatory names and racial slurs towards other residents. Pertinent interventions included intervening before agitation escalated, guiding the resident away from the source of distress, engaging calmly in conversation and walking away and approaching later if the resident responded aggressively. The 4/28/25 nurse progress note revealed that two CNAs witnessed Resident #2 grabbed Resident #1's hair in the dining room. Resident #1 refused to allow staff to assess his skin. D. Resident #2 - assailant The 4/29/25 nursing progress note revealed that Resident #2 informed the nurse that he had pulled another resident's hair. The resident said that Resident #1 called him a racial slur in the dining room and Resident #2 got up and pulled the resident's hair. -However, the care plan was not revised until 5/5/25, seven days after the 4/28/25 incident involving Resident #1. E. Resident #9 interview Resident #9 was interviewed on 6/3/25 at 4:02 p.m. Resident #9 said Resident #1 had called Resident #2 a racial slur and Resident #2 became upset and pulled Resident #1's hair. IV. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 6/3/25 at 4:26 p.m. CNA #2 said he had been in the dining room when the incident occurred between Resident #1 and Resident #2 on 4/28/25. CNA #2 said he had been the staff member who held Resident #2's hand to prevent him from pulling Resident #1's hair. He said that since the incident, staff had increased monitoring of the two residents and ensured they did not sit together. He said he redirected residents when he observed potential triggers and, if they attempted to sit at the same table, staff separated them or adjusted their dining times to prevent them from being in the dining room at the same time. CNA #2 said he was not working during the 4/20/25 incident involving Resident #5 and Resident #2 but he had heard about the incident from the management team. He said staff were expected to observe the residents closely and monitor for any signs of agitation to help ensure resident safety. CNA #3 was interviewed on 6/4/25 at 9:45 a.m. CNA #3 said she had worked at the facility for 17 years. She said she had heard about the altercation between Resident #1 and Resident #2 that occurred on 4/28/25 and said that Resident #2 got upset easily. She said that since the incident, a nurse had consistently been present in the dining room when Resident #1 and Resident #2 were there to ensure their safety. She said when she observed any altercations, she intervened and notified the nurse and then the NHA. She said Resident #2 tended to ignore CNAs but responded better when nurses were present. She said that since the incident in the dining room between Resident #1 and Resident #2, a nurse had always been present there to help prevent a recurrence. She said she was not working on 4/20/25, the day of the incident between Resident #2 and Resident #5 but she had heard about the incident from other staff. CNA #1 was interviewed on 6/4/25 at 10:04 a.m. CNA #1 said he had worked at the facility for one year and was familiar with Resident #2. He said Resident #2 became upset when others used racial slurs or violated his personal space. He said that when there was an altercation, he intervened, redirected the residents, and notified the nurse, the DON, and the NHA. He said that following the incident in the dining room when Resident #2 pulled Resident #1's hair, Resident #1 had been eating in his room for 30 days to avoid further altercations. The DON was interviewed on 6/4/25 at 12:30 p.m. The DON said staff completed crisis prevention intervention (CPI) training during onboarding and as needed. She said leadership discussed resident behaviors and related concerns during staff meetings. She said once she became aware of an incident, she separated the residents involved and placed the aggressor on 15-minute checks for 24 hours. She said the facility did not implement checks for the victim if no injury was observed, as frequent checks could agitate some residents. She said if the aggressor continued to escalate, staff implemented one-to-one supervision for the resident. The DON said Resident #2 was difficult to manage due to multiple diagnoses, refusals of medications and elevated blood sugars. She said staff notified her when a resident missed two consecutive doses of medication, especially if increased behavioral symptoms were observed. The DON said Resident #1 had previously been restricted from dining in the dining room for one week due to an altercation. She said Resident #1's behaviors tended to improve before escalating again, and despite staff efforts, the facility could not always prevent resident-to-resident altercations.

Based on record review, observations and interviews, the facility failed to ensure one (#64) of 35 residents sampled out of 40 total sample residents was provided the necessary care and services to attain or maintain his highest practicable physical and mental well-being. Specifically: The facility failed to take steps to manage resident #64's right lower leg pain, post tibia fracture with a halo [DEVICE], contributing to the resident experiencing indescribable pain, generally at a pain level of 8 out 10 (10 being the worst pain). Resident interview and record review confirmed the resident's pain was not re-evaluated, an order for [REDACTED]. On 3/14/17 at 5:18 p.m., the resident was observed in pain and failed to receive medication to relieve his reported pain until the next morning. The facility's failure to address the resident's pain on 3/14/17 and on other dates as revealed in the resident's record created a situation of immediate jeopardy for serious harm. The findings include: Cross reference F425: The facility failed to have medications ordered for resident #64 available to administer. The facility had identified staff was frequently unable to administer the resident's medications due to not having medications on hand; however, the facility had not found a resolution or temporary solution to meet the resident's need for the medications, the primary intervention in managing his pain prior to survey. I. Immediate Jeopardy (IJ) A. Findings Triggering Immediate Jeopardy Observation, record review, and interviews with staff, health professionals, and residents revealed the facility knew it frequently ran out of resident #64's pain medications and it had identified problems with ordering and obtaining narcotics from the facility's pharmacy. These problems were not corrected and contributed to resident #64 experiencing pain that could not be treated because his medication was unavailable. On 3/14/17 at 5:18 p.m. resident #64 was observed in the lobby of the facility. He stated he needed help and was in pain. He said he had not received his muscle relaxant for over a week and it made his muscle twitch and pull against the external halo in his right leg, causing extreme pain. The resident was diaphoretic and grimacing as he spoke. He pulled up his right pant leg, exposing a halo [DEVICE] (two metal rings surrounding his ankle and calf, held in place by screws going directly into his skin). -At 5:19 p.m. licensed practical nurse (LPN) #2, who was caring for the resident, was interviewed. He said the facility had been out of the resident's muscle relaxant for a couple of days. He said the physician had been contacted and staff was waiting on the physician to send a new script to the pharmacy. He said the resident's medication was available in the emergency kit (e-kit) and a fax had been sent to the pharmacy for an authorization from the pharmacy to take the medication from the e-kit. He said staff had sent the fax today around 11:00 a.m. He said he had not called the pharmacy to check if they had any issues with the request. -At 5:23 p.m. the pharmacy was contacted via phone by the surveyor and the representative checked all faxed orders from the facility for 3/14/17. The representative said she could not find a request to pull medication from the e-kit for resident #64. -At 5:35 p.m. the director of nursing (DON) was interviewed. She said she was not aware of resident #64 not having his muscle relaxant, but confirmed there were issues managing the resident's pain. He was taking [MEDICATION NAME] as needed (PRN) and the facility had issues running out of the medication. She called the physician and got an order for [REDACTED]. On 3/15/17 at 9:59 a.m. resident #64 was interviewed. He said he did not get his muscle relaxant ([MEDICATION NAME]) until this morning. He further stated he ran out of his pain pills every couple of days. He said, It (right leg) hurts before I (get) my meds. I am scared I'm not going to get my next dose. The resident started to cry and stated, I am terrified. -At 12:59 p.m., the DON was interviewed again. She said the resident seemed to be in constant pain from his right leg. She said he was on [MEDICATION NAME] 60 mg twice daily and had PRN [MEDICATION NAME] available which he was taking around the clock. She said the resident was getting the maximum amount of [MEDICATION NAME] ordered. -She said they had called the physician and spoken with the nurse practitioner (NP) and asked for the resident's medication to be scheduled; however, the NP had said he did not want to change the resident's medications, but to refer the resident to a pain clinic instead. For non-pharmacological interventions, she said she had scheduled for a massage therapist to come in for the residents. - She detailed the issues (medication/narcotic ordering and availability) the facility was having with the pharmacy regarding resident #64's medications and said the facility staff was to meet with the pharmacy to discuss possible resolution to these issues. However, the DON could not identify a process to ensure resident #64 had effective pain interventions, including medications available as ordered to address his pain. The facility's failures to manage the resident's severe pain, including taking steps to ensure his pain medication was available, created a situation of immediate jeopardy for serious harm. B. Imposition of Immediate Jeopardy On 3/15/17 at 2:39 p.m., the nursing home administrator (NHA) and DON, were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to manage the resident's severe pain, including taking steps to ensure his pain medication was available, created a situation of immediate jeopardy for serious harm. C. Facility Response and Removal of Immediate Jeopardy On 2/16/17 at 11:16 a.m., the facility submitted the following plan (draft #3) to remove the immediate jeopardy. The plan read in pertinent part: 3/15/17 1. Nurse managers completed audit of all residents for pain medication availability on 3/15/17. 