Every finding on record at Willow Tree Care Center

Based on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for two (#33 and #20) of three residents reviewed for abuse out of 37 sample residents.Resident #42 was admitted to the facility on [DATE] with diagnoses of a traumatic brain injury (TBI), altered mental status, other specified disorders of the brain, unspecified dementia of unspecified severity with other behavioral disturbance, alcohol-induced persisting dementia and delirium due to known physiological condition.On 11/15/25 the facility initiated an aggression care plan for Resident #42 which identified that the resident was physically and/or verbally aggressive with staff and residents at times due to poor impulse control, dementia and history of TBI. Pertinent interventions, (initiated 11/15/26) directed staff to maintain a safe environment for Resident #42 and others, observing and evaluating the times of day, places, circumstances, potential triggers and what helped redirect his behavior and monitoring, documenting and reporting the danger to self and others. On 2/7/26 a certified nurse aide (CNA) reported that Resident #42 entered the room of Resident #33 and shouldered him to the floor, which resulted in a pelvic fracture for Resident #33.The facility revised Resident #42's aggression care plan after the altercation on 2/7/26 and directed staff to intervene before Resident #42 agitation escalated by redirecting him from sources of distress and calmly engaging him in conversation. According to the intervention, staff should walk away if his response was aggressive and reapproach later.On 2/13/26, just six days after the altercation involving Resident #42 and Resident #33, Resident #42 and Resident #20 were observed wandering in the same hallway of the memory care unit. Resident #42 began to verbally accuse Resident #20 of stealing his shoes. A CNA heard raised voices and shouting and observed Resident #42 holding Resident #20 by the shirt and Resident #20 had his hand on Resident #42's left shoulder. The CNA stepped between the residents to separate them and de-escalated the situation. Resident #20 said Resident #42 had hit him. The altercation resulted in a split lip and an abrasion to the chin for Resident #20. Specifically, the facility failed to protect Resident #33 and Resident #20 from physical abuse by Resident #42, which resulted in a pelvic fracture for Resident #33 and a lip laceration and chin abrasion for Resident #20.Findings include: I. Facility policy and procedureThe Resident Abuse Prevention policy, undated, was provided by the nursing home administrator (NHA) on 2/23/26 at 2:28 p.m. The policy read in pertinent part, (The facility) will not tolerate any form of abuse, neglect or exploitation of our residents This policy is to ensure that allegations of abuse, neglect or exploitation are identified, investigated, reported, documented and followed up with interventions to prevent recurrence and assure protection. Each resident has the right to be free from physical, mental or sexual abuse, neglect, corporal punishment, involuntary seclusion, and physical or chemical restraints.II. Incident of physical abuse of Resident #33 by Resident #42 on 2/7/26A. Facility investigationThe facility investigation of the abuse incident between Resident #33 and Resident #42 was provided by the NHA on 2/25/26 at 5:56 p.m. The facility investigation documented Resident #42 attempted to enter the room of Resident #33 on 2/7/26 at 12:15 a.m. and said he needed to perform electrical work in the room. The investigation documented Resident #33 had placed a chair up against the door from inside the room as part of a nightly routine, which made the door difficult to open. According to the investigation, CNA #1 attempted to redirect Resident #42 but Resident #42 continued to attempt to open Resident #33's room door, prompting CNA #1 to hold the door knob closed. Resident #42 entered the room after opening the door by pushing CNA #1 into the door frame when she attempted to step in front of him. CNA #1 witnessed Resident #33 get out of bed and walk towards Resident #42. The investigation documented Resident #42 used his right shoulder and upper arm to make physical contact with Resident #33, causing Resident #33 to fall backward and land on the floor. The investigation indicated Resident #42 proceeded to enter Resident #33's bathroom and attempt to exit out the window. Review of the investigation identified the facility substantiated abuse. B. Resident #33 (victim)1. Resident statusResident #33, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included dementia, unspecified severity, with other behavior disturbances, cognitive communication deficit and unspecified fracture of unspecified pubis. The 2/12/26 minimum data set (MDS) assessment identified Resident #33 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. According to the MDS assessment, Resident #33 did not exhibit hallucinations or delusional thinking. He did not have behaviors directed towards himself or others.The MDS assessment indicated Resident #33 was independent with most of his activities of daily living (ADLs). 2. Record reviewThe fall care plan, revised 11/15/25, identified Resident #33 was at risk for falls. Interventions directed staff to anticipate and meet his needs (initiated 8/20/25).The risk for intrusion care plan, initiated 2/7/26, identified Resident #33 had anxiety related to unwanted entry into his room. The care plan goal, revised 2/21/26, was to ensure the resident remained free from distress or injury related to unwanted room entry from others, as evidenced by decreased agitation and the ability to rest safely in his room. Interventions, initiated 2/7/26 directed staff to allow the resident to place a chair on the inside of the room as a visual and physical cue to discourage other residents from entering his room, monitoring chair placement each shift to ensure continued safety and appropriateness, ensuring chair placement did not obstruct the resident's ability to exit the room and did not pose a fall risk, providing frequent checks and supervision, reassessing the need for intervention with any change in the resident's behavior or condition, redirecting other residents away from Resident #33's room as needed and reinforcing the resident's right to privacy and personal space. According to the care plan, staff were educated that Resident #33's chair placement was a protective measure, not a restraint, and was initiated based on the resident's preference.The 2/7/26 change of condition assessment documented Resident #33 had a fall and needed more assistance with ADLs due to decreased mobility related to a fall. According to the assessment, Resident #33 landed on the floor at 12:00 a.m. (on 2/7/26) and complained of pain in his neck, back and hips six hours later. The assessment identified he was sent to the hospital for an Xray and evaluation. The 2/7/26 admission progress note documented a CNA found Resident #33 sitting on the floor in his room and the resident (Resident #42) who shouldered Resident #33 was standing in the resident's room. The 2/7/26 nursing progress note documented Resident #33 went to the hospital on 2/7/26 at approximately 7:45 a.m. for evaluation after an altercation with another resident (Resident #42) overnight and returned to the facility at 11:30 a.m. According to the progress note, Resident #33 had a right sided inferior pubic rami fracture (pelvic fracture). The resident was evaluated by occupational therapy and was provided with a walker. C. Resident #42 (assailant) 1. Resident statusResident #42, age less than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included personal history of traumatic brain injury, Wernicke's encephalopathy (neurological disorder), altered mental status, other specified disorders of the brain, unspecified dementia of unspecified severity with other behavioral disturbance, alcohol-induced persisting dementia, delirium due to known physiological condition, and generalize epilepsy and epileptic syndromes.The 1/30/26 MDS assessment documented Resident #42 had severe cognitive impairment with a BIMS score of zero out of 15. According to the MDS assessment, Resident #42 had behaviors of physical aggression directed at others, wandering, rejections of care and other behavioral symptoms not directed at others. He was independent with mobility and did not require a mobility device.2. Record reviewResident #42's behavior care, initiated 11/15/25, identified Resident #42 had a potential for impaired behavioral patterns related to alcohol induced persisting dementia, delirium, delusions, history of TBI and altered mental status. Interventions, initiated 11/15/25, included anticipating and meeting Resident #42's needs, engaging him in activities for distraction, maintaining consistency in timing of ADLs, caregivers, and routines as much as possible, providing medications as ordered and monitoring and documenting the medications for effectiveness and side effects.The aggression care plan, initiated 11/15/25, indicated Resident #42 was physically and/or verbally aggressive with staff and residents at times due to poor impulse control, dementia and history of TBI. Pertinent interventions, (initiated 11/15/25) included maintaining a safe environment for Resident #42 and others, observing and evaluating the times of day, places, circumstances, potential triggers and what helped redirect his behavior and monitoring, documenting and reporting the danger to self and others. The intervention, revised 2/7/26, directed staff to intervene before Resident #42 agitation escalated by redirecting him from sources of distress and calmly engaging him in conversation. According to the revised intervention, staff should walk away if his response was aggressive and reapproach later. The 2/7/26 behavior note documented a CNA reported that Resident #42 entered the room of Resident #33 and shouldered Resident #33 to the floor. Resident #33 denied pain or discomfort and was assisted back to bed. Resident #42 was escorted out of the room and into the hallway. According to the progress note, staff continued the redirection of Resident #42, provided 15-minute checks and kept him in line of sight. The 2/7/26 change of condition assessment documented Resident #42 had physical aggression and shouldered another resident (Resident #33) to the ground. III. Incident of physical abuse of Resident #20 by Resident #42 on 2/13/26A. Facility investigationThe facility investigation of the abuse incident between Resident #20 and Resident #42 was provided by the NHA on 2/25/26 at 5:56 p.m. The physical abuse facility investigation documented Resident #42 and Resident #20 were involved in a physical altercation on 2/13/26 at 6:22 p.m. The investigation documented Resident #42 and Resident #20 were observed wandering in the same hallway of the memory care unit. Resident #42 had removed his shoes and placed them under the key pad near the unit entrance. According to the facility investigation, Resident #42 began to verbally accuse Resident #20 of stealing his shoes. A CNA heard raised voices and shouting and observed Resident #42 holding Resident #20 by the shirt and Resident #20 had his hand on Resident #42's left shoulder. The CNA stepped between the residents to separate them and de-escalated the situation. Resident #20 had a split lip as a result of the altercation and Resident #42 had no visible injuries. The investigation documented Resident #42 was redirected to his room with constant monitoring to ensure Resident #42 was not in close proximity to any other residents to ensure safety before being transferred to the emergency department for stabilization. Resident #20 was interviewed after the incident and said he was hit by Resident #42. Resident #20 denied feeling unsafe or fearful. Review of the investigation identified the facility substantiated abuse. The investigation documented physical contact occurred between both residents. The strike to Resident #20's face was not directly witnessed, but the presence of the abrasion and split lip on the resident's face was consistent with Resident #20's report and supported the accuracy of his statement that Resident #42 hit him. According to the investigation, the simultaneous presence of both residents in the same area, combined with Resident #20's tendency to approach others closely, may have contributed to triggering the altercation.The facility provided education to the memory care unit staff regarding the importance of recognizing seemingly normal activities that could represent behaviors capable of triggering negative responses from other residents. The staff were instructed to remain observant, intervene early, and utilize proactive strategies to minimize potential behavioral escalations.B. Resident #20 (victim)1. Resident statusResident #20, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included Alzheimer's disease unspecified, dementia with other diseases classified elsewhere, moderate with other behavioral disturbance, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), unspecified mood disorder and generalized muscle weakness. The 12/8/25 MDS assessment identified Resident #20 had severe cognitive impairment, per the staff assessment for mental status. The MDS assessment documented he had long and short term memory loss, disoriented thinking, inattention and an altered level of consciousness. The assessment identified Resident #20 required set up and supervision for most of his ADLs. He did not require a mobility device. According to the MDS assessment, Resident #20 had physical behaviors directed towards others.2. Resident's representative interview Resident #20's representative was interviewed on 2/26/26 at 2:39 p.m. The representative said Resident #42 had verbal altercations with Resident #20 and would frequently go in his room. She said the altercation on 2/13/26 was the first time Resident #42 was physical with Resident #20. She said after that incident, Resident #20 preferred not to be around Resident #42 and told her that he did not like Resident #42.3. Record reviewThe aggression care plan, initiated 8/4/25, indicated Resident #20 was physically and/or verbally aggressive with staff and residents at times due to poor impulse control and dementia. Interventions, initiated 8/4/25, included administering medications as ordered, assessing his comfort needs and sensory deficits, offering choices and activities, providing physical and verbal cues to alleviate anxiety, giving him positive feedback, assisting him with verbalization of the source of agitation, assisting him to set goals for more pleasant behavior and encouraging him to seek out staff members when agitated. According to the care plan, Resident #20 needed one-to-one redirection when he entered other residents' physical space and opened and closed their doors. If he became agitated, staff should intervene before he escalated through calm conversation, keeping him safe and walking away if needed to reapproach later (initiated 8/19/25). The care plan identified Resident #20 was verbally and physically triggered when other residents were disruptive (initiated 10/24/25). The elopement and wandering care plan (revised 11/19/25) identified Resident #20 had wandering behaviors. Interventions included providing him reorientation strategies (initiated 12/10/24), identifying his pattern of wandering and intervening as appropriate, monitoring his location throughout the shift and documenting his wandering behavior and attempting diversional interventions (initiated 11/15/25). The 2/13/26 nursing progress note documented Resident #20 was involved in a physical altercation with another resident (Resident #42) and the residents were separated and kept in line of sight of staff. According to the note, Resident #20 said he was not fearful and told the staff he was fine and not to worry about him. The 2/14/26 change of condition assessment documented Resident #20 had a split in his right upper lip and a small abrasion to his chin. C. Resident #42 (assailant) 1. Record review The 2/13/26 nursing progress note documented the on-call nurse was contacted at approximately 7:22 p.m. and was notified Resident #42 was involved in a physical altercation with another resident (Resident #20). The on-call nurse arrived at the facility and saw Resident #42 in his room with staff standing at his doorway, providing one-to-one supervision. According to the note, the primary registered nurse (RN) had contacted the police. Resident #42 proceeded to go in and out of his room and paced the halls with the all on-call nurse. The note indicated the resident had to be redirected from areas with other residents. The physician was notified and gave orders at 10:00 p.m. to transfer Resident #42 to the hospital's emergency room for medication management and uncontrolled behaviors.IV. Staff interviewsThe NHA was interviewed on 2/26/26 at 1:51 p.m. The NHA said abuse was substantiated related to the 2/7/26 incident between Resident #33 and Resident #42. The NHA said Resident #42 said he had to do electrical work in Resident #33's room. She said CNA #1 attempted to stop Resident #42 from going into Resident #33's room by holding the door shut, but the resident forced his way into the room. The NHA said Resident #33 got out of bed and Resident #42 and Resident #33's paths crossed and Resident #33 fell on his buttocks. The NHA said she substantiated abuse because Resident #33 was injured. She said Resident #33 was taken to the hospital after he expressed he was in pain. The NHA said the hospital determined Resident #33 sustained a pelvic fracture as a result of the altercation with Resident #42 that was nonoperable.The NHA said staff was provided additional education related to interventions with memory care residents and CNA #1 was educated on what to do in the future regarding the incident between Resident #42 and Resident #33. The NHA said holding the door shut and physically attempting to prevent Resident #42 from entering Resident #33's room probably escalated his behavior. She said staff should continue to look for escalating behaviors of residents before they attempted to enter a resident's room. The NHA said to prevent Resident #42 from additional altercations, staff continued to look for escalating behaviors, perform 15-minute checks on him and tried to redirect him before he went into anyone's room. She said his prior interventions were effective but the situations involving Resident #33 and Resident #20 were two different scenarios.The NHA said the 2/13/26 incident between resident #42 and Resident #20 was the first time Resident #20 and Resident #42 had a physical altercation. She said both residents had the anxious behavior of wandering up and down the hallway. She said Resident #20 tended to get into other peoples' personal space and Resident #42 would go into other residents'rooms. The NHA said Resident #42 had removed his shoes on 2/13/26 and placed them under the keypad by the front entrance door and next to the entryway of Resident #20's room. She said both residents were wandering and intersected in the same location. The NHA said CNA #2 was helping another resident when she heard Resident #42 yelling at Resident #20 that he stole his shoes. She said both residents were using profanities towards each other. The NHA said CNA #2 turned towards Resident #42 and Resident #20 and witnessed Resident #42's hand on the shirt collar of Resident #20 and Resident #20 had his hand on the left shoulder of Resident #42. The NHA said CNA #2 and CNA #9 ran towards the residents and CNA #2 stepped between the two residents to separate them. The NHA said Resident #20 said Resident #42 had hit him. The NHA said no one saw the punch, but Resident #20 had a split in his lip and an abrasion to his chin. She said Resident #20 reported that he was mad but not fearful of Resident #42. The NHA said she substantiated the allegations of physical abuse because Resident #20 had injuries related to the altercation. The NHA said Resident #42 was taken to the hospital for medication adjustment and a neurological consult after the incident with Resident #20. She said Resident #42 was on a medication dose reduction and also had a seizure. She said he was already on 15minute checks at the time of the incident with Resident #20, but a lot could happen in 15 minutes. She said to prevent the recurrence of altercations, Resident #42's medications were readjusted, staff were educated on what to look for with resident triggers and the resident was on close monitoring with staff and 15-minute checks of his whereabouts. The NHA said Resident #42 had been more in the line of sight of staff since the altercations. CNA #2 was interviewed on 2/26/26 at 2:44 p.m. CNA #2 said Resident #33 was afraid of other residents entering his room while he was in there so he placed a chair in front of his door to help prevent other residents from going into his room. CNA #2 said Resident #42 was fixated on going into Resident #33's room. She said to prevent more altercations with Resident #42 and Resident #33, staff continued to watch where he was located.CNA #2 said Resident #42 had aggressive behaviors. She said the 2/13/26 incident with Resident #20 happened during shift change when she was giving report to CNA #9 who was new to the memory care unit. She said she heard yelling and observed Resident #42's hand was holding onto Resident #20's shirt collar and Resident #20 had his arm stretched out towards Resident #42 in an attempt to push Resident #42 away from him. CNA #2 said she and other staff members helped de-escalate Resident #42 and took him to a quieter location to calm down.

Based on record review and interviews, the facility failed to ensure one (#5) of two residents received treatment and care in accordance with professional standards or practice out of 37 sample residents.Resident #5 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (total paralysis on one side of the body) and hemiparesis (weakness affecting one side of the body) affecting the left side.On 2/2/26 Resident #5 was being transferred by licensed practical nurse (LPN) #1 and certified nurse aide (CNA) #3 using the sit-to-stand lift. The resident let go of the handle of the lift, resulting in her left arm getting hung up in the lift sling in an awkward position. Resident #5 was lowered back to her bed and was found to have no bruising at the time to her left arm. According to staff, the resident did not express pain, but typically had difficulties expressing pain, so the nurse administered acetaminophen (Tylenol) to the resident for pain after the incident. The facility failed to notify the resident's representative at the time of the incident (see representative interview below).On 2/5/26 new bruising was noted to Resident #5's left upper arm and the resident was assessed to have a pain level of 7 out of 10. The physician was notified and recommended an Xray be obtained of the resident's left shoulder area. However, the Xray was not obtained until 2/13/26, 11 days after the incident occurred (see record review below). The 2/13/26 Xray results revealed Resident #5 had an acute displaced fracture of the left humerus at the surgical neck. On 2/16/26 Resident #5's hospice nurse recommended a sling for the resident's left arm and a physician's order for a sling was obtained from the hospice physician on 2/17/26. However, a sling was not provided to the resident until 2/23/26, 21 days after the incident occurred and 10 days after the Xray results revealed the resident's left humerus fracture (see record review below).Specifically, the facility failed to: -Complete a timely Xray for Resident #5 after a change in condition; and,-Provide a sling for Resident #5, based on the hospice provider's recommendation, in a timely manner.Findings include:I. Facility policy and procedureThe Change In A Resident's Condition or Status policy, revised February 2021, was provided by the regional corporate resource on 2/27/26 at 2:45 p.m. It revealed in pertinent part, The nurse will notify the resident's attending physician or physician on call when there has been a(an): accident or incident involving the resident; b. discovery of injuries of an unknown source; adverse reaction to medication; significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times; need to transfer the resident to a hospital/treatment center; discharge without proper medical authority; and/or specific instruction to notify the physician of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan; and ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument.II. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included hyperlipidemia, hypertension, depression, anxiety, hemiplegia and hemiparesis affecting the left side following cerebrovascular disease, dementia with agitation, chronic obstructive pulmonary disease (COPD), diabetes, atrial fibrillation, heart failure and displaced fracture of the left humerus. The 2/19/26 minimum data set (MDS) assessment revealed Resident #5 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The assessment revealed Resident #5 had difficulty expressing and understanding verbal communication. Resident #5 was dependent on staff for repositioning in bed, transfers, bathing, toileting, hygiene, upper and lower body dressing and footwear. Resident #5 required substantial assistance with eating. B. Resident's representative interviewResident #5's representative was interviewed on 2/24/26 at 9:24 a.m. Resident #5's representative said the facility never notified her of an accident occurring during a transfer using a lift at the beginning of February 2026. Resident #5's representative said she was informed of the incident by the hospice nurse over the phone, days after the incident occurred. Resident #5's representative said she was told Resident #5 broke her left arm when the lift the facility staff were using to transfer Resident #5 tipped over. Resident #5's representative said she visited Resident #5 and Resident #5 winced in pain with movement to her left arm. Resident #5's representative said she felt unhappy and worried for Resident #5 when she found out it took the facility over 10 days to complete an Xray of Resident #5's arm and another 10 days to provide Resident #5 with a sling (see record review below). Resident #5's representative said she remembered a weekend nurse was trying to push things through to get her seen for an Xray, but she did not know why the facility did not contact her the day it occurred or why the resident's care was delayed. Cross reference F580 for failure to notify of changes (injury).C. Record reviewThe progress note, dated 2/10/26 at 1:15 p.m., documented a late entry progress note describing events which occurred on 2/2/26. The progress note documented Resident #5 let go of the handle during a transfer using the sit-to-stand lift. The progress note documented her arm was held up only by the sit-to-stand lift sling and in an awkward position. The progress note documented the resident was lowered in the lift and assisted back on to the bed. The progress note documented the resident was then transferred to her wheelchair using a hoyer lift (full body mechanical lift). The progress note documented Resident #5 expressed no pain, but frequently was unable to express pain verbally; therefore Resident #5 was administered as needed (PRN) acetaminophen for pain. The progress note documented Resident #5 did not have bruising upon assessment.The skin alteration note, dated 2/5/26 at 1:00 p.m., revealed an unidentified CNA reported new bruising on Resident #5's forehead to registered nurse (RN) #2 on 2/4/26 and new bruising to Resident #5's left arm to RN #2 on 2/5/26. The skin alteration note documented RN #2 contacted her supervisor and was asked to take pictures of both areas of bruising, in addition to completing skin assessments. The skin alteration note documented pain to Resident #5's left arm and shoulder during the assessment with a Pain Assessment in Advanced Dementia (PAINAD) assessment score of seven out of 10. The skin assessment, dated 2/5/26 at 1:00 p.m., documented an area of bruising to Resident #5's left temple and an area of bruising to Resident #5's left shoulder and arm. The area of bruising on the left arm and shoulder measured 8.7 centimeters (cm) in length and 8.25 cm in width.The change in condition progress note, dated 2/5/26 at 1:00 p.m., documented new bruising was found on Resident #5's shoulder, bicep, and forehead. The progress note documented Resident #5's physician was contacted and the physician recommended an Xray of Resident #5's left shoulder. The physician's follow-up note, dated 2/6/26 at 6:24 p.m., documented Resident #5 experienced a recent fall resulting in bruising to the left arm with pain when staff provided care. The progress note documented an Xray was indicated. The progress note revealed physician's orders for a 2 view Xray of Resident #5's left humerus were given.