2. DON/ADON (assistant director of nursing)/designee will provide education to nursing staff; medication availability, signing out PRN pain medication on the narcotic log and in the EMAR (electronic medication administration record), timely administering of prn pain medication when requested, followup (sic) on effectiveness and document for prn pain med use and education on what to do if not effective, such as non-pharm interventions, call MD (physician), reposition, etc. and communicate and document. (MAR documentation and Narcotic count system). Will be completed for each nurse prior to them working the cart. 3. DON putting plan in place to ensure meds are available; (checking, reordering, having at least 48 hours available), working with medical director and provider pharmacy. Provider pharmacy has given authorization for facility to have more than one card at a time for identified resident only. Backup pharmacy is (pharmacy named). When 5 day supply remaining is reached, the nurse will reorder from the pharmacy. Night nurse will be assigned to audit all prn pain medications to ensure that they are refilled with the same 5 day supply threshold. If meds are not delivered within 48 hours from reorder, the night nurse will contact the pharmacy and the audit tool will be provided to the DON/ADON/designee to follow up. 4. DON/ADON/designee will In-service nursing staff on steps to follow if medication is not available at time of a administration and documentation in the MAR; notify MD immediately, DON immediately, ADON if DON is not available, pharmacy immediately, medical director within 30 minutes if no response from primary MD. (DON will coordinate with pharmacy). Will be completed for each nurse prior to them working the cart. 5. Medical Director will be contacted if refills of narcotics are out and primary physician does not respond within 48 hours to obtain emergency supply. If the medical director is not available, contact DVP (division vice president) Clinical Services and/or Division Director of Pharmacy. 6. PT (physical therapy) evaluation completed on 3/15/17. OT (occupational therapy) evaluation will be completed 3/16/17. 7. Medical Director completed medication review of pain medications over the phone on 3/15/17 and will review in person on 3/17/17 for identified resident. Medical director made recommendations on 3/15/17 and they are being reviewed by the IDT (interdisciplinary team) and the attending physician. 8. DON/ADON/designee will audit the narcotic sheet and MAR indicated [REDACTED]. Any discrepancies will be investigated immediately and any suspected diversion will be reported to appropriate authorities, including the Health Department. 9. DON/ADON/designee will inservice the nursing staff regarding diversion to include what it is, and when and how to report. This will be completed prior to each nurse working the cart. 10. DON/ADON/designee will inservice the nursing staff on the process for the Ekit to include when to use and how to use. This will be completed prior to each nurse working the cart. 11. The DVP of Clinical Services inserviced the DON on diversion on 3/16/2017. 12. The facility will receive inservice training on diversion from the Health Department. This will be completed as soon as possible based on availability of the trainer. On 3/16/17 at 12:03 p.m. the DVP of Clinical Services was notified that the immediate jeopardy had been removed. However, based on observations, interviews, and record review, deficient practice remained at a G level (actual harm that is isolated). II. Facility Policies A facility policy titled 'Pain Management and dated 2012 noted in pertinent part: -Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan should include both pharmacological and non-pharmacological pain management interventions. RCS (resident care specialist) Assignment sheet/Care Kardex updated if appropriate. -The Licensed Nurse will implement a Medication Administration Record [REDACTED]. -The Licensed Nurse will communicate any new onset or change of resident pain or change in resident pain through the 24 Hour Report process. The IDT will discuss the new onset of pain or change in resident pain at the daily stand-up meeting and the IDT team conference. -The Pain Management Care Plan with interventions will be updated as indicated and discussed at the IDT stand up meetings, as needed. -The staff will implement the Care Plan, monitor the resident, and administer therapeutic interventions for pain if ordered. -The Licensed Nurse when administering scheduled or routine pain medications, will record the drug administration and the following information in the MAR: Pain level using the Wong-Baker FACES 0-10 rating scale, administration of the routine pain medication, effectiveness of the routine pain medication. -Note: Effectiveness of routinely scheduled pain medications may be documented on the back of the MAR indicated [REDACTED]. If the resident is case managed or receiving skilled services, the note can be written on the Nursing Daily Skilled Summary. -The Licensed Nurse, when administering PRN pain medications, will record the drug administration and the following on the MAR: Pain level using the Wong-Baker FACES 0-10 rating scale; Pharmacological interventions attempted; Non-pharmacological interventions attempted; follow-up observations post intervention to determine the effectiveness for PRN pain interventions. If resident is asleep or resting, document as an observation. -At any time through the process of Pain Management, the IDT may conduct an At-Risk Review Meeting on the resident, in conjunction with other risk areas reviewed. IDT referral to rehab as needed. -If areas for improvement are identified, the Pain Management Program will be reviewed and discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting. III. Professional References According to Potter and Perry, Fundamentals of Nursing, 8th ed., Elsevier, St. Louis Missouri, 2013, pp. 966-996: Attitudes of nurses and other health care providers affect pain management . (The nurse and other health care providers) must accept a patient's report of pain and act according to professional guidelines, standards, position statements, policies and procedures, and evidence based research findings. IV. Resident #64 A. Resident demographics Resident #64, age under 60 , was admitted on [DATE]. According to the 3/17 computerized physicians orders (CPO), the [DIAGNOSES REDACTED]. According to the most recent minimum data set (MDS) assessment dated [DATE], he was cognitively intact, scoring 15 out of 15 on a brief interview for mental status (BIMS). The MDS identified the resident as needing one person assistance for bed mobility, transfers, locomotion on and off the unit, toilet use and personal hygiene. He was on scheduled and PRN pain medications, but was not receiving non-pharmacological pain interventions. He scored his pain at 8 out of 10 with the 10 being the worst. His previous MDS dated [DATE] noted the same pain regimen and pain level score of 8 out of 10. A care plan, initiated 11/1/16 and revised on 11/14/16, noted the resident had acute/chronic pain related to trauma. Interventions included to administer pain medication prior to treatments and therapy, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness for pain interventions. Review of the March CPO revealed the resident was prescribed in pertinent part: -[MEDICATION NAME] (muscle relaxant) 5mg every eight hours as needed for muscle spasms (ordered 10/27/16) -[MEDICATION NAME] (anti-spasm medication) 4mg two times a day for pain. - [MEDICATION NAME] (opiate pain medication also known as [MEDICATION NAME]) ER (extended release) 60 mg one tablet two times a day for pain (ordered 10/28/17) -[MEDICATION NAME] 10 mg (a short acting opiate pain medication) one tab every four hours as need for pain 1-5, and two tabs every four hours as needed for pain 6-10. B. Resident interview On 3/14/17 at 5:18 p.m. resident #64 was observed in the lobby of the facility. He stated he needed help and was in pain. He said he had not received his muscle relaxant for over a week and it made his muscle twitch and pull against the external halo in his right leg, causing extreme pain. The resident was diaphoretic and grimacing as he spoke. He pulled up his right pant leg, exposing a halo [DEVICE] (two metal rings surrounding his ankle and calf, held in place by screws going directly into his skin). On 3/15/17 at 9:59 a.m. the resident was interviewed again. He said he was hit by a car while jogging and after surgery, one of the screws in his tibia became infected. He had to have a bone graft and the halo placed to help him heal. He said his goal was to have the halo removed the next month and start walking more. He said he was always in pain, but when he did not get his medications, the pain would become so bad it feels like it is coming apart, and I don't know how to make it stop. He said the facility had issues getting his medication and stated the facility runs out of his pain pills every couple of days. When he did not get his medication, he said the pain would be much worse, describing the pain as indescribable, it takes your spirit and soul and twists it. He said, It (right leg) hurts before I (get) my meds. I am scared I'm not going to get my next dose. The resident started to cry and stated, I am terrified. He said he could manage to have a conversation and function at a pain level of 4 or 3 (out of 10) when he received his medication; however, without the pain medication, the pain was a 10 (out of 10). He had asked the nursing staff if he could have his pain medication reviewed but he felt he did not get a response from the staff. The resident described a recent incident where he had requested pain medication, stating the nurse had poured the medication but then started talking to another person and told him he had to wait to receive the pain medication. He said he was already in pain and he said things to the nurse that were not acceptable. He said staff called the police who came and talked to him about being appropriate. After the police were gone, staff gave him his pain medication but did not address the issue of his having to wait for his pain medication. He said he had run out of his [MEDICATION NAME] 60 milligrams (mg) a couple of times and he ran out of [MEDICATION NAME] at least twice a week. He had never run out of his muscle relaxant until this week. The staff had talked to him about fixing the issue but nothing had improved. C. Record review 1. Pain evaluation An admission pain evaluation dated 10/27/16 noted the resident was not satisfied with his current level of pain and hurting. The pain management plan noted, schedule and PRN meds. Review of the record revealed the resident had not had a pain evaluation or change to his pain medication regimen since his admission to the facility. Likewise, there was no evidence the resident's pain management plan had been referred to the At Risk Committee for IDT review. 2. Nursing progress notes Review of the nursing notes from 11/19/16 to 3/14/17 confirmed the resident experienced pain and his pain medications were frequently not available at the facility. Specifically, the notes revealed in pertinent part: -11/19/16: At 1400 (2:00 p.m.) Pt (patient) called (emergency services) and was transported to (hospital emergency room ) for complain (sic) of right lower extremity pain. Pt has had scheduled pain meds as precribed, pt has [MEDICATION NAME] for breakthrough pain still needing script from the pharmacy. Pharmacy faxed for ER (emergency) authorizations to pull meds from the ER kit but pt refused to wait and called the ambulance and went to (hospital) and after evaluations from ER (emergency room ) pt was medicated for pain and sent back to the facility with a script to get the meds delivered form the pharmacy. This nurse faxed the script to the pharmacy pending delivery. Pt is sleeping at this time. -12/11/16: Res (resident) c/o (complained of) pain this morning, this nurse give (sic) [MEDICATION NAME] 20 mg PRN, scheduled 60mg [MEDICATION NAME] sulfate was not delivered from pharmacy, PT called (emergency services) and 2 (two) EMP's (emergency medical professionals) take him to (hospital) via ambulance at 1000 (10:00 a.m.) and back form hospital at 1315 (1:15 p.m.) via ambulance, per EMP's report pt treated emergency basis treatment pain medication in ER. -12/16/16: Pt is alert, able to make needs known. Pt was upset d/t (due to) pain meds were not delivered on time. Medicated for RLE (right lower extremity) pain with positive response. Orthopedic pins in place. Pt is resting comfortably in bed at present. -12/18/16: Pt is alert, able to make needs known, pleasant all day. Medicated for RLE pain with positive response. Orthopedic pins are in place. Poor appetite. Sleeps most of the day. Aroused easily. Pt is resting comfortably in bed at present. - 12/18/16 to 3/15/17 was void of progress notes. 3. Physician notes Review of the physician notes dated 11/30/16 revealed the resident had chronic pain due to trauma. The nurse practitioner (NP) noted to consider a pain clinic consult if the resident's pain remained unstable. 4. Medication Administration Record [REDACTED] Review of the MARs revealed the the resident rarely received the maximum daily dose of [MEDICATION NAME] PRN (as prescribed he would be able to get one tab every four hours as need for pain 1-5, and two tabs every four hours as needed for pain 6-10). MAR indicated [REDACTED] October from 10/27/16 (admission) to 11/1/16: -10/29/16 was the only day the resident received the maximum amount of pain medication prescribed. November: -The resident did not receive the maximum amount of [MEDICATION NAME] on any day of the month. The resident had four out of six doses of [MEDICATION NAME] one time, three out of six daily doses 12 times, two out of six possible doses eight days, one out of six doses six days, and no doses one day during the month. December: -The resident did not receive the maximum amount of [MEDICATION NAME] on any day of the month. He received three doses eight days, two doses eight days, one dose seven days, and no PRN [MEDICATION NAME] eight days. January: -The resident did not receive the maximum amount of [MEDICATION NAME] on any day of the month. He received five doses three days, four doses four days, three doses 12 days, two doses eight days, one dose two days and no doses two days. February: -The resident did not receive the maximum amount of [MEDICATION NAME] on any day of the month. He received five doses one day, four doses six days, three doses five days, two doses nine days, one dose five days, and no doses on two days. March (through 3/15/17 when immediate jeopardy situation was identified: -The resident did not receive the maximum amount of [MEDICATION NAME] on any day of the month. He received four doses four days, three doses three days, two doses three days, one dose two days and no doses two days. 5. Telephone orders Review of the telephone orders from admission to 3/23/17 (date of survey exit) revealed the following: -On 12/12/16 a telephone order was written to discontinue all pass privileges and to schedule a pain clinic consult for the resident. This was one day after the resident was noted to have called emergency services for pain control due to his pain medication not being available at the facility (see nursing note 12/11/16 above). Record review revealed no notes or follow-up documentation that the facility took steps to obtain a consult with a pain clinic as a result of the 12/12/16 telephone order. D. Actions taken during survey 3/14/17 and 3/15/17 On 3/14/17 a telephone order was written to schedule an appointment for the resident to be seen at the pain clinic due to complaints of inadequate pain control. A progress note dated 3/16/17 noted the resident was scheduled on 3/27/16 to see a specialist for a pain evaluation. A care plan initiated on 3/15/17 noted the resident had the potential to be verbally aggressive (yelling at staff, using racial slurs towards staff) related to pain. Interventions included to administer medications as ordered and observe for side effects and effectiveness; analyze key times, place, circumstances, triggers and what de-escalates the behavior and document, assess and anticipate the resident's needs; assess the resident's understanding of the situation, observe behaviors, and when the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation and if response is aggressive, staff is to walk calmly away and approach later. A nursing progress note written by the DON on 3/15/17 read: Resident is on PRN pain and anti-anxiety medications that he is taking routinely. Medications turn (sic) to run out quickly as pharmacy is supplying 1 (one) card at a time and receiving of refills turn to take a while. Issue were reported to our regional pharmacist and (pharmacy) representative, both visited the facility on 3/9/17 and promised to look into the situation and come up with a resolution. Issue was also discussed with Resident's healthcare provider for medication review. Orders were received on 3/14/17 to send him to a pain clinic. Resident is currently on the list for massage therapy. E. Staff interviews Interviews confirmed the unavailability of medications, revealed some questioning of the resident's reported pain, and a misunderstanding of the amount of medication resident #64 was receiving for pain. On 3/15/17 at 4:30 p.m. registered nurse (RN) #2 was interviewed. The nurse said if a resident requested a PRN pain medication and reported a level of pain, the resident had to be believed and the medication would be administered as ordered. The nurse confirmed the facility was having issues with medications being available for administration. On 3/14/17 at 5:19 p.m. LPN #2 confirmed the facility had an issue with medication availability. He was aware resident #64 did not have all medications prescribed available. He was aware the resident was requesting a muscle relaxant ([MEDICATION NAME]) He had not informed the DON that the medication was not available. On 3/15/17 at 12:59 p.m. the DON was interviewed regarding the incident with the police referenced by the resident (see resident interview above). She said the nurse had called her after the fact and said she had felt attacked by resident #64 and called the police because he was yelling at her. The DON could not identify any steps the nurse took to deescalate the situation or manage the resident's pain, except that after the police were gone the nurse administered the resident's pain medication. On 3/15/17 at 3:18 p.m. the NHA, DON and clinical consultant (CC) were interviewed. -The CC said she did not see the immediacy of the issue involving resident #64's pain management. Regarding the unavailability of his medications, the facility was working with the pharmacy to find a solution. However, she was not able to describe how in the interim, resident #64's pain was being managed. -The NHA stated she was not a nurse but the resident did not appear in pain. Even so, she said they were taking the issue of managing resident #64's pain seriously and seeking a solution. -The DON said the resident was receiving the maximum dose of [MEDICATION NAME] and they had requested a pain clinic consult for the resident. She said because he was getting the maximum dose she did not know how to manage his pain. But see above; rarely in the last four and a half months had the resident received the maximum dose of [MEDICATION NAME]. And, record review revealed no follow up on the 12/12/16 order for a pain consult until 3/14/17, during survey. On 3/17/17 at 8:17 a.m. the resident's physician was interviewed via phone. She said she was informed by the facility after the facility was notified of the immediate jeopardy situation on 3/15/17, that resident #64's pain medication were not available. She said prior to that, the facility had requested an increase in pain medication or scheduled pain medication for the resident, indicating to her the prescribed amount was not addressing the resident's pain. She said she would not currently adjust his medications because if he had not been receiving them as ordered she would not know how they were actually working. She said she would need to review the resident's pain medications after he had been receiving the medications as prescribed for a while before changing anything. On 3/21/17 1:35 p.m. the nurse practitioner (NP) was interviewed. He said the resident was on too many meds and he had ordered a pain clinic review for the resident. The NP stated he was told by the nursing staff that the resident was receiving the maximum amount of the narcotics ordered and was unaware that this was not the case per the MAR indicated [REDACTED]. He said he would not change anything without speaking to the resident directly.