-However, the Xray ordered on 2/6/26 was never obtained (see interviews below).The hospice nurse note, dated 2/6/26 at 10:45 a.m., revealed the facility's medical director placed a physician's order to Xray Resident #5's left arm for new bruising found on 2/5/26. The progress note documented Resident #5 appeared with nonverbal signs of pain, including fidgeting, frowning and appearing weary during the assessment. The progress note documented Resident #5 requested the nurse not touch her left arm during the assessment.The progress note documented the hospice nurse contacted Resident #5's representative, informing her of the new bruising and reported the incident with the sit-to-stand lift. The progress note documented the hospice nurse reinforced with the facility staff to contact the hospice provider in a timely manner, on the same day incidents occurred. The progress note, dated 2/12/26 at 6:42 p.m., revealed the bruising to Resident #5's forehead was resolved. The progress note documented the bruising on Resident #5's shoulder was improving, however Resident #5 continued to complain of shoulder pain.The radiology results, dated 2/13/26, revealed a 2 view Xray was ordered by Resident #5's hospice provider. The results revealed Resident #5 had an acute displaced fracture of the left humerus at the surgical neck.The facility progress note, dated 2/15/26 at 1:24 p.m., revealed the facility received new physician's orders from the hospice provider on 2/13/26. The progress note documented a new order for a 2 view Xray of Resident #5's left shoulder. If the Xray was unable to visualize the entire humerus, an X-ray of the resident's left humerus was additionally to be completed.The progress note, dated 2/16/26 at 10:40 a.m., documented the hospice nurse spoke with the facility's floor nurse regarding a sling recommendation for Resident #5's left arm. The progress note documented the hospice nurse was supposed to call back with further instructions.The hospice nurse note, dated 2/17/26 at 12:45 p.m., documented a physician's order from the hospice provider for a sling to be applied to Resident #5's left arm for support and comfort for six weeks.-However, the sling for the resident's left arm was not obtained until 2/23/26 (see interviews below). The physician's order note, dated 2/23/26 at 9:44 a.m. (six days after the initial order for a sling), documented a physician's order completed by the medical director for a sling to support Resident #5's left arm.III. Staff interviewsThe hospice nurse was interviewed on 2/25/26 at 2:36 p.m. The hospice nurse said her hospice CNA informed her on 2/4/26 of new bruising and pain to Resident #5's left arm while providing a bath. The hospice nurse said she visited the resident on 2/6/26 for her routine visit. The hospice nurse said she spoke with the facility's nursing staff and found out Resident #5 had sustained an accident of some kind during a transfer with the sit-to-stand lift. The hospice nurse said she spoke with the director of nursing (DON) during her visit on 2/6/26 and the DON told her she was already getting an Xray order for Resident #5 and the hospice nurse did not need to do anything at the time. The hospice nurse said she spoke with Resident #5's representative over the phone to inform her of the resident's new pain and bruising. The hospice nurse said Resident #5's representative was not aware of the incident or bruising until she was informed by the hospice nurse. The hospice nurse said Resident #5's representative called her back to report Resident #5 appeared to have pain when she visited Resident #5 in person. The hospice nurse said after Resident #5's representative called back, she followed up with the DON and found out the Xray ordered on 2/6/26 was never completed. The hospice nurse said she then contacted the hospice physician and obtained another physician's order for an Xray, which was completed on 2/13/26 and revealed Resident #5 had sustained a left humerus fracture. The hospice nurse said once they received the results of the Xray, the hospice physician gave a physician's order for a sling for Resident #5's left arm for comfort, but the physician did not want to pursue more invasive interventions since the fracture occurred almost two weeks before the Xray was eventually completed. The hospice nurse said she checked on the status of the resident's left arm sling during her next visit to the facility on 2/20/26 and the DON told her she was ordering one.-However, the physician's order had been obtained on 2/17/26, three days prior.RN #2 was interviewed on 2/25/26 at 5:22 p.m. RN #2 said she was the nurse who completed the assessments for the bruising on Resident #5's left arm and forehead on 2/4/26 and 2/5/26. RN #2 said the bruising looked a few days old when she assessed them. RN #2 said she contacted the assistant director of nursing (ADON) and the DON on 2/4/26. RN #2 said the DON instructed her to take pictures of the bruises and additionally told her that LPN #1 reported that Resident #5 slipped during a sit-to-stand transfer on 2/2/26. RN #2 said she spoke with the medical director after his follow up visit on 2/6/26. RN #2 said the medical director told her he was going to enter a physician's order for an Xray for Resident #5's left arm and shoulder. RN #2 said Resident #5 reported pain and displayed non-verbal signs of pain with movement. RN #2 said Resident #5 was not always able to report pain verbally, so she also completed the PAINAD assessment and provided PRN Tylenol for pain. RN #2 said she did not know why, but the 2/6/26 Xray had not been completed when she returned to work on 2/12/26. RN #2 said she called the hospice nurse on 2/13/26 to inform her no Xray had been completed. RN #2 said the hospice nurse contacted the hospice physician, obtained a new order and Resident #5's Xray was completed on 2/13/26. RN #2 said she heard of the recommendation from the hospice physician to provide Resident #5 with a sling, but Resident #5 did not have a sling during her shifts from 2/19/26 through 2/21/26.The director of rehabilitation (DOR) was interviewed on 2/26/26 at 9:26 a.m. The DOR said she was not made aware of Resident #5's injury until 2/23/26. She said when she was informed of the injury,she spoke with the floor nurse right away. The DOR said she heard Resident #5 did not receive an Xray to confirm the fracture for almost two weeks. She said she was told the hospice physician recommended a sling for comfort, but Resident #5 did not have one when she spoke to the floor nurse on 2/23/26. The DOR said she provided a sling for Resident #5 on 2/23/26. The DON and the nursing home administrator (NHA) were interviewed together on 2/26/26 at 4:01 p.m. The DON said LPN #1 contacted her over the phone on 2/2/26, reporting Resident #5 slipped while using the sit-to-stand lift with LPN #1 and CNA #3. The DON said LPN #1 told her Resident #5 let go of the handle of the sit-to-stand lift and Resident #5's arm became compromised in the sling, but LPN #1 said Resident #5 did not fall. The DON said LPN #1 reported Resident #5 had no signs of injury and did not report pain, but because of the way Resident #5's arm was positioned, LPN #1 administered PRN Tylenol for pain. The DON said she called CNA #3 who also said Resident #5 did not fall during the incident. The DON said she did not investigate the incident further because both staff members reported Resident #5 did not fall and there was no apparent sign of injury when they contacted her. The DON said she remembered the medical director completed a follow up and wanted to order an Xray of Resident #5's left arm. The DON said she did not know how Resident #5 acquired bruising to her forehead if she did not fall, but since the bruising appeared to be the same age as the bruising on her arm, she attributed both areas of bruising to the incident on 2/2/26. The DON said she thought the radiologist was still waiting for the Xray order when she checked before taking leave from work on 2/11/26 to 2/16/26. The NHA said the facility completed an investigation as to why the delay of care happened for Resident #5 once they found out the physician's order for the Xray was never completed and had to be re-ordered by the hospice nurse on 2/13/26. The NHA said the facility found out the physician's office forgot to fax the physician's order to the radiologist. The NHA said she heard the radiologist's office only accepted physician's orders from the physician's office. The NHA said she contacted the director of the local area radiologist's office and established communication with him so the facility could follow up with him directly and allow the facility to resend an order for Xrays if a physician's office forgot in the future. The DON said she was first made aware of the recommendation for a sling for Resident #5 during the meeting with the hospice nurse on 2/20/26. The DON said she was not aware the DOR provided the sling on 2/23/26, since she was not sure if the facility or hospice needed to cover the cost of the sling.

Based on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen, main dining room and secured memory unit. Specifically, the facility failed to ensure staff followed accepted hand hygiene practices during the meal service.Findings include:I. Professional referenceAccording to The Colorado Retail Food Regulations (3/16/24), retrieved on 3/9/26, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands.II. Facility policy and procedureThe Food Preparation and Service policy, November 2022, was provided by the regional corporate resource on 2/26/26 at 4:55 p.m. The policy read in pertinent part, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Cross-contamination can occur when harmful substances (chemical or disease-causing microorganisms) are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. Cross-contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods. The Handwashing/Hand Hygiene policy, October 2023, was provided by the regional corporate resource on 2/26/26 at 4:55 p.m. The policy read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infectionsAll personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.III. Observations During a continuous observation of the dinner meal service in the kitchen on 2/25/26, beginning at 4:20 p.m. and ending at 5:36 p.m., the following was observed:At 4:41 p.m. [NAME] (CK) #2 began plating residents' meals for dinner. CK #2 retrieved the plates from the plate warmer with a suction device. CK #2 held the plates with his hand under the plate with his thumb on top of the surface of each plate to hold the plate steady as he dished the ready-to-eat food on top of the plates. He switched between the right and the left hand and right and left thumb holding the plate in place as he dished the food. At 5:15 p.m. CK #2 unwrapped alcohol wipes and took the final temperatures of the food in the steam table. At 5:20 p.m. CK #2 collected a pile of alcohol wipe wrappers from the counter, dropping one on the floor. He picked the wrapper up with his bare hands and threw it in the trash can. -CK #2 did not wash his hands after picking up the item off the floor. At 5:21 p.m. CK #2 proceeded to plate the food, putting his thumbs on top of each plate without performing hand hygiene. At 5:28 p.m. the dietary consultant entered the kitchen and observed the plating process of [NAME] #2. She instructed him to hold the plates from the side and not to place his thumb on top of resident plates. IV. Staff interviewsThe infection preventionist (IP) was interviewed on 2/26/26 at 1:41 p.m. The IP said she provided staff hand hygiene education twice a year. She said the last hand hygiene education was conducted in January 2026. She said education was conducted with small groups of staff reviewing soap and water hand hygiene with a return competency evaluation. She said she provided education on alcohol based hand rub (AHBR) when appropriate. The dietary consultant was interviewed on 2/26/26 at 3:16 p.m. The dietary consultant said she was currently coming to the facility twice a week for the past two weeks since the former dietary manager was gone. She said she would come to the facility once and a while and was at the facility in January 2026 to help the dietary department prepare for an upcoming survey. She said she reviewed sanitation with the dietary staff during her visits.