Based on record review, observations and interviews, the facility failed to provide or obtain routine and emergency drugs to meet the needs of facility residents, including one sample resident (#64). Specifically, the facility lacked procedures to ensure accurate and timely acquiring, receiving, dispensing and administering of drugs to meet the needs of the residents. The facility's failure to have procedures to ensure drugs were timely acquired, received, dispensed and administered created a situation of immediate jeopardy for serious harm, typified by the pain experienced by resident #64, whose medications (muscle relaxant and pain medication) and the resident's primary pain management intervention prior to survey, were unavailable at various times, and on 3/14/17, for an extended period of time. The findings include: I. Immediate Jeopardy (IJ) A. Findings Triggering Immediate Jeopardy Observation, record review, and interviews with staff, health professionals, and residents revealed the facility did not have an effective system to ensure a supply of pain medications to meet resident needs. The facility knew resident #64 frequently ran out of pain medications and it had identified problems with ordering and obtaining narcotics from the facility's pharmacy. These problems were not corrected and contributed to resident #64 experiencing pain that was not treated because his medication was unavailable. On 3/14/17 at 5:18 p.m. resident #64 was observed in the lobby of the facility and stated he needed help and was in pain. He said he had not received his muscle relaxant for over a week and it was causing his muscle to twitch and pull against the external halo in his right leg, causing extreme pain. The resident was diaphoretic and grimacing as he spoke. He pulled up his right pant leg exposing a halo [DEVICE] (two metal rings surrounding his ankle and calf, held in place by screws going directly into his skin). -At 5:19 p.m. licensed practical nurse (LPN) #2, who was caring for the resident, was interviewed. He said the facility had been out of the resident's muscle relaxant for a couple of days. He said the physician had been contacted and staff was waiting on the physician to send a new script to the pharmacy. He said the resident's medication was available in the emergency kit (e-kit) and a fax had been sent to the pharmacy for an authorization from the pharmacy to take the medication from the e-kit. He said staff had sent the fax today around 11:00 a.m. He said he had not called the pharmacy to check if they had any issues with the request. -At 5:23 p.m. the pharmacy was contacted via phone by the surveyor and the representative checked all faxed orders from the facility for 3/14/17. The representative said she could not find a request to pull the medication from the e-kit for resident #64. -At 5:35 p.m. the director of nursing (DON) was interviewed. She said she was not aware of an issue with resident #64 not having his muscle relaxant, but confirmed there were issues managing the resident's pain. He was taking Oxycodone as needed (PRN) and the facility had issues running out of the medication. She called the physician and got an order for [REDACTED]. On 3/15/17 at 9:59 a.m. resident #64 was interviewed. He said he did not get his muscle relaxant (Valium) until this morning. He further stated he ran out of his pain pills every couple of days. He said, It (right leg) hurts before I (get) my meds. I am scared I'm not going to get my next dose. The resident started to cry and stated, I am terrified. -At 12:59 p.m., the DON was interviewed. She said the resident seemed to be in constant pain from his right leg. She said he was on OxyContin 60 mg twice daily and had PRN Oxycodone available. She detailed the issues (medication/narcotic ordering and availability) the facility was having with the pharmacy and said the facility staff was to meet with the pharmacy to discuss a possible resolution to these issues. However, the DON could not identify interim procedures that would ensure resident #64's had medications available as ordered to address his pain. The facility's failure to have procedures to ensure drugs were timely acquired, received, dispensed and administered created a situation of immediate jeopardy for serious harm, typified by the pain and anguish experienced by resident #64, whose medications (muscle relaxant Valium and narcotic pain medications) were unavailable at various times, and on 3/14/17, for an extended period of time. B. Imposition of Immediate Jeopardy On 3/15/17 at 2:39 p.m., the nursing home administrator (NHA) and director of nursing (DON) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to have procedures to ensure drugs were timely acquired, received, dispensed and administered to meet resident #64's needs created a situation of immediate jeopardy for serious resident harm. C. Facility Response and Removal of Immediate Jeopardy On 3/16/17 at 11:16 a.m., the facility submitted the following plan (draft #3) to remove the immediate jeopardy. The plan read in pertinent part: 3/15/17 1. Nurse managers completed audit of all residents for pain medication availability on 3/15/17. 2. DON/ADON (assistant director of nursing)/designee will provide education to nursing staff; medication availability, signing out PRN pain medication on the narcotic log and in the EMAR (electronic medication administration record), timely administering of prn pain medication when requested, followup (sic) on effectiveness and document for prn pain med use and education on what to do if not effective, such as non-pharm interventions, call MD (physician), reposition, etc. and communicate and document. (MAR documentation and Narcotic count system). Will be completed for each nurse prior to them working the cart. 3. DON putting plan in place to ensure meds are available; (checking, reordering, having at least 48 hours available), working with medical director and provider pharmacy. Provider pharmacy has given authorization for facility to have more than one card at a time for identified resident only. Backup pharmacy is (pharmacy named). When 5 day supply remaining is reached, the nurse will reorder from the pharmacy. Night nurse will be assigned to audit all prn pain medications to ensure that they are refilled with the same 5 day supply threshold. If meds are not delivered within 48 hours from reorder, the night nurse will contact the pharmacy and the audit tool will be provided to the DON/ADON/designee to follow up. 4. DON/ADON/designee will In-service nursing staff on steps to follow if medication is not available at time of administration and documentation in the MAR; notify MD immediately, DON immediately, ADON if DON is not available, pharmacy immediately, medical director within 30 minutes if no response from primary MD. (DON will coordinate with pharmacy). Will be completed for each nurse prior to them working the cart. 5. Medical Director will be contacted if refills of narcotics are out and primary physician does not respond within 48 hours to obtain emergency supply. If the medical director is not available, contact DVP (division vice president) Clinical Services and/or Division Director of Pharmacy. 6. PT (physical therapy) evaluation completed on 3/15/17. OT (occupational therapy) evaluation will be completed 3/16/17. 7. Medical Director completed medication review of pain medications over the phone on 3/15/17 and will review in person on 3/17/17 for identified resident. Medical director made recommendations on 3/15/17 and they are being reviewed by the IDT (interdisciplinary team) and the attending physician. 8. DON/ADON/designee will audit the narcotic sheet and MAR indicated [REDACTED]. Any discrepancies will be investigated immediately and any suspected diversion will be reported to appropriate authorities, including the Health Department. 9. DON/ADON/designee will inservice the nursing staff regarding diversion to include what it is, and when and how to report. This will be completed prior to each nurse working the cart. 10. DON/ADON/designee will inservice the nursing staff on the process for the Ekit to include when to use and how to use. This will be completed prior to each nurse working the cart. 11. The DVP of Clinical Services inserviced the DON on diversion on 3/16/2017. 12. The facility will receive inservice training on diversion from the Health Department. This will be completed as soon as possible based on availability of the trainer. On 3/16/17 at 12:03 p.m. the DVP Clinical Services (DVP) was notified that the immediate jeopardy had been removed. However, based on observations, interviews, and record review, deficient practice remained at a G level (actual harm that is isolated). II. Facility Policies A pharmacy policy, provided by medical records on 3/22/17, titled 'New Orders for Schedule II controlled Substances,' and dated 2013 read in pertinent part: -New orders for Schedule II controlled substances require a complete written prescription prior to dispensing, unless there is an Emergency Situation (as defined below). Where permitted under Applicable Law, Facility staff may fax Schedule II prescriptions for long term care residents, terminally ill residents, or where the medication is used for direct infusion (e.g. morphine drip). -Physicians/Prescribers should provide Pharmacy with verbal authorization for Schedule II controlled substances in cases of an Emergency Situation. An Emergency Situation is one in which the prescribing practitioner determines that: Immediate administration of the Schedule II controlled substance is necessary for proper treatment of [REDACTED]. -If the controlled substance is needed before the pharmacy can make arrangements for a timely delivery, Facility must fax a request to remove the controlled substance from the emergency drug supply to the pharmacy. III. System Failure - Lack of procedures to ensure accurate and timely acquiring, receiving, dispensing and administering of drugs to meet the needs of the residents. A. Interviews On 3/15/17 at 12:59 p.m. the DON was interviewed. She said the facility was aware of issues with getting medications for residents. She said facility staff had met with the pharmacy representative and their pharmacy consultant the previous Thursday and had identified the facility was running out of medications for multiple residents. -She said when bringing narcotics to the facility, the pharmacy was bringing one card of the ordered medication at a time; this caused a problem for residents that frequently used their PRN medications because they could go through a card of medications in a little over two days. -Every time the card would run out, the pharmacy required the facility to send a new narcotic script to the pharmacy prior to sending any medication or allowing access to the e-kit. She said this could take some time, depending on how quickly they could get the physician to write the script and fax it to the pharmacy. -She said the pharmacy was going to look into this issue but in the meantime, facility staff called the physician for resident #64 and requested the physician order [REDACTED]. She said the nurse practitioner had declined the request to change the pain medications due to the resident being above the recommended dose already. -She said the medical director (MD) had been contacted about the pharmacy issues and he was going to meet with the other doctors to see if they could address the issue. The DON could not identify immediate action the facility was taking to ensure residents had their medications. On 3/15/17 at 3:08 p.m. the on-call service for physician #1 was interviewed via phone. Physician #1 said there was a note in their system dated 3/7/17, requesting the physician evaluate why the resident's pain medications were not sent. There was no follow up note to the request. The physician said there were no notes indicating the facility called regarding resident #64 not receiving his medications due to the medication not being available. On 3/15/17 at 3:18 p.m. the DON, NHA and the clinical consultant (CC) were interviewed. The CC said she did not see the immediacy of the issue involving acquiring, receiving, dispensing and administering of drugs to meet the needs of the residents because the facility had arranged for the pharmacy and physicians to meet and determined the issue was the pharmacy was not filling the prescriptions. The DON said the pharmacy would not automatically fill narcotics, but if the physician changed the order of administration from PRN to scheduled, the pharmacy would send the medication. The DON, NHA, and CC could not identify any action or plan they could put into place to ensure medications were available for all residents as prescribed. On 3/15/17 at 7:45 p.m. the DVP was interviewed. He said the facility had found four additional residents in their audit (conducted after the facility was notified of the immediate jeopardy situation on 3/15/17) who needed medications that were not available in the facility. They had scripts written and the pharmacist was going to the backup pharmacy (see abatement plan above) immediately to pick them up. On 3/17/17 at 8:17 a.m. physician #1 was interviewed again via phone. She said she was informed by the facility after the facility was notified of the immediate jeopardy situation on 3/15/17, that resident #64's pain medication were not available. She said the pharmacy had a policy with the facility that they would only send one card of narcotics at a time and this caused a problem because the resident potentially could go through the card in a couple of days. She said that even though she was writing a script to cover the resident for a month, after the pharmacy sent five cards, they required a new script regardless of the refills or pills remaining on the script. She said that since being notified of the immediate jeopardy situation, the facility had worked things out with the pharmacy to get more cards of medication sent at one time. On 3/17/17 at 9:50 p.m. the DON and assistant DON (ADON) were interviewed. The DON said that every weekday morning, they (the DON and ADON) pull a report that shows them what medications were not administered and the reason why. She said they follow up with the unit nurse for any medication noted not given because it was not available. On 3/23/17 at 10:26 a.m., a follow-up interview with the DON and ADON revealed the report pulled every weekday morning does not include PRN medications, only scheduled medications. The DON said this has been corrected; the facility now has a process (since acceptance of the abatement plan on 3/16/17) to capture PRN medications although the process had not been implemented because no PRN medications had been administered due to the current lack of the availability of PRN medications. On 3/21/17 at 5:11 p.m., the pharmacist was interviewed. She said she did a monthly review of all residents in the facility and would give her recommendations and reports to the DON and the medical director. She said she also attended their quality assurance meeting monthly and the psychotropic review committee as well. She said resident #64 was a special case because he had extreme pain. She said the facility had not communicated to her that the resident was not receiving his PRN medication because the supply was not available. On 3/23/17 at 4:30 p.m. during a group interview, two residents in attendance other than resident #64 stated they had issues in the recent past of not receiving their medications due to their medications not being available. IV. Effect of System Failure - Resident #64 A. Resident demographics Resident #64, age under 60, was admitted on [DATE]. According to the 3/17 computerized physician's orders [REDACTED]. According to the most recent minimum data set (MDS) assessment dated [DATE], the resident was cognitively intact, scoring 15 out of 15 on a brief interview for mental status (BIMS). The MDS identified the resident as needing one person assistance for bed mobility, transfers, locomotion on and off the unit, toilet use and personal hygiene. He was on scheduled and PRN pain medications, but was not receiving non-pharmacological pain interventions. He scored his pain at 8 out of 10, 10 being the worst pain. His previous MDS dated [DATE] noted the same pain regimen and pain level of 8 out of 10. A care plan, initiated 11/1/16 and revised on 11/14/16, noted the resident had acute/chronic pain related to trauma. Interventions included to administer pain medication prior to treatments and therapy, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness for pain interventions. Review of the March CPO revealed the resident was prescribed in pertinent part: -Diazepam/Valium (muscle relaxant) 5mg every eight hours as needed for muscle spasms (ordered 10/27/16) -Tizanidine (anti-spasm medication) 4mg two times a day for pain. - Morphine Sulfate (opiate pain medication also known as OxyContin) ER (extended release) 60 mg one tablet two times a day for pain (ordered 10/28/17) -Oxycodone 10 mg (a short acting opiate pain medication) one tab every four hours as need for pain 1-5, and two tabs every four hours as needed for pain 6-10. B. Resident interview On 3/14/17 at 5:18 p.m. resident #64 was observed in the lobby of the facility stating he needed help and was in pain. He said he had not received his muscle relaxant for over a week and it was causing his muscle to twitch and pull against the external halo in his right leg, causing extreme pain. The resident was diaphoretic and grimacing as he spoke. He pulled up his right pant leg, exposing a halo [DEVICE] (two metal rings surrounding his ankle and calf, held in place by screws going directly into his skin). On 3/15/17 at 9:59 a.m. the resident was interviewed. -He repeated that he had run out of his pain medications and his muscle relaxant, and this was causing him pain. He said that he was not getting his PRN medications when requested because the facility did not have his medications available. He said he could manage to have a conversation and function at a pain level of 4 or 3 when he received his medication; however, without the pain medication, his pain level was a 10. He said the pain, shakes so bad it feels like it is coming apart, don't know how to make it stop. He said, It (right leg) hurts before I (get) my meds. I am scared I'm not going to get my next dose. The resident started to cry and stated, I am terrified. -He said he had run out of his OxyContin 60 milligrams (mg) (routinely given twice a day) a couple of times and he ran out of Oxycodone (given PRN every four hours as needed) at least twice a week. He said he had never run out of his muscle relaxant (every eight hours as needed) until this week. - He said he had asked the nursing staff if he could have his pain medication reviewed but felt he did not get a response from the staff. The staff had talked to him about fixing the issue of the unavailability of his medications, but nothing had improved. C. Record review Review of the resident's Medication Administration Record [REDACTED]. Review of the nursing notes confirmed his pain medication had been unavailable at various times. The notes revealed in pertinent part: -11/19/16: At 1400 (2:00 p.m.) Pt (patient) called (emergency services) and was transported to (hospital emergency room ) for complain (sic) of right lower extremity pain. Pt has had scheduled pain meds as prescribed pt (sic) has oxycodone for breakthrough pain still needing script from the pharmacy. Pharmacy faxed for ER (emergency) authorizations to pull meds from the ER kit but pt refused to wait and called the ambulance and went to (hospital) and after evaluations from ER (emergency room ) pt was medicated for pain and sent back to the facility with a script to get the meds delivered from the pharmacy. This nurse faxed the script to the pharmacy pending delivery. Pt is sleeping at this time. -12/11/16: Res (resident) c/o (complained of) pain this morning, this nurse give (sic) Oxycodone 20 mg PRN, scheduled 60mg morphine sulfate was not delivered from pharmacy, PT (patient) called (emergency services) and 2 (two) EMP's (emergency medical professionals) take him to (hospital) via ambulance at 1000 (10:00 a.m.) and back form hospital at 1315 (1:15 p.m.) via ambulance, per EMP's report pt treated emergency basis treatment pain medication in ER. -12/16/16: Pt is alert, able to make needs known. Pt was upset d/t (due to) pain meds were not delivered on time. Medicated for RLE (right lower extremity) pain with positive response. Orthopedic pins in place. Pt is resting comfortably in bed at present. -12/18/16: Pt is alert, able to make needs known, pleasant all day. Medicated for RLE pain with positive response. Orthopedic pins are in place. Poor appetite. Sleeps most of the day. Aroused easily. Pt is resting comfortably in bed at present. -There were no progress notes from 12/18/16 to 3/15/17. -3/15/17: Written by DON: Resident is on PRN pain and anti-anxiety medications that he is taking routinely. Medications turn (sic) to run out quickly as pharmacy is supplying 1 (one) card at a time and receiving of refills turn to take a while. Issue were reported to our regional pharmacist and (pharmacy) representative, both visited the facility on 3/9/17 and promised to look into the situation and come up with a resolution. Issue was also discussed with Resident's healthcare provider for medication review. Orders were received on 3/14/17 to send him to a pain clinic. Resident is currently on the list for massage therapy. Record review revealed there was no note indicating the facility had called the physician to inform the physician the resident was not receiving medication as ordered.