Based on record review and interviews, the facility failed to complete a performance review of certified nurse aides at least once every 12 months and to provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNAs).Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #3, CNA #6 and CNA #7.Findings include:I. Facility policy and procedureThe All Staff In-Service Training policy and procedure, undated, was provided by the regional corporate resource on 2/27/26 at 10:22 a.m. It read in pertinent part, All staff are required to participate in regular in-service education, including all new and existing personnel, individuals providing services under contractual agreements, and volunteers. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the residents' quality of life and quality of care and can demonstrate competency in the topic areas of the training. The required training topics include resident rights and responsibilities, preventing abuse, neglect, exploitation, and misappropriation of resident property.II. Record reviewAnnual performance reviews were requested on 2/25/26 at 10:22 a.m. from the nursing home administrator (NHA).The facility was unable to provide annual performance evaluations for 2025 for CNA #3 (hired on 8/1/21), CNA #6 (hired on 8/1/21) and CNA #7 (hired on 8/30/23).-CNA #3, CNA #6, and CNA #7 did not have an annual performance review completed and did not have an in-service education plan based on the outcome of the review.III. Staff interviewsThe staff development coordinator was interviewed on 2/26/26 at 2:40 p.m. The staff development coordinator said she was responsible for training all new hires and existing personnel. The staff development coordinator said annual performance reviews and in-service education were important and required to be completed at least once a year. However, she said she had only been in her current role for a few months and was not sure if the annual performance reviews had been completed for 2025. The NHA was interviewed on 2/26/26 at 3:30 p.m. The NHA said performance reviews should be completed annually based on the CNAs date of hire. The NHA said performance reviews were not completed for CNA #3, CNA #6 and CNA #7. The NHA said she was not sure why the training was not completed. She said most of the department managers were recent hires, including herself. The NHA said she would immediately establish a system to provide annual performance evaluations and in-service training for all CNAs.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive and at an appetizing temperature. Specifically, the facility failed to ensure residents were served warm food that was appetizing.Findings include:I. Resident interviewsResident #2 was interviewed on 2/23/26 at 11:36 a.m. Resident #2 said the food was always cold when it got to his room. He said a lot of the food the facility served was tasteless.Resident #2 was interviewed again on 2/23/26 at 1:03 p.m., after he was provided his lunch on a room tray. He said the meal was cold. He said most of the meals were cold. He said he had complained to the nurses, the certified nurse aides (CNA), the dietary staff and the registered dietitian (RD) but the food continued to be cold. Resident #45 was interviewed on 2/23/26 at 2:40 p.m. Resident #45 said her food was frequently cold.Resident #18 was interviewed on 2/23/26 at 1:14 p.m. Resident #18 said her lunch today (2/23/26) was tasteless because it lacked seasoning. She said it tasted like institutional food.Resident #22 was interviewed on 2/24/26 at 9:45 a.m. Resident #22 said her food was consistently cold. She said she knew the facility had just hired a new person and they hoped things improved. She said yesterday (2/22/26) during lunch, her soup and her vegetables were cold. Resident #4 was interviewed on 2/24/26 at 10:13 a.m. Resident #4 said the food was frequently cold. She said her eggs were cold almost every single morning and her soup was always cold. She said her breakfast yesterday (2/23/26) was tough and overcooked. She said she had to ask another resident to help her cut it up because it was so tough.II. Record reviewThe December 2025 and the January 2026 resident council minutes were provided by the nursing home administrator (NHA) on 2/25/26 at 9:32 a.m. The December 2025 resident council minutes documented residents reported concerns of cold food served. According to the minutes, the dietary manager (DM) acknowledged the concerns of cold food and said she would review food temperature monitoring practices with the dietary staff. The January 2026 resident council minutes documented residents had concerns regarding the food being served at inadequate temperatures. According to the minutes, the DM acknowledged the concerns and said she would monitor the food temperatures. III. ObservationsOn 2/25/26 at 4:41 p.m. [NAME] (CK) #2 was observed preparing to serve food in the kitchen. CK #2 removed the lids covering the food in the steam table and started plating the food. He retrieved a plate from the plate warmer and placed the plate on a plastic plate base with a pellet. The ready-to-eat food was then covered with a lid and placed in a cart for delivery. CK #2 dished up the broccoli and pork and beans into separate bowls that were not covered to maintain heat and directly placed the bowls of food on a tray in the mobile cart.At 5:34 p.m. the dietary consultant instructed dietary aide (DA) #1 to cover the bowls of pork and beans and broccoli before they were put in the cart for delivery.At 5:38 p.m. the last meal cart left the kitchen with resident room trays and a sample test tray of barbeque chicken breast, cooked broccoli and pork and beans. IV. Test trayOn 2/25/26 at 5:55 p.m. the dinner test tray was retrieved from the hall cart, immediately after the last room tray was delivered. At 5:56 p.m. the temperature and taste of the tray, consisting of barbeque chicken breast, cooked broccoli and pork and beans was evaluated by three surveyors. The following was observed:Each of the food items was placed all on one plate and covered. -The internal temperature of the pork and beans registered at 113 degrees Fahrenheit (F) and tasted lukewarm. -The broccoli tasted bland and was watery and very soft in texture. Resident #30 and Resident #12 were observed eating the dinner meal on 2/25/26 at approximately 6:07 p.m. in the dining room. Both residents said the broccoli was mushy and tasted watery. V. Staff interviewsCertified nurse aide (CNA) #8 was interviewed on 2/25/26 at 5:40 p.m. CNA #8 said she often had to serve the residents' room trays by herself on two of the halls. She said she wished other staff would be available to help her so the residents would receive their meals faster and hotter. The dietary consultant and the registered dietitian (RD) were interviewed together on 2/26/26 at 3:16 p.m. The dietary consultant said she had been coming to the facility twice a week for the past two weeks since the former dietary manager was gone. She said she had reviewed food temperatures with the dietary staff. The dietary consultant said the former dietary manager had called her and told her that the steam table was not holding food temperatures. The dietary consultant said she instructed the former dietary manager to contact a kitchen service vendor. She said the vendor came to the facility and determined the oven required calibration because the temperature in the oven was not registering correctly by 15 degrees F. She said the vendor identified the dietary staff was not using the proper switch on the steamer and educated the staff. The vendor identified the steam table needed a new part to make the repairs. She said the facility was still waiting on the part and it was scheduled to arrive at the facility on 2/27/26 and the vendor would then make the repairs on the steam table. The dietary consultant said residents did not share food concerns at the February 2026 resident council meeting. She said she did not know if the residents brought up food concerns in prior resident council meetings. She said the former dietary manager thought room trays were not delivered fast enough by staff and the plastic pellet inserts to keep the plate warm were not holding their temperature. She said after the vendor looked at the kitchen equipment on 2/16/26, it was determined that the food temperature problem was primarily related to the equipment failing.

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 diseases and infection. Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene when assisting residents with eating; and,-Ensure residents were offered the opportunity for hand hygiene prior to eating.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, retrieved on 3/9/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, It read in pertinent part, CDC provides the following recommendations for hand hygiene in healthcare settings. Know when to clean your hands: immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient surroundings; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal. When to use an alcohol-based hand sanitizer (ABHS): Unless hands are visibly soiled, ABHS is preferred over soap and water in most clinical situations because: it is more effective at killing germs on hands than soap; easier to use when providing care, especially when moving from soiled to clean activities on the same patient or when moving between care of patients in shared rooms; results in improved skin condition with less irritation and dryness than soap and water; improves hand hygiene adherence. When to wash with soap and water: when hands are visibly soiled; before eating; after using the restroom; during the care of patients with suspected or confirmed infection during outbreaks of C. difficile and norovirus.II. Facility policy and procedureThe Handwashing/Hand Hygiene policy, dated October 2023, was provided by the regional corporate resource on 2/26/26 at 4:55 p.m. The policy read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Residents, family members and/or visitors are encouraged to practice hand hygiene. Fact sheets, pamphlets and/or other written materials promoting hand hygiene practices are provided at the time of admission and/or posted throughout the facility.III. ObservationsDuring a continuous observation of the lunch meal in the main dining room on 2/23/26, beginning at 12:02 p.m. and ending at 1:08 p.m., the following was observed:Between 12:02 p.m. and 12:47 p.m. hand hygiene was not offered or available to the residents in the dining room. Observations did not identify that hand cleansing wipes or alcohol based hand rub (AHBR) were offered to residents by staff nor were they within reach of the residents at the tables and in the dining room. Several of the residents were observed holding on to their walkers to walk into the dining room or self-propelling themselves in a wheelchair to the dining room by use of their hands. At 12:26 p.m. staff began to serve residents their meals. The residents were not offered hand hygiene in the dining room prior to meal service. Observations identified many of the residents who were served rolls and cake, used their hands to eat the rolls. One resident used her hands to eat her cake, At 12:45 p.m. a resident blew her nose at the table with other residents and then continued eating. The resident was not provided hand hygiene after she blew her nose. At 12:47 p.m. hand hygiene wipes were offered by an unidentified staff member to the residents in the dining room. The unidentified staff member opened packages of hand hygiene wipes and told residents that the wipes were for after they were finished eating. At 12:48 p.m. a second unidentified staff member started to offer hand hygiene wipes to the residents and stocked the tables with wipes. During a continuous observation of the lunch meal in the secured memory care unit dining room on 2/23/26, beginning at 11:50 a.m. and ending at 12:30 p.m., the following was observed: At 12:05 p.m. the meal cart arrived on the secured unit and the staff proceeded to pass out the meal trays to the residents in the dining room. The residents were not offered hand hygiene in the dining room before they were served their meals. The staff wore gloves to pass out the meal trays. At 12:10 p.m. registered nurse (RN) #1 cut up a resident's food for him and served him a bite of the food, using the same gloves she wore to pass trays out to the other residents. At 12:14 p.m. RN #1 adjusted the napkin of another resident and then went back to the first resident and positioned his fork so he could grab it. The resident used the fork to take a bite of his food and then he put the fork down. -RN #1 did not change her gloves between the two residents.At 12:15 p.m. RN #1 doffed (took off) her gloves and wiped her hands with hand hygiene wipes. At 12:24 p.m. activity assistant (AA) #1 attempted to encourage the first resident to eat. The resident was coughing and sneezing. With her gloved hand, AA #1 picked up the resident's fork and then placed a small bite-sized piece of chocolate cake on his fork for him to eat. At 12:26 p.m. AA #1 got up from the resident's table, used her gloved hand to press the code on a key pad and turned the door knob to unlock and open the nurse office door. AA #1 entered the office and collected napkins with the same gloved hands she assisted the resident with his cake who was coughing and squeezing. She provided the resident napkin and set the other napkins down at another resident's table before she removed her gloves.IV. Staff interviewsThe infection preventionist (IP) was interviewed on 2/26/26 at 1:41 p.m. The IP said she provided staff hand hygiene education twice a year. She said the last hand hygiene education was conducted in January 2026. She said education was conducted with small groups of staff reviewing soap and water hand hygiene with a return competency evaluation. She said education alcohol based hand rub (AHBR) when appropriate. The IP said staff offered hand hygiene wipes at meals for residents. She said some residents were able to wash their hands in their rooms prior to going to the dining room. She said staff needed to educate residents to use the hand hygiene wipes before and after meals. She said staff should educate residents that if they were feeling ill, they were to be encouraged to use masks or spend time in their room when symptomatic. The IP said residents in their wheelchairs were at particular risk for an infection control issue because they touched the wheel base when self-propelling their wheelchairs.