Based on observation, interview, and record review the facility failed to implement preventative measures to keep one (#10) of three residents out of 40 residents sampled from developing pressure ulcers. Specifically: Resident #10 was identified as high risk on her quarterly Braden (scale for predicting pressure sore risk) assessment. Although the resident was non-compliant with the treatment plan to offload and lie down due to a preference to sit up in a chair for respiratory effectiveness, there was inadequate documentation of alternative measures and/or treatment put in place prevent additional pressure injuries. The findings included: I. Professional reference According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. -- Scheduled repositioning should be done to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. -- Heels should be placed in a position that eliminates pressure, referred to as floating the heels, by placing a cushion under the full back of the resident's calf. The following steps should be taken to prevent the worsening of existing pressure ulcers and to promote healing: -- Positioning that places pressure on the pressure injury should be avoided. -- For heel ulcers, the heel should be floated. -- The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -- The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -- Signs of deterioration in the wound should be addressed immediately. -- The assessment should include: Location Category/stage Size Tissue types Color Peri-wound (the skin around the wound) condition Wound edges Any undermining or tunneling Exudate Odor National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. From http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf (2/17/2017). II. Facility Policy Facility policy titled, Skin Management,' read in pertinent part: Skin management: wounds are tracked as acquired (developed in-house or admitted with) and are assessed and documented on the weekly pressure ulcer record. These records are maintained in the resident's treatment record while in use. III. Resident #10 A. Resident Status Resident #10, age 97, was admitted on [DATE]. According to the 3/17 computerized physician orders [REDACTED]. According to the 11/19/16 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. No mood or behavior symptoms were noted. She required extensive assistance for bed mobility, transfers, grooming and toileting. She was always incontinent of bowel and bladder. The care plan, initiated 12/10/15 revised on 3/5/17, with a hospice revision on 3/21/17, identified the resident had a wound and decline due to a [DIAGNOSES REDACTED]. Interventions included, the resident's preference to remain in wheelchair (w/c) from morning until night, the resident had a pressure reducing cushion in w/c, follow facility policies/protocols for the prevention/treatment of [REDACTED]. B. Observations On 3/15/17 at 1:20 p.m. wound care to resident's coccyx was observed. The resident was pre-medicated with pain medication. The hospice case manager and another registered nurse (RN) not employed by the facility provided treatment. The treatment was provided per the physician's orders [REDACTED]. The stage IV wound bed had 90% granular tissue with 10% slough, it measured 4 centimeters (cm) x 4 cm x 4 cm with 4 cm of undermining at 12 o'clock. A large amount of serosanguineous (blood and liquid part of blood) drainage was noted. During the assessment, the resident was noted by the hospice nurses to have two new wounds located in the right inner knee (a stage II pressure ulcer) and left inner knee (a stage I pressure ulcer). Treatment was provided per physician order. On 3/21/17 at 10:05 a.m., morning care was observed as the resident declined to get out of bed. The resident was pre-medicated. The resident received a bed bath with the assistance of the hospice certified nurse aide (CNA) and CNA #5. The coccyx dressing was dry and intact. During cleansing of the resident's feet, the heels were observed dark/deep purple in color with slight [DIAGNOSES REDACTED] (intact skin). The hospice CNA called in the floor nurse. The licensed practical nurse (LPN) #6 said she would call the hospice case manager and the doctor to obtain an order for [REDACTED]. C. Record review The treatment administration record (TAR) revealed an existing order dated 10/23/15 elevate bilateral lower extremities while in bed for [MEDICAL CONDITION] . A telephone order dated 3/15/17 read, trial of tipping patient (pt.) chair back for 30 minutes three times a day if tolerated to offload . A telephone order dated 3/15/17 read, use pillow to separate knees . A telephone order dated 3/21/17 read, heel protectors to bilateral heels while in bed for deep tissue injury (DTI), offload heels while in bed . An updated hospice care plan dated 3/21/17, provided by the hospice nurse, read: assess skin for signs and symptoms of breakdown as well as preventative measures provided to maintain skin integrity. Evaluate need for home medical equipment/durable medical equipment (hme/dme). Integumentary (skin) changes are identified promptly and interventions initiated quickly to minimize associated uncomfortable symptoms. Patient/caregiver verbalizes the importance and rationale for use of hme/dme and other protective devices to prevent skin breakdown. A hospice note dated 2/1/17 revealed the resident had 4+ [MEDICAL CONDITION] (severely swollen) to her bilateral lower extremities. A hospice note dated 2/15/17 revealed the resident had 4+ [MEDICAL CONDITION] from her upper calves to her feet. A hospice note dated 3/1/17 revealed the resident had 4+ [MEDICAL CONDITION] to her lower extremities. A hospice summary note dated 3/15/17 revealed the resident had marked lower extremity swelling and [MEDICAL CONDITION]. Review of the facility nursing progress notes for the months of January, February, and March revealed no documentation of the resident's refusal of care or to lie down. Also there was no documentation in the nursing notes pertaining to the resident's coccyx wound. A weekly skin assessment dated [DATE] at 3:19 p.m. and signed 3/16/17 3:55 p.m. revealed no indication of new wounds to the right inner knee and left inner knee, (see observations above). The monthly summary for February and Mach revealed the resident had a coccyx wound; however, there was no documentation of the wound characteristics. D. Staff interview On 3/15/17 at 1:20 p.m. the hospice case manager was interviewed. She said the resident had been refusing to lie down. She said the resident had a low air loss mattress. She said the resident had trialed a waffle cushion, and was currently on a 50/50 gel/foam cushion and she planned to obtain a Roho cushion for the resident's wheel chair. On 3/21/17 at 10:54 a.m. the hospice case manager was interviewed. She said the resident's wounds to her bilateral heels were a new finding. She said she did not have any documentation of her wounds being unavoidable. On 3/22/17 at 8:36 a.m. the director of nursing (DON) was interviewed. She said that she was the wound nurse. She said she had been assessing the resident's coccyx wound weekly. The resident was followed by hospice and they were responsible for anticipating a decline. She said she specifically reviewed the resident's wound with the hospice nurse and hospice nurse practitioner who in turn recommend treatment. She said that there was no pertinent documentation by nursing or the primary physician that the resident's wounds were unavoidable. The medical director had a late chart entry dated 3/23/17 which indicated that resident's coccyx wound was likely to deteriorate due to non-compliance with the treatment plan as evidenced by the resident declining to offload and the resident's preference to be up in chair because she had respiratory compromise. However, there was no indication that the resident was likely to develop unavoidable wounds. Summary: The the resident was discovered with four new pressure areas. Preventative measures were not implemented until after new pressure injuries were identified as noted in the telephone orders written on 3/15/17 and 3/21/17.

Based on record review and staff/family interviews, the facility failed to ensure the highest practicable physical well-being was attained or maintained for one (resident #1) of ten sample residents. Specifically, resident #1 experienced a change in condition for which there was no documented evidence of timely monitoring or intervention on the resident's behalf. The failures contributed to the resident's hospitalization with severe dehydration, acute [MEDICAL CONDITION], aspiration pneumonia, pneumonitis and a naso-[MEDICAL CONDITION] feeding tube was placed. The findings include: Professional Reference --According to "The Merck Manual Home Health Handbook", 2008, James L. Lewis III, MD, "Symptoms of mild to moderate dehydration include thirst, reduced sweating, reduced skin elasticity, reduced urine production, and dry mouth. With severe dehydration, blood pressure can fall, causing light-headedness or faintness, particularly upon standing (a condition called orthostatic [MEDICAL CONDITION]). If dehydration continues, shock and severe damage to internal organs, such as the kidneys, liver, and brain occur. Brain cells are particularly susceptible to more severe levels of dehydration. Consequently, confusion is one of the best indicators that dehydration has become severe. Very severe dehydration can lead to coma. . . . Dehydration normally causes the sodium level in the bloodstream to increase (see Electrolyte Balance: Syndrome of Inappropriate Secretion of Antidiuretic Hormone </home/hormonal_and_metabolic_disorders/electrolyte_balance/sodium.html>). The reason is that although the common causes of dehydration (such as profuse sweating, vomiting, and diarrhea) result in a loss of electrolytes (especially sodium and potassium), even more water is lost, so the concentration of sodium in the blood rises. . . . Older people are particularly susceptible to dehydration. In older people, common causes of dehydration include confusion and disorders that make obtaining fluids difficult (usually because of restricted mobility). Additionally, older people sense thirst more slowly and less intensely than younger people do, so those who are otherwise well may not drink enough fluids." --According to the Mayo Clinic.com, ". . . If a blood urea nitrogen test reveals that your urea nitrogen levels are higher than normal, it probably indicates that your kidneys aren't working properly. Or it could point to high protein intake, inadequate fluid intake or poor circulation." --According to Pamela Charney, Ainsley Malone, ADA Pocket Guide to Nutrition Assessment, American Dietetic Association, 2004, p. 78, "A sodium level of > 145 indicates [MEDICAL CONDITION]. . . . " [MEDICAL CONDITION] is almost always associated with a water deficit (dehydration) ... [MEDICAL CONDITION] essentially never occurs in a patient with a normal thirst mechanism and access to water. The elderly are at risk of dehydration because of declining renal sodium conservation and diminished thirst perception. The onset of symptoms will depend on both the rate and degree of increased serum sodium. Early signs include thirst and dry mucous membranes. Neurologic signs, such as drowsiness, lethargy, disorientation, and confusion, are observed as water progressively shifts from intracellular fluid (ICF) spaces into the hyperosmolar extracellular fluid (ECF). Severe [MEDICAL CONDITION] can result in respiratory paralysis and ultimately, in death." Facility Policy According to the facility policy for "Changes in Resident Condition," "The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit . . . assess and document changes in condition in an efficient and effective manner . . . provide assessment information to the physician . . . provide clear comprehensive documentation . . . changes in condition are communicated from shift to shift through the 24 hour report management system." Record Review Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was transferred to the hospital on [DATE] and did not return to the facility. The resident's family member was interviewed on 5/30/12 at 12 p.m. She said the resident was ill with a respiratory disease and slept a majority of the time; she said they did not adequately assess the resident after a change in condition. She said she informed nursing staff the resident appeared to be dehydrated, but nursing staff did not assess the resident and fluid treatment was not provided for another ten days after she told them. Review of the hospital's History and Physical from the resident's hospital stay prior to admission, 1/15/12 - 1/20/12, revealed his BMP (basic metabolic panel) was WNL (within normal limits). Specifically, his sodium level was 141 (range 135-145), potassium was 4.1 (range 3.5-5.5), chloride was 100 (range 98-110), [MEDICATION NAME] was 28 (range 22-30), BUN (Blood urea nitrogen) was 32 (range 7-25), and his creatinine was 0.85 (range 0.4-1.5). Review of the 1/20/12 nursing admission assessment revealed the resident was alert, confused and aphasic. His lips were moist, tongue and gums were within normal limits, mucus membranes were not assessed/documented, he required frequent mouth suctioning due to increased secretions, he was on a pureed diet with nectar thickened liquids, and he required extensive assistance with all activities of daily living (ADLs). Review of the 1/22/12 care plan revealed the resident was at risk for fluid deficit related to thickened liquids, dysphagia and unable to take fluids independently. The goal was the resident would have adequate hydration levels evidenced by moist mucosa, adequate urinary output and supple skin through next review April 2012. The Approaches included: --Monitor vital signs as indicated. --Observe skin turgor PRN (as needed). --Place thickened fluids at bedside in resident's reach. --Provide 6-8 ounces of thickened fluids at each medication pass as tolerated. --Notify physician on change of status as indicated. --Monitor lab values. --Nectar thickened liquids as ordered by the physician. --Observe urinary output for concentration and odor. Review of the 1/21/12 BMP revealed only sodium was out of range. Specifically, his sodium level was 147 (range 135-145), potassium was 4.2 (range 3.5-5.5), chloride was 110 (range 98-110), [MEDICATION NAME] was 25 (range 22-30), BUN was 13 (range 7-25), and his creatinine was 0.9 (range 0.4-1.5). Review of the 2/6/12 physician's "acute visit" revealed the resident's sodium level was high on the last check - 147 - and the resident "takes PO (oral) food & fluid (with) ease." Review of the 2/7/12 CMP (complete metabolic panel) revealed his BUN was high. Specifically, his sodium level was 141 (range 135-145), potassium was 4.7 (range 3.5-5.5), chloride was 104 (range 98-110), [MEDICATION NAME] was 25 (range 22-30), BUN was 28 (range 7-25), and his creatinine was 0.7 (range 0.4-1.5). Review of the 2/26/12 physician's visit revealed the resident's lung sounds included a "few rhonchi" on the right side and limited inspiration. Review of the 3/1/12 physician's telephone order (TO) revealed the resident's diet was changed to mechanical soft texture and continue nectar thick liquids. The 3/10/12 night shift nursing summary revealed "(no) s/s (signs/symptoms) of any problems noted, (no) SOB (shortness of breath) noticed, slept all night." However, there were no other nursing notes until 3/14/12, three days later. The 3/14/12 Change of Condition nursing note at 3:20 p.m. revealed the resident was "lethargic" and it started "today." The vital signs were documented as temperature - 98.9, blood pressure - 120/70, pulse - 70, respirations - 20, lung sounds clear and oxygen saturation level was 92% on room air. There were new orders for "CXR (chest x-ray)." The PA was notified. In addition, the form revealed "also wife reported." However, there were no other nursing notes until 3/21/12, a week later; there was no documented evidence of consistent monitoring of the resident's condition during this week, even though there were subsequent TOs. Review of the 3/14/12 TO revealed a "2 way chest x-ray - chest congestion" was ordered. Review of the 3/14/12 chest x-ray revealed, "Heart size at the upper limits of normal to mildly enlarged. Aorta appears [MEDICAL CONDITION]. No focal infiltrate, effusion or pneumothorax is seen. Bilateral neural stimulator devices overlie the chest wall. Lung volumes are hyperexpanded . . . NO ACUTE CARDIOPULMONARY DISEASE. STABLE CHANGES OF [MEDICAL CONDITION] AND CARDIOMEGALY." Review of the 3/17/12 TO revealed a urinalysis with culture and sensitivity was ordered for possible urinary tract infection. Review of the 3/19/12 urinalysis revealed the clarity of the urine was "EX. TURBID" rather than clear, and a culture was not indicated. Review of the 3/20/12 physician's assistant (PA) visit revealed, "lethargy - per nursing staff over last few days. O2 sats OK. . . . fever - reported to on call by his wife. UA (urinalysis) requested - not sent yet." The notes included the resident was "in W/C (wheelchair) slumped over, lap buddy in place . . . opens eyes to his name - just stares, doesn't show signs of understanding." The "CXR - (had no) acute findings, stable [MEDICAL CONDITION] & cardiomegaly." The assessment and plan included: "lethargy - (check) basic labwork . . . (increased) congestion - very thick - start [MEDICATION NAME] x 10 d(ays). Encourage good fluid intake." Review of the 3/20/12 TO revealed [MEDICATION NAME] medication (an [MEDICATION NAME] used to relieve chest congestion) for increased congestion and labs for lethargy were ordered. Review of the 3/20/12 CMP, a comprehensive blood panel, revealed his sodium was critically high, his chloride was high, his BUN was high, and his creatinine was high. Specifically, his sodium level was 162 (range 135-145), potassium was 4.5 (range 3.5-5.5), chloride was 120 (range 98-110), [MEDICATION