Based on interviews and record review, the facility failed to inform the resident's representative when a change in condition occurred for one (#5) of two residents reviewed out of 37 sample residents.Specifically, the facility failed to notify Resident #5's representative when the resident experienced a significant change in physical condition after bruising appeared to her left temple, as well as bruising and new pain to her left arm and shoulder following an incident that occurred during a sit-to-stand lift transfer.Findings include:I. Facility policy and procedureThe Change In A Resident's Condition or Status policy, revised February 2021, was provided by the regional corporate resource on 2/27/26 at 2:45 p.m. It revealed in pertinent part, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; there is a significant change in the resident's physical, mental, or psychosocial status; there is a need to change the resident's room assignment; a decision has been made to discharge the resident from the facility; and/or it is necessary to transfer the resident to a hospital/treatment center.II. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included hyperlipidemia, hypertension, depression, anxiety, hemiplegia and hemiparesis (weakness and immobility affecting one side of the body) affecting the left side following cerebrovascular disease, dementia with agitation, chronic obstructive pulmonary disease (COPD), diabetes, atrial fibrillation, heart failure and displaced fracture of the left humerus. The 2/19/26 minimum data set (MDS) assessment revealed Resident #5 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The assessment revealed Resident #5 had difficulty expressing and understanding verbal communication. Resident #5 was dependent on staff for repositioning in bed, transfers, bathing, toileting, hygiene, upper and lower body dressing and footwear. Resident #5 required substantial assistance with eating. B. Resident representative interviewResident #5's representative was interviewed on 2/24/26 at 9:24 a.m. Resident #5's representative said the facility never notified her of an accident occurring during a transfer using a lift at the beginning of February 2026. She said the facility additionally never notified her when new bruising was found on Resident #5's left arm and left temple. Resident #5's representative said she was informed of the incident by the hospice nurse over the phone, days after the incident occurred. Resident #5's representative said she visited Resident #5 and Resident #5 winced in pain with movement to her left arm. Resident #5's representative said she felt unhappy and worried for Resident #5 when she found out it took the facility over 10 days to complete an Xray of Resident #5's arm and another 10 days to provide Resident #5 with a sling. Resident #5's representative said she remembered a weekend nurse was trying to push things through to get her seen for an Xray, but she did not know why the facility did not contact her the day it occurred or why the resident's care was delayed. Cross reference F684 for failure to provide treatment in accordance with professional standards.C. Record reviewThe change in condition progress note, dated 2/5/26 at 1:00 p.m., documented new bruising was found on Resident #5's shoulder, bicep and forehead. The progress note documented Resident #5's physician was contacted and the physician recommended an Xray of Resident #5's left shoulder.-However, review of the progress note revealed no documentation notifying Resident #5's representative of the change in condition and no documentation notifying the representative that Resident #5 slipped while using the sit-to-stand lift on 2/2/26.III. Staff interviewsThe hospice nurse was interviewed on 2/25/26 at 2:36 p.m. The hospice nurse said her hospice certified nurse aide (CNA) informed her on 2/4/26 of new bruising and pain to Resident #5's left arm while providing a bath. The hospice nurse said she visited the resident on 2/6/26 for her routine visit. The hospice nurse said she spoke with the facility's nursing staff and found out Resident #5 had sustained an accident of some kind during a transfer with the sit-to-stand lift. The hospice nurse said she spoke with Resident #5's representative over the phone to inform her of the resident's new pain and bruising. The hospice nurse said Resident #5's representative was not aware of the incident or bruising until she was informed by the hospice nurse.Registered nurse (RN) #2 was interviewed on 2/25/26 at 5:22 p.m. RN #2 said she was the nurse who completed the assessments for the bruising on Resident #5's left arm and forehead on 2/4/26 and 2/5/26. RN #2 said the bruising looked a few days old when she assessed them. RN #2 said she contacted the assistant director of nursing (ADON) and the director of nursing (DON) on 2/4/26. RN #2 said the DON instructed her to take pictures of the bruises and additionally told her that licensed practical nurse (LPN) #1 reported Resident #5 slipped during a sit-to-stand transfer on 2/2/26. RN #2 said she did not contact Resident #5's representative because when she was told about Resident #5 slipping out of the sit-to-stand lift, she assumed Resident #5's representative was notified of the incident on the day it occurred. RN #2 said she did not remember if the DON or the ADON instructed her to contact Resident #5's representative.The DON and the nursing home administrator (NHA) were interviewed together on 2/26/26 at 4:01 p.m. The DON said LPN #1 contacted her over the phone on 2/2/26, reporting Resident #5 slipped while using the sit-to-stand lift with LPN #1 and CNA #3. The NHA said she informally investigated the incident due to the delay in obtaining Resident #5's Xray. The NHA said LPN #1 told her she did not call Resident #5's representative on the day of the incident (2/2/26) because Resident #5 did not appear to have any injuries and did not fall. The NHA said she did not remember speaking with the resident's representative, but did remember speaking with another family member approved for medical information on 2/18/26 (16 days after the incident and five days after the Xray results indicated the resident had a fractured humerus). The DON said a staff member should have contacted Resident #5's representative when the extensive bruising was found, but she could see how RN #2 might have thought the family was already aware of the situation. The DON said she educated staff that if the incident was significant enough to contact the physician, staff should also notify the resident's representative.

Based on interviews and record review, the facility failed to ensure residents received notification of changes in eligibility for Medicare or Medicaid covered services, what the resident's financial responsibility may be, and their appeal rights for three (#59, #60 and #61) of four residents out of 37 sample residents.Specifically, the facility failed to ensure Resident #59, Resident #60 and Resident #61 were provided with notices of Medicare Non-Coverage when their skilled nursing benefits ended. Findings include:I. Facility policy and procedureThe Notice of Medicare Non-Coverage form was provided by the nursing home administrator (NHA) on 3/3/26 at 9:58 a.m. via email. According to the NHA, the facility did not have a policy for beneficiary notices, but used the regulations as their guidance. The notice of Medicare Non-Coverage form read in pertinent part, Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current services after the effective date (indicated date). You may have to pay for any services you receive after (indicated date). II. Resident #59A. Resident statusResident #59, age greater than 65, was admitted on [DATE] and discharged on 8/20/25. According to the 9/5/25 MDS assessment, diagnoses included obstructive pulmonary disease (COPD), unspecified hepatic failure (liver disease), unspecified with coma, and chronic respiratory failure with hypoxia. The MDS assessment documented Resident #59's discharge was planned. B. Record review The notice of Medicare Non-Coverage for Resident #59 was requested from the facility but not provided. III. Resident #60 A. Resident statusResident #60, age greater than 65, was admitted on [DATE] and discharged on 1/27/26. According to the 1/31/26 MDS assessment, diagnoses included cerebral infarction due to unspecified occlusion or stenosis of the right middle cerebral artery, diabetes mellitus and anxiety disorder. The MDS assessment documented Resident #60's discharge was planned. B. Record review The notice of Medicare Non-Coverage for Resident #60 was requested from the facility but not provided.IV. Resident #61 A. Resident statusResident #61, age greater than 65, was admitted on [DATE] and discharged on 2/5/26. According to the 2/11/26 MDS assessment, diagnoses included acute chronic systolic congestive heart failure, methicillin resistant staphylococcus aureus (MRSA) and anxiety. The MDS assessment documented Resident #61's discharge was planned. B. Record review The notice of Medicare Non-Coverage for Resident #61 was requested from the facility but not provided.V. Staff interviewsThe social services director (SSD) was interviewed on 2/26/26 at 11:24 a.m. The SSD said she could not find the Notice of Medicare Non-Coverage forms for Resident #59, Resident #60 and Resident #61. The SSD was interviewed again on 2/26/26 at 11:28 a.m. The SSD said it was important for residents to be given the Notices of Medicare Non-Coverage form so they were fully aware of their financial responsibility if they chose to stay at the facility when their skilled services ended. She said she missed sending out the notices for Resident #59, Resident #60 and Resident #61. She said she added an updated check list to make sure she did not miss any residents going forward. The regional corporate resource was interviewed on 2/26/26 at 6:17 p.m. The regional corporate resource said the facility was looking at additional methods to streamline the discharge process and improve communication so the Notices of Medicare Non-Coverage forms could be sent out to residents timely.

Based on record review and interviews, the facility failed to prevent misappropriation of property for three (#7, #22 and #57) of eight residents reviewed for personal property out of 37 sample residents.Specifically, the facility failed to prevent the loss of property for Resident #7, Resident #22, and Resident #57 from their rooms.Findings include:I. Facility policy and procedureIdentifying Exploitation, Theft and Misappropriation of Resident Property policy and procedure, revised April 2021, was provided by the regional corporate resource on 2/27/26 at 12:14 p.m. It read in pertinent part, As part of the Abuse Prevention Strategy, volunteers, employees and contractors hired by the facility are expected to be able to recognize exploitation of residents and misappropriation of resident property. Exploitation, theft and misappropriation of resident property are strictly prohibited. It is understood by the leadership in this facility that preventing these occurrences requires staff education and training. The quality assurance and performance improvement (QAPI) committee reviews and creates plans of action to address quality deficiencies that may lead to exploitation, theft or misappropriation of resident property.II. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included pressure ulcer of the right heel, chronic kidney disease and chronic obstructive pulmonary disease (COPD)The 12/10/25 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. The resident's behavior of rejection of care occurred 1 to 3 days during the assessment look-back period.B. Resident interviewResident #7 was interviewed on 2/23/26 at 4:28 p.m. Resident #7 said he went to the bank to withdraw $200.00 from his account and spent $50.00. The resident said he could not locate the remaining $150.00 from his wallet in his room. Resident #7 said he reported the incident to the activity department and the social services director (SSD). He said he believed the facility completed an investigation, but there was no restitution made to him for his loss of the money. Resident #7 said he refused to sign the grievance form because he did not receive his money back. Resident #7 said he was not offered a lockbox until his money went missing. The resident said he had not lost any money since he was offered a lockbox.C. Record reviewThe facility's loss of property investigation for Resident #7, dated 12/16/25, was provided by the nursing home administrator (NHA) on 2/25/26 at 11:38 a.m. It documented Resident #7 reported to an unidentified staff member that he was missing $150.00 of his $200.00. The investigation revealed that Resident #7, in a conversation with NHA on 12/19/26, mentioned that his money might have been stolen or thrown away with his old wallet. The resident's financial advisor was contacted by the facility and confirmed Resident #7 withdrew $200.00 from his account on 12/11/25.The police were notified and Resident #7 was provided with a lockbox for valuables. Resident #7's care plan was updated to reflect the resident's agreement to keep money in a lockbox and not visible to others. The facility's admission procedure was updated to include notification upon admission of the availability of a lockbox for residents' personal use.The facility concluded the incident of loss of property was unsubstantiated.-However, the resident could not find $150.00 of the $200.00 that his financial advisor confirmed the resident withdrew from his account on 12/11/25.-The facility updated its admission procedure to include notification upon admission of the availability of a lockbox for residents after the incident of missing money was reported (see above).-A grievance form for Resident #7, dated 12/15/25, was provided by the SSD on 2/25/26 at 1:25 p.m. It revealed that Resident #7 stated that on 12/11/25, he withdrew $200.00 from his bank accounts. The resident reported that later the same evening around 9:00 p.m., he requested that an unidentified nurse DoorDash him a McDonald's food order. Resident #7 confirmed receipt of the food and stated that he gave the nurse $50.00 out of his $200.00 to cover the cost of the food and delivery. The next day, 12/13/25, Resident #7 reported switching to use a new wallet and disposing of the old one. Resident #7 reported on 12/15/25 that he was missing $150.00. The resolution listed on the grievance form was that the incident was reported to the State Agency.-However, both the interview with Resident #7 and the facility's investigation revealed the resident's financial advisor confirmed a withdrawal of $200.00 on 12/11/25 (see above).A review of Resident #7's progress notes and electronic medical record (EMR) documented that Resident #7 was yelling at a certified nurse aide (CNA) on 12/10/25 at 8:00 a.m. that he needed to go to the bank. The EMR did not reveal any other information regarding Resident #7's missing money.-The safety and security care plan revealed that it was not initiated until 12/27/25, 12 days after the resident's allegation of missing money. Interventions included staff were to ensure Resident #7 had a lockbox available and accessible, and to educate the resident on safe use and proper storage of personal belongings.III. Resident #22A. Resident statusResident #22, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included muscle weakness, anxiety disorder and insomnia. The 11/19/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #22 was dependent and required substantial assistance with personal hygiene, toileting, and set assistance with eating.B. Resident interviewResident #22 was interviewed on 2/24/26 at 9:42 a.m. Resident #22 said some time last year (2025), her daughter had brought her $50.00 for spending money. Resident #22 said she had kept the money in an envelope in the back of the top drawer of her dresser. The resident said she recalled being out of her room, likely at activities, when the incident of her missing money occurred. She said upon returning to her room, she discovered her top dresser drawer was open and $30.00 was missing from the envelope. Resident #22 said she reported the theft to the facility, and an investigation was conducted, which included a search of her room; however, they were unable to locate the missing money. Resident #22 said she had begun keeping her money hidden in a different location and felt it was now secure.C. Record reviewThe facility's misappropriation investigation for Resident #22, dated 1/30/26, was provided by the NHA on 2/25/26 at 11:38 a.m. It documented Resident #22 reported to a CNA that she was missing money from her wallet. An investigation was started and the resident's wallet was found to have $28.00 in cash. Resident #22 said her daughter gave her $50.00, not $28.00 and said she was missing the rest of her money. The resident's daughter confirmed she gave her mother $50.00, in addition to $8.00 that her mother already had. Resident #22 said she had not participated in any outing that would require her to spend money. The resident stated that she used a debit card for all online purchases and had not spent any physical cash.The investigation revealed there had been a pattern of misappropriation of Resident #22's property.Description of the misappropriation of Resident #22's property included an incident reported on 12/4/25 of a missing $40.00 on A-hall, an incident reported on 12/15/25 of $150.00 on A-hall, and the current incident involving Resident #22 additionally occurred on A-hall.Based on interviews and a review of documentation, the facility concluded there was possible misappropriation of some source, but the source was not identified. The interventions implemented were communication to residents and residents' families and utilization of visible stain theft detection powder was ordered and a process was in place.-However, the interventions failed to include staff and resident education for the prevention of misappropriation of residents' property.-A review of Resident #22's care plan did not reveal any updates, including interventions to prevent further misappropriation of property for the resident.-A review of Resident #22's progress notes and electronic medical record (EMR) did not reveal any information regarding the property misappropriation incident.A grievance form for Resident #22, dated 1/30/26, was provided by the SSD on 2/25/26 at 1:25 p.m. It was documented on 1/30/26 at approximately 9:15 a.m. that the director of nursing (DON) reported to the SSD that Resident #22 informed her that she was missing $30.00. The resolution listed on the grievance form was that the incident was escalated to the grievance official, the NHA for review and it was reported to the State Agency. There was no documentation included on the grievance form indicating restitution for the missing money was made to Resident #22.-However, the interview with Resident #22 and the facility's investigation revealed the resident's daughter confirmed giving the resident $50.00, together with her additional $8.00, totalling $58.00, which resulted in $30.00 being unaccounted for.IV. Resident #57A. Resident statusResident #57, age greater than 65, was admitted on [DATE] and discharged on 2/9/26. According to the February 2026 CPO, diagnoses included COPD, chronic respiratory failure, chronic kidney disease and muscle weakness.The 10/24/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15.B. Record reviewThe facility's misappropriation investigation for Resident #57, dated 12/4/25, was provided by the SSD on 2/25/26 at 1:25 p.m. It documented Resident #57 reported to the SSD that she was missing $64.00. The report revealed that an immediate investigation of staff, family, and the resident's roommate occurred. During the course of the investigation, the facility conducted interviews and a search with the resident's permission. The investigation documented Resident #57 and her family gave varying information related to the amount of cash missing. The facility did not identify any alleged assailants or a pattern of missing items. The investigation could not determine whether the money was lost or stolen.The resident did not want law enforcement notified; however, the police were notified.The facility provided a lockbox for the resident and the allegation of missing money was not substantiated; however, there were several incidents of misappropriation of residents' property during the same period and the facility failed to provide education for staff on the prevention of misappropriation of residents property (see above investigation).A grievance form for Resident #57, dated 12/4/25, was provided by the SSD on 2/25/26 at 1:25 p.m. It revealed Resident #57 reported to the SSD that she was missing $64.00 given to her by a friend. The resident's representative was interviewed by the facility, and she confirmed that Resident #57 received $40.00 from a friend.A review of Resident #57's progress note and EMR did not reveal any other information related to the incident of misappropriation of the resident's property.V. Staff interviewsCNA #3 was interviewed on 2/25/26 at 1:45 p.m. CNA #3 said she had not heard or witnessed any residents having property go missing in her unit. CNA #3 said she had not been trained by anyone in the facility on the prevention of the misappropriation of property for Resident #7, Resident #22 and Resident #57. CNA #3 said she was not involved in addressing the incidents; therefore, she did not receive any training.CNA #3 said she was familiar with the facility's grievance process. She said she would assist residents who needed help writing a formal grievance and report the incident to the SSD, the NHA, and possibly the DON.Registered nurse (RN) #3 was interviewed on 2/25/26 at 1:55 p.m. RN #3 said he had not had any incident of misappropriation of residents' property on his shift. RN #3 said he heard a few months ago of an incident of misappropriation of property on other units. He said he was not aware of the details, whether it was substantiated or not. RN #3 said he was not involved in the investigation and had not received any training related to misappropriation of residents' property. RN #3 said he understood and followed the facility's grievance process by reporting all incidents of misappropriation of residents' property immediately to the SSD.The SSD was interviewed on 2/26/26 at 1:51 p.m. The SSD said when a missing item of property was reported, she conducted a search for the property with the resident's permission. She said that if the property could not be located, a grievance form would be completed, and investigations would begin immediately. The SSD said if she was not able to reach a resolution with the resident involved, she would escalate the incident to the NHA, the grievance official. The SSD said she conducted the investigation for the incidents of misappropriation of residents' property for Resident #7, Resident #22 and Resident #57. She said she was unable to locate the three residents' property. The SSD said she escalated the incidents to the NHA. The SSD said she did not know whether the three incidents were substantiated. The SSD said the residents did not receive restitution for the missing property.The NHA and the DON were interviewed together on 2/26/26 at 3:30 p.m. The DON said she was involved in investigating allegations of misappropriation of residents' property. She said that incidents of misappropriation of property for Resident #7, Resident #22 and Resident #57 were confirmed by their families and representatives.The NHA said she was the grievance official and reported all three incidents of misappropriation of property for Resident #7, Resident #22 and Resident #57 to the police and the State Agency. The NHA said the facility had acquired a visible-stain theft-detection powder to help eliminate such occurrences. The NHA said the three residents did not receive restitution for the loss of their properties. She said she did not know the reason for several incidents of the misappropriation of residents' funds at the facility. The NHA said she did not know the facility's policy on restitution and had to verify and get back with an answer. The NHA said the facility was currently working on hiring a business office manager who would be in charge of securing residents' property. She said the facility was now offering lockboxes for residents who required them for storing valuables.

Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level I screening from the State Mental Health Agency in the case of residents without serious mental illness or a related condition for one (#7) of three residents reviewed for PASRR out of 37 sample residents.Specifically, the facility failed to follow the recommendation to re-evaluate Resident #7's PASRR level I screening if the resident's symptoms or behavior did not improve or resolve within 60 days of the screening.Findings include:I. Facility policy and procedureThe Admissions policy, revised March 2019, was provided by the nursing home administrator (NHA) on 3/2/26 at 12:28 p.m. It read in pertinent part, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD.II. Resident #7A. Resident statusResident #7, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included unspecified mood disorder, other psychoactive substance use, unspecified psychoactive substance-induced disorder, chronic kidney disease, heart failure and restlessness and agitation.The 12/10/25 minimum data set (MDS) assessment revealed Resident #7 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment revealed Resident #7 declined to answer the patient health questionnaire (PHQ - a standardized, nine-question tool used by physicians to screen for, diagnose, and monitor the severity of depression). The assessment revealed Resident #7 had behaviors of threatening or cursing at others and refusing care. Resident #7 required partial assistance with dressing, bathing, and toileting.B. Resident interview and observationResident #7 was interviewed on 2/23/26 at 5:19 p.m. Resident #7 said he was refusing to eat. Resident #7 said he occasionally ate a prepackaged snack in his room or had food delivered, but he refused to eat food provided by the facility. Resident #7 said he initially stopped eating out of protest related to inferior services provided by the local urologists and lies the occupational therapist made claiming Resident #7 required assistance with dressing and going to the bathroom. Resident #7 said he was not concerned about losing weight, because he was 84 and did not want to live much longer.On 2/24/26 at 10:36 a.m. Resident #7 was observed arguing with and yelling at staff in the hallway outside of his room. Resident #7 said staff were violating his rights and to leave him alone.C. Record reviewResident #7's PASRR level I screening, dated 11/20/25, indicated that a PASRR qualifying disability (serious mental illness or intellectual disability) was not present. The assessment recommendations revealed low level behavioral health symptoms were present. However, those behavior symptoms appeared to be situational. The assessment revealed if Resident #7's symptoms/behaviors did not improve or resolve within 30 to 60 days of the initial PASRR level I screening, then the nursing facility must submit an updated status change PASRR level I screen to reevaluate the need for a PASRR level II behavioral health evaluation.Resident #7's care plan, revised 1/29/26, revealed a care plan documenting Resident #7 had a level I PASRR determination. Interventions included staff monitoring of Resident #7's mood, social engagement, and emotional status during daily interactions and reporting any changes or concerns to social services or the physician as indicated.-However, Resident #7's care plan failed to include recommendations to submit for re-evaluation of the PASRR level I screening if the resident's behaviors did not improve or resolve. The progress note, dated 2/10/26 at 10:01 p.m., revealed during wound care with the wound clinic nurse, Resident #7 said he was not going to live anymore so he was no longer going to eat. The progress note documented Resident #7 was offered hospice services, but Resident #7 declined, saying he did not want to be like his neighbor, referring to another resident. The progress note documented Resident #7 did not want interventions at the time of the note. The physician communication note, dated 2/10/26, documented the director of nursing (DON) communicated a concern regarding Resident #7 to the medical director. The communication note documented Resident #7 was not eating. The communication note documented Resident #7 said he was choosing not to eat or drink because he no longer wanted to live. The communication note documented Resident #7 had lost 15 pounds since 1/6/26. The communication note documented the facility offered a hospice consultation to the resident, but Resident #7 declined. The communication note documented observations of Resident #7 eating minimal amounts of food, including popcorn and potato chips, and an observation of Resident #7 eating one slice of pizza on 2/8/26. The communication note documented the communication was noted and to transition Resident #7 to comfort measures care. The communication note documented the physician asked if Resident #7's family was aware of the situation. The progress note, dated 2/16/26 at 10:22 a.m., revealed Resident #7 continued to refuse all food offered in 24 hours. The progress note documented Resident #7 told staff he was doing this on purpose and that he was reporting it to the newspaper.The weight change alert note, dated 2/23/26 at 3:15 p.m. documented Resident #7 had continued weight loss. The progress note documented Resident #7 said he was ready to die and he was not eating. The progress note documented Resident #7 declined hospice services, but received comfort-focused care, per the medical director. The progress note, dated 2/24/26 at 1:54 p.m. documented Resident #7 continued his pattern of protest by not eating.Review of Resident #7's intake documentation from 1/26/26 through 2/24/26 documented Resident #7 ate any percentage of a meal only 11 times in 29 days.III. Staff interviewsThe registered dietitian (RD) was interviewed on 2/26/26 at 10:26 a.m., The RD said the facility discussed Resident #7's significant weight loss and behaviors during the interdisciplinary team (IDT) meetings. The RD said Resident #7 refused all interventions for supplemental food when offered. The RD said she could not force Resident #7 to eat, and she did not know what other interventions she could offer him. The RD said she knew Resident #7 ordered food delivery through his phone. The RD said the documentation in the certified nurse aide (CNA) documentation was probably not accurately capturing meals Resident #7 ate but did not tell the staff about. The RD said she knew the social services director (SSD) was in the IDT meetings reviewing Resident #7. The RD said she was not sure if the SSD had offered any mental health services to the resident. The SSD was interviewed on 2/26/26 at 10:38 a.m. The SSD said she heard reports from floor nurses about Resident #7's behaviors and refusals to eat. The SSD said she heard multiple claims of Resident #7 refusing to eat because he was dissatisfied with the services provided by the facility. The SSD said she attempted to complete the PHQ-9 screening, but Resident #7 refused to answer questions. The SSD said she offered tele-health talk therapy sessions to Resident #7 shortly after his admission to the facility but he declined. The SSD said Resident #7 refused to talk to the SSD ever since she had to present him with a grievance from another resident about Resident #7's yelling. The SSD said the facility had reviewed Resident #7's behavior and refusals to eat in IDT meetings, but she said she was not informed of Resident #7 making statements to staff about wanting to die. The SSD said she felt Resident #7's behaviors and mood had not improved since his admission. The SSD said she was not previously aware of the recommendation on the PASRR level I screen to reassess Resident #7 if his symptoms did not improve. The SSD said all staff should report statements about a resident wanting to die to a supervisor so the SSD was aware and could offer interventions or ensure the resident was safe.The NHA was interviewed on 2/26/26 at 10:47 a.m. the NHA said the facility frequently discuss Resident #7's significant weight loss and behavior in at-risk IDT meetings. The NHA said it was difficult to determine if Resident #7's behavior had improved or worsened since his admission to the facility. The NHA said Resident #7 was unpredictable, and would yell at staff members one day and get along well with the same staff members later in the same day. The NHA said Resident #7 spoke with the DON earlier today (2/26/26) about ending his hunger strike if the facility followed his recommendations. The NHA said the facility was aware Resident #7 ordered food for delivery and the documentation of his meals was likely not accurate. Registered nurse (RN) #2 was interviewed on 2/26/26 at 2:49 p.m. RN #2 said floor staff offer Resident #7 a tray at every meal but Resident #7 always refused to eat. RN #2 said she could not recall if Resident #7 ever told her directly that he wanted to die, but she did hear he made a statement about it to the DON. RN #2 said she observed Resident #7 eat the prepackaged snacks in his room and order food delivery, but she was not sure if the floors CNA documented those foods in Resident #7's intake records.CNA #4 was interviewed on 2/26/26 at 2:52 p.m. CNA #4 said Resident #7 told her to get out of his room frequently when she offered him meals. CNA #4 said Resident #7 said he did not want to do anything or receive care until things got solved. CNA #4 said the resident made various complaints, including the restorative services by the facility and his shoes. CNA #4 said the resident ordered food delivery probably a couple times every month. CNA #4 said Resident #7 made no statements to her about wanting to die. CNA #4 said she was not sure if his behavior improved, but Resident #7 did seem to scream at others less often compared to when Resident #7 first admitted to the facility CNA #4 said any time any resident made a statement about wanting to die, she would immediately report it to the charge nurse and the DON. The DON and the NHA were interviewed together on 2/26/26 at 4:01 p.m. The DON said the SSD typically reviewed PASRR recommendations prior to admission, but she also completed reviews of any PASRR level II recommendations. The DON said she had not seen the recommendation to reevaluate in 60 days on Resident #7's PASRR level I screening. The DON said Resident #7's mood and behavior was very situational. The DON said Resident #7 could have one behavior toward someone and have totally different behavior for the next person in the room. The NHA said Resident #7 could be egocentric or perseverate on the same topic. The DON said she could not say for certain if Resident #7's behaviors had resolved or improved since his admission to the facility. The DON said some of the behaviors were related to dementia and she would not expect those behaviors to improve. The DON said the conversation about the resident wanting to die happened during a wound care visit with the wound care nurse. The DON said when he made a statement about wanting to die, she asked him about a plan. The DON said Resident #7 did not have a plan and Resident #7 instead began to perseverate about his veteran's benefits. The DON asked Resident #7 why he would not want to live if he had this benefit and Resident #7 did not answer. The DON said she asked Resident #7 if he wanted hospice services but Resident #7 declined. The DON said Resident #7 frequently told staff he would end his hunger strike if they did these things but later changed his mind. The DON said said when she sent the communication with the physician regarding Resident #7's weight loss and refusal for hospice referral, she was hoping the physician would consider something like a psychiatric consult instead of only approving comfort measures orders.