NAME] was 22 (range 22-30), BUN was 102 (range 7-25), and his creatinine was 2.5 (range 0.4-1.5). Review of the 3/21/12 PA's (Physician Assistant) visit revealed the sodium level was high - "lab called this AM (with) critical high (sodium) of 162 - waiting for final . . . lethargy - (increased) hours of sleep." The resident was "sleeping in bed ... oral mucosa appears dry." The assessment and plan included: "[MEDICAL CONDITION] - call to wife - she agrees to IVF (intravenous fluids) - will start on . . . BMP completion . . . (increased) congestion - mild improvement (with) [MEDICATION NAME] . . . lethargy - remaining labwork pending." Review of the 3/21/12 TO at 1 p.m. revealed 2 liters of intravenous fluids were ordered, and to check the BMP at the completion of the 2 liters. Review of the 3/21/12 TO at 7:30 p.m. revealed "stat 2 view CXR (chest x-ray), CBC (complete blood count) and BMP, stat. [MEDICATION NAME] (a medication to treat bacterial infections) 1 gm IM (intramuscularly) now and tomorrow. Tylenol 650 mg PR (rectally) q (every) 6 (hours) PRN (as needed) - fever. [MEDICATION NAME] neb q (every) four (hours) while awake PRN." Review of the 3/21/12 chest x-ray revealed, "Heart size at the upper limits of normal to mildly enlarged. Aorta appears [MEDICAL CONDITION]. No focal infiltrate, effusion or pneumothorax is seen. Bilateral neural stimulator devices are present . . . NO ACUTE CARDIOPULMONARY DISEASE. STABLE MILD CARDIOMEGALY." Review of the 3/21/12 TO at 9 p.m. revealed, "Ok to send pt (resident) to ER (emergency room )." The only nursing notes after the change of condition form was filled out on 3/14/12 were at 9:30 and 10 p.m. on 3/21/12. Specifically: --At 9:30 p.m. the resident's vital signs were: "(blood pressure) 104/60, (pulse) 90, (respirations) 22, (temperature) - 102.8, (oxygen saturation level) 90% (on oxygen at) 2 L(/min). IV started by (paramedics) on (left lower extremity). D5 1/2 NS (type of normal saline) started @ 80 cc/hr. (Elevated) temp noted. MD (physician) notified and spoke with on-call practitioner, TO noted to give Tylenol 650 mg PR and do stat CXR, CBC and CMP, and to give IM [MEDICATION NAME] now and then one more dose tomorrow and to ask wife if she wants him to go to the hospital, called his wife several times and she returned call and said to send pt to hospital." --At 10 p.m. "Tylenol 650 mg given earlier and (decreased) temp 100.7 noted, stat CXR done and result (negative), UA result also (negative), [MEDICATION NAME] IM I gm not given - waiting for pharmacy to deliver. Pt transported to (hospital) ER . . . resident was lethargic and unable to swallow, all PO (oral) meds not given." Review of the 3/21/12 resident transfer form revealed the resident was lethargic, his sodium level was 162 and he had an elevated temperature of 102.8 degrees Fahrenheit. Interviews A certified nurse aide (CNA) who worked at the facility for three years was interviewed at 2:10 p.m. on 6/5/12. The CNA said she remembered resident #1 and she took care of him. She said he was lethargic, was not able to eat and was unresponsive for "like 3 days before he went to the hospital." She said she told the nurse something was wrong. The schedule was reviewed for 3/14/12 through 3/21/12 with the CNA. The CNA confirmed she worked on resident #1's unit on 3/14/12, 3/15/12, 3/16/12 and 3/17/12; she was off 3/18/12 and 3/19/12; she worked a different unit 3/20/12 and 3/21/12. The CNA said it could have been longer than three days that the resident was lethargic prior to going to the hospital. A licensed practical nurse (LPN) who worked at the facility for five years was interviewed at 2:30 p.m. on 6/5/12. The LPN said she remembered the resident, but she did not actually take care of him. She said she remembered before he went to the hospital he became lethargic, stopped eating, slept most of the time, had a hard time controlling his saliva and it was hard to keep him alert. An LPN who worked at the facility for eight months was interviewed at 2:50 p.m. on 6/5/12. The LPN said she remembered the resident, he was sick quite a few times, he received IV fluids, he was dehydrated, and he did not drink much fluid. A CNA who worked at the facility for three years was interviewed at 3:10 p.m. on 6/5/12. He said he remembered the resident, sometimes the resident was resistant to assistance, some days the resident could eat, other days he could not eat so they changed the food to suit his appetite. An LPN who worked at the facility for four years was interviewed at 3:20 p.m. on 6/5/12. She said she remembered the resident, he was sometimes sick and other times ok. She said she filled out the 3/14/12 change of condition form, she called the physician on the same day and she talked to the resident's wife. She said, "We'd been documenting (in the nursing notes) and on the 24 hour report," but "maybe the notes were misplaced." The LPN explained when something was added to the 24 hour report, there was to be follow up every shift for 72 hours. She said a urinalysis was ordered on [DATE], he had increased congestion so was started on [MEDICATION NAME] on 3/20/12, and received IV fluids on 3/21/12. The LPN said the resident never got "better," but sometimes he would get up to eat, then he was sick again. A CNA who worked at the facility for nine years was interviewed at 3:30 p.m. on 6/5/12. He said he remembered the resident and he remembered he had a change in condition around 3/14/12. He said the resident changed completely - needed to be fed after that and did not eat well, took less fluids and "everything went down with him." A CNA who worked at the facility for ten years was interviewed at 3:55 p.m. on 6/5/12. She said she remembered the resident and before 3/14/12 he ate well; after 3/14/12 he needed to be fed and he no longer ate well, but still drank "okay." Further Record/Report Review Record review of the 24 hour report/change of condition reports were reviewed from 3/14/12 to 3/21/12. They revealed the resident was not monitored as expected per the facility policy. Specifically: --Resident #1 was not listed on 3/14/12. --On 3/15/12 resident #1 was listed as "lethargic" and the day shift remarks read, "no change in his condition. The evening shift and night shift remarks were blank. --Resident #1 was not listed on 3/16/12. --Resident #1 was not listed on 3/17/12. --On 3/18/12 resident #1 was listed as "lethargic," the day shift remarks read, "UA not collected" and the night shift remarks read, "OK, unable to collect UA." The evening shift remarks were blank. --On 3/19/12 resident #1 was listed as "lethargic," the day shift remarks read, "still lethargic," the evening shift remarks read, "OK," and the night shift remarks read, "(no) problem noted." --On 3/20/12 resident #1 was listed as "lethargic," the day shift remarks read, "still lethargic, new order in place," the evening shift remarks read, "temp 99.4, Tylenol 650 98.1," and the night shift remarks read, "OK." --On 3/21/12 resident #1 was listed (without a condition), the evening shift remarks read, "Sent to hospital," the night shift remarks read, "in hospital," and the day shift remarks were blank. The Medical Records LPN was interviewed at 3:50 p.m. on 6/5/12. In response to a specific request for nursing notes after 3/10/12 and other missing records, she said, "I've been looking for that stuff for over a month . . . stuff they may have copied to send with him to the hospital." The Director of Nursing (DON) was interviewed at 4:15 p.m. on 6/6/12. She said she looked for documentation of the missing information regarding resident #1's condition after 3/14/12, and "we did an inservice" but could not find the missing information. The DON said she did a timeline of his stay because she knew the family was not pleased with his care; however, review of the timeline revealed the same information was missing. There was no evidence the resident was adequately monitored or assessed for one week between 3/14/12 and 3/21/12. Review of the hospital records for his stay from 3/21/12 to 3/31/12 revealed he was "sent to the emergency room due to a 2-day history of lethargy, fever to 102.8 recorded at the nursing home and [MEDICAL CONDITION] to 162 on the day of admission. It was felt that he was dehydrated so he had received IV fluids at the nursing home, but no improvement and he was sent to the ER late last night. Urinalysis was checked on 3/20/12 in the nursing home, but we do not have an actual report. He was noted to have large respiratory secretions or congestion, was started on [MEDICATION NAME]. The patient has very poor PO intake and his overall mental status is essentially obtunded, may occasionally open his eyes to commands. In our emergency room , he was noted to have continued acute [MEDICAL CONDITION] with a BUN of 125, creatinine 4.63, sodium of 155 and was felt to be severely dehydrated. He was given 2 L of normal saline in the emergency room with some improvement of his blood pressure - hypotensive when he arrived at the emergency room . He is also requiring 4 L of oxygen to get adequate saturation. Apparently at the nursing home, oxygenation saturations were okay on room air. He had a pneumonia on February 26, 2012, treated with antibiotics at that time . . . and he has been increasingly lethargic for the past couple weeks according to the records . . . discharge Diagnoses: [REDACTED]. 2) respiratory insufficiency secondary to the above. 3) chronic severe [DIAGNOSES REDACTED]. 4) [MEDICAL CONDITION]. 5) Resolved [MEDICAL CONDITION]. 6) Moderate [MEDICAL CONDITION]." The hospital records revealed a naso-[MEDICAL CONDITION] feeding tube was placed, but the percutaneous gastrostomy placement was declined. The facility's Medical Director was interviewed on 5/30/12 at 2:50 p.m. She said the resident was dehydrated when he left the facility and he had acute [MEDICAL CONDITION].