Based on observations, record review and interviews, the facility failed to to ensure residents received treatment and care in accordance with professional standards of practice for one (#4) of three residents out of 37 sample residents.Specifically, the facility failed to follow the physician ordered parameters for the administration of Resident #4's pain medication.Findings include:I. Professional referenceAccording to Fundamentals of Nursing 10th edition by [NAME] and [NAME] et. al, 2021 pp. 672,1063-1064, Responsibilities of medication administration include knowing medication therapeutics, assessing a patient before administration, calculating doses, administering medications using the seven rights, monitoring and evaluating medication effects, and assessing a patient's ability to self-administer medications. The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication. Studies of nurses' attitudes regarding pain management show that a nurse's personal opinion about a patient's self-report of pain affects pain assessment and titration of medication doses. It has been shown that nurses' assessment of pain intensity often underestimates patients' pain reports. Also, nurses may infer cues on pain severity solely from how pain is treated and then use the cues when making symptom judgments, often leading to underestimationand overestimation of pain. Patients with a high self-report of pain, even when nurses are aware of their pain experience and analgesic treatment, are vulnerable to underestimation and hence to pain undertreatment. Also, patients with a low self-report of pain are subject to overestimation and thus are exposed to overtreatment with potential treatment hazards.II. Facility policy and procedureThe Documentation policy, revised November 2022, was provided by the regional corporate resource on 2/27/26 at 2:45 p.m. It revealed in pertinent part, Documentation of medication administration includes, as a minimum: the resident's name; name and strength of the drug; dosage; route of administration; date and time of administration; reason(s) why a medication was withheld, not administered, or refused (as applicable); initials, signature and title of the person administering the medication; resident response to the medication, if applicable (PRN -as needed, pain medication); and the condition of the venipuncture or vascular access device site before and after medication administration (if administered intravenously).III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included lymphedema, chronic kidney disease, atrial fibrillation, hypertension, venous insufficiency, heart failure, osteoarthritis, stiffness of the right and left shoulder, muscle weakness, chronic pain syndrome and depression.The 11/26/25 minimum data set (MDS) assessment revealed Resident #4 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #4 was dependent on staff for repositioning in bed, transfers, bathing, toileting, upper and lower body dressing and footwear. Resident #4 required substantial assistance with oral and personal hygiene. Resident #4 required set up assistance with eating.The assessment revealed Resident #4 had constant pain with moderate pain as the worst rating of pain during the assessment look back period. B. Resident interviewResident #4 was interviewed on 2/24/26 10:18 a.m. Resident #4 said she had constant pain in her shoulders. Resident #4 said the facility's therapy staff told her they wanted her to participate in physical therapy with the goal of being able to propel herself in her wheelchair with her arms. Resident #4 said it was currently too painful for her to use her arms when propelling her wheelchair. Resident #4 said the facility's nurses gave her a couple of medications for pain including a pain patch, a topical gel, and as needed norco (hydrocodone/acetaminophen 7.5 milligrams (mg)/325 mg) tablets for pain. Resident #4 said she felt the facility was trying to manage her pain, but she still had constant pain despite the current interventions.C. Record reviewReview of Resident #4's February 2026 CPO revealed the following physician's order:Hydrocodone-acetaminophen 7.5-325 mg. Give one tablet by mouth every six hours for a pain level of 5-10, ordered 2/12/26 at 5:00 p.m.Review of Resident #4's February 2026 medication administration record (MAR) revealed administrations of hydrocodone-acetaminophen with no pain assessment at the time of administration for the following administrations: 2/12/26 at 5:00 p.m., 2/13/26 at 11:00 a.m., 2/13/26 at 5:00 p.m., 2/19/26 at 11:00 a.m., 2/19/26 at 5:00 p.m., 2/20/26 at 11:00 a.m., 2/20/26 at 5:00 p.m., 2/21/26 at 11:00 a.m., 2/21/26 at 5:00 p.m., 2/22/26 at 11:00 a.m., 2/22/26 at 5:00 p.m. and 2/25/26 at 11:00 a.m.Review of Resident #4's February 2026 MAR revealed administrations of hydrocodone-acetaminophen with a pain assessment below five out of 10 (various pain ratings between 0 and 5) at the time of administration for the following administrations: 2/14/26 at 11:00 a.m., 2/14/26 at 5:00 p.m., 2/15/26 at 11:00 a.m., 2/15/26 at 5:00 p.m., 2/15/26 at 9:00 p.m., 2/17/26 at 11:00 a.m., 2/17/26 at 5:00 p.m., 2/17/26 at 9:00 p.m., 2/18/26 at 5:00 a.m., 2/18/26 at 11:00 a.m., 2/18/26 at 5:00 p.m., 2/22/26 at 9:00 p.m., 2/23/26 at 5:00 a.m., 2/23/26 at 11:00 a.m., 2/23/26 at 5:00 p.m., 2/24/26 at 11:00 a.m., 2/24/26 at 5:00 p.m., 2/24/26 at 9:00 p.m. and 2/25/26 at 5:00 a.m.IV. Staff interviewsRegistered nurse (RN) #2 was interviewed on 2/26/26 at 9:15 a.m. RN #2 said Resident #4 had constant pain and several interventions for pain. RN #2 said she assessed Resident #4 for pain every shift, but did not assess Resident #4's pain with each administration of hydrocodone-acetaminophen 7.5-325 mg because the physician's order was scheduled and not as needed (PRN). RN #2 said she was not previously aware of the additional instructions to administer for pain rated 5 through 10. RN #2 said scheduled medication orders for pain medication did not usually include an order to assess pain at the time of administration. RN #2 said Resident #4 almost always rated her pain at a 5 or 6 out of 10 any time RN #2 completed a pain assessment. RN #2 said she felt Resident #4's pain was well managed, but not following the physician's order to assess pain could affect the physician's ability to determine how well Resident #4's pain was managed. The director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 2/26/26 at 4:01 p.m. The DON said Resident #4's physician's order for hydrocodone-acetaminophen 7.5-325 mg as written would indicate the need for a pain assessment at the time of the medication's administration. The DON said normally instructions to complete a pain assessment with the medication order would not be added to scheduled medications. The DON said the facility completed a recent audit of all pain medications for all residents in the facility. The DON said she thought what happened was they received a lot of recommendations from physicians and Resident #4's physician's order was possibly not updated correctly.The DON said it appeared Resident #4 had too many pain assessments for staff to complete, so staff did not document pain assessments with the administration of the medication because they had already completed a previous pain assessment. The DON said she was not sure if the physician's order should have been written as a PRN order or if the pain assessment should be removed from the order. The DON said she planned to clarify the order with the physician.

Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#42) of six residents reviewed for accident hazards out of 37 sample residents. Specifically, the facility failed to prevent an elopement for Resident #42 on 1/15/26. Findings include:I. Facility policy and procedureThe Wandering and Elopement policy, revised March 2019, was provided by the nursing home administrator (NHA) on 2/26/26 at 1:00 p.m. It read in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If a resident is identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. II. Facility investigationThe facility's investigation was provided by the NHA on 2/24/26 at 5:18 p.m. The facility's investigation identified Resident #42, who resided on the secured memory unit, was seen sleeping in his bed on 1/15/26 at 5:30 a.m. Resident #42 was not located when staff checked on him at 6:02 a.m. and was determined to be missing from the facility at 6:05 a.m. The staff initiated a search inside and outside the facility and contacted the police. The police located the resident off premises at 7:06 a.m. The resident was returned to the facility by a police officer. The investigation documented Resident #42 was missing for approximately an hour to an hour and a half.Resident #42's vital signs were taken when he returned to the facility. His oxygen saturation level was at 85 percent (%) and his temperature registered at 96.4 degree Fahrenheit (F). According to the investigation, the resident appeared at baseline cognitively and physically but was transported to the emergency department at the hospital at 7:22 a.m., via non-emergent transport for an evaluation due to an abrasion to his right elbow and his history of seizures. The investigation documented Resident #42 was treated at the hospital with warm intravenous (IV) fluids to increase his body temperature and then returned to the facility approximately an hour and a half to two hours later. The investigation documented the facility implemented 15-minute safety checks for 72 hours to ensure Resident #42 remained in the secure unit. His care plan was reviewed and redirection techniques were increased. Tactile busy boards were moved to more prominent locations on the secured unit for a higher visual awareness and access.The investigation indicated Resident #42 eloped from the secured unit and the facility by going out a window in the secured unit. According to the facility investigation, all door alarms were operable and working appropriately at the time of the elopement and no alarm had sounded. Upon perimeter checks, an open window was found with the screen replaced except for the bottom which was not secured to the window frame. A safety stop on the window was found to be broken. The investigation documented Resident #42 opened the window in another resident's empty room and broke the safety stop. The resident then exited through the window, replaced the screen except for the very bottom and climbed over the fence to exit the secure courtyard.The facility's investigation documented additional measures were taken to prevent a recurrence of elopement to include all the windows were assessed and windows with the small plastic safety stops were disabled with metal screws to ensure that the windows could not be opened to full capacity, leaving one window operable with stronger safety stops for egress. III. Resident #42 A. Resident status Resident #42, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included personal history of traumatic brain injury (TBI), Wernicke's encephalopathy (neurological disorder), altered mental status, other specified disorders of the brain, unspecified dementia of unspecified severity with other behavioral disturbance, alcohol-induced persisting dementia, delirium due to known physiological condition and generalized epilepsy and epileptic syndromes.The 1/30/26 minimum data set (MDS) assessment documented Resident #42 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The MDS assessment identified he was independent with mobility and did not require a mobility device. According to the MDS assessment, Resident #42 had wandering behaviors. B. Observation and staff interviewsOn 2/23/26 at 2:50 p.m. Resident #42 came out of his room and into the dining room. The certified nurse aide (CNA) offered him a snack and put on a western show for him. After a few minutes, Resident #42 told registered nurse (RN) #1 that he had to be somewhere else and she needed to let him go. RN #1 told him he did not need to be anywhere else right now. At 3:42 p.m. Resident #42 was by the back door of the memory care unit. He was repeatedly pushing on the emergency push bars in an attempt to open the door.At 3:43 p.m. RN #1 came up to Resident #42 and showed him the red light above the door and told him when the red light was on, the door was locked. He looked at the red light on the door, touched the light and then continued to push on the emergency bars of the door. At 3:45 p.m. activity assistant (AA) #1 told Resident #42 that she would take him for a walk after she was done playing a game with the other residents. At 3:47 p.m. the CNA tried to redirect Resident #42 from the back door but he continued to try to open the door so the CNA sat down in a chair by the door.At 3:48 p.m. Resident #42 walked down the hallway and attempted to open the main entrance door to the secured unit by pushing buttons on the keypad. The resident then entered a resident's room next to the entrance door. At 3:50 p.m. the resident walked back up the hallway and sat on the couch in a small lounge and closed his eyes. On 2/24/26 at 3:40 p.m. a sign was on the outside door of the memory care unit. The sign directed staff not to force the door closed. On 2/26/26 at 10:18 a.m. the secured courtyard was observed with the maintenance director (MTD). Observation of the secured unit courtyard identified the courtyard was surrounded by a six foot fence with a latching device on the outside of the fence. The MTD said a resident would not have been able to open the gate from inside the courtyard. He said he was told that Resident #42 could have used the tree to climb over the fence. He motioned to a tree in the corner of the courtyard that was approximately four feet away from the fence. He said the facility determined the tree was used in the resident's elopement because some of the resident's personal items were found on the backside of the fence near the tree. The MTD said after Resident #42's elopement, additional measures were put in place with the windows so residents could not get out to the courtyard by using the windows. He said he reviewed the doors on the secured unit and reminded the staff to allow the entrance door on the secured unit to fully shut on its own while making sure residents were not near the door. He said the door should not be forced closed or it would not lock properly. C. Record reviewThe mood and behavior care plan, revised 2/7/26, identified Resident #42 had a pattern of elopement attempts.The care plan identified Resident #42 had a history of kicking out window screens, slamming windows in an attempt to open them and going into other residents' rooms and bathrooms due to a traumatic brain injury (TBI), dementia, delirium and other disorders of the brain. The care plan interventions, initiated 11/15/25, included assisting and encouraging the resident in developing the most appropriate methods of coping, interacting and expressing his feelings appropriately, and offering opportunities for positive interaction and attention by talking to him and providing activities. According to the care plan, staff should discuss the resident's behavior with them, when reasonable, and explain/reinforce why the behavior was inappropriate and/or unacceptable. The staff should intervene when necessary to protect the rights and safety of others, to include approaching/speaking in a calm and controlled manner, offering redirection and removing him from a situation to alternate location as needed and administering medications as ordered with monitoring and documentation of side effects and effectiveness. The care plan intervention, revised 2/7/26, directed staff to anticipate and meet Resident #42's needs.The elopement/wandering care plan, revised 10/16/25, identified Resident #42 was an elopement risk. According to the care plan, Resident #42 had a history of leaving his home unattended and had an impaired awareness of safety. Interventions included placing the resident on a secured unit and personalization of his room with familiar objects (initiated 7/2/26), ensuring a staff awareness of his elopement risk and identifying his pattern of wandering and need to intervene when appropriate (initiated 8/4/25), encouraging the resident to maintain his own personal space (initiated 9/2/25) and providing redirection for his wandering behavior by offering pleasant diversions and structured activities (revised 10/16/25). The 1/15/26 at 7:00 a.m. change of condition evaluation documented Resident #42 had a change in skin condition or skin color. The evaluation documented Resident #42 had an abrasion to his right elbow and reddened skin to both hands. According to the evaluation, the resident was transported to the hospital.The 1/15/26 at 10:54 a.m. nursing progress note documented the resident returned from the hospital to the facility. The note identified Resident #42 was treated for acute hypothermia. According to the note, his laboratory (lab) work was normal, and there were no broken bones or internal bleeding. The note indicated he had scratches on his hands and knees. The resident was provided breakfast and his morning medication and then helped to bed where he was sleeping soundly. The note indicated the facility initiated 15-minute checks to monitor his whereabouts. -Review of the progress notes did not identify Resident #42's 1/15/26 elopement from the facility. IV. Staff interviewsRN #1 was interviewed on 2/24/26 at 3:45 p.m. RN #1 said Resident #42 was at risk for elopement and had eloped in the past. She said she was not on shift at the facility when the resident eloped on 1/15/26, but said she was told that he went out a window, put the screen back in place and then jumped over the fence of the secured courtyard to get out. She said he was found south of the facility. RN #1 said Resident #42 was now on 15-minute checks which were logged on a form. She said the staff needed to continue to ensure his location. The MTD was interviewed on 2/24/26 at 3:50 p.m. The MTD said each window on the secured memory unit had a plastic stopping device put in place to prevent the windows from fully opening. The MTD said he was not told which window Resident #42 was believed to have eloped from. He said he noticed in November 2025 that one of the window screws was coming loose from a plastic stopper, so he tightened the device and started a weekly check to ensure all the window stopping devices were secured. The MTD said in December 2025 he installed a top panel to the windows for extra securement so the window could not be easily removed. He said in January 2026, after Resident #42's elopement, he installed self-tapping screws on the left side of each double window in the secured memory unit to prevent the removal of the windows. The NHA, the director of nursing (DON) and the staff development coordinator were interviewed together on 2/26/26 at 12:03 p.m. The DON said CNA #10 went outside to take trash out to the dumpster in the early morning of 1/15/26. The DON said CNA #10 noticed a picture and a magazine on the back side of the fence that she recognized belonged to Resident #42. CNA #10 re-entered the facility through the courtyard and reported that Resident #42 was gone. The NHA said staff did a full search and contacted the police. The NHA said Resident #42 was last seen at 5:30 a.m. The NHA said CNA #10 found the resident's belongings at approximately 5:50 a.m. and he was determined to be not in or around the facility shortly after 6:00 a.m. The NHA said the resident was located by the police on the other side of the highway near the railroad tracks. She said he would have had to cross the highway to get to the railroad tracks. The DON said Resident #42 was cold when he was found. She said he left without a coat so his body temperature was 96.4 degrees F. She said his oxygen saturation level was at 85%. The DON said his oxygen saturation levels were low (by use of a pulse oximeter on his finger) but his fingers were cold, so the results may not have been completely accurate. She said he went to the hospital for an evaluation and was brought back two to three hours later. She said Resident #42 was placed on 15-minute checks for ongoing monitoring and supervision after the elopement and he would remain on 15-minute checks. The DON said she interviewed the staff who were working at the time of Resident #42's elopement. She said the staff did not report that they did not hear an exit door alarm sounding, which she felt ruled out that the resident did not exit through a door to leave the facility. The NHA said the staff found a broken window stopper on the window ledge of a wide open window in room [ROOM NUMBER] and the window screen was not fully secured to the window frame. The NHA said the facility did a complete check of all the windows in the facility and additional screws in the seals were inserted in the windows to ensure the windows were all secured. She said the facility conducted two hour perimeter checks until the window in room [ROOM NUMBER] was fixed and all residents were accounted for. The NHA said the MTD made sure all the door alarms were in proper working order and the courtyard was secured. The DON said the facility added a sign to the outside of the secured unit doors that reminded visitors to make sure no one was near the door when they entered the secured unit and not to push the automatic doors to the unit closed because it could cause the doors not to properly lock. The NHA said verbal education with staff was conducted with the memory care staff on 1/15/26. The staff development coordinator said she conducted education with all staff on 1/21/26 which focused on elopement risk and ensuring all windows and doors were secure. The staff development coordinator said the memory care unit staff received dementia care education on 2/18/26 and the facility would have an all-staff dementia training in March 2026.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for two of four medication storage carts. Specifically, the facility failed to:-Date residents' insulin pens with the date they were opened; and,-Discard expired medications in a timely manner.Findings include:I. Professional referenceAccording to the manufacturer, Sanofi-Aventis, Prescribing and Safety information, revised May 2025, retrieved on 3/4/26 from https://products.sanofi.us/Lantus/Lantus.pdf. The 3 milliliter (ml) single-patient use SoloStar prefilled pen can be stored unopened in a refrigerator until the expiration date, stored unopened at room temperature for 28 days and used for 28 days after opened at room temperature.According to the manufacturer, Sanofi-Aventis, Prescribing and Safety information, September 2025, retrieved on 3/4/26 from https://www.novolog.com/taking-novolog.html, Store unused NovoLog pens, PenFill cartridges, and vials at room temperature up to 86 degrees Fahrenheit (F) for up to 28 days. Store unused NovoLog pens and vials in the refrigerator at 36 degrees F to 46 degrees F until expiration. Storage after use: keep at room temperature (below 86 degrees F) or refrigerate for up to 28 days; keep away from direct heat and light. Dispose after 28 days, even if there is insulin left in the pen or vial.II. Facility policy and procedureThe Medication Labeling and Storage policy, revised February 2023, was provided by the regional corporate resource on 2/27/26 at 2:45 p.m. It revealed in pertinent part, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: medication name (generic and/or brand); prescribed dose; strength; expiration date, when applicable; resident's name; route of administration; and appropriate instructions and precautions. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.III. Observations and interviewsOn 2/25/26 at 9:03 a.m., the #1 medication administration cart was observed with registered nurse (RN) #3. The following medications were found:-An opened Lantus SoloStar 100 units per ml injectable insulin pen for Resident #43 which expired on 1/13/26.-An opened Lantus SoloStar 100 units per ml injectable insulin pen for Resident #14, which had smeared marker on the pen. The opened date on the pen was no longer legible.-An opened Lantus SoloStar 100 units per ml injectable insulin pen for Resident #30, which expired on 2/20/26.RN #3 said each insulin pen should have been checked prior to administration. RN #3 said any insulin pen found to be expired should have been removed from the resident's individual plastic container and replaced. RN #3 said the smeared marker showed a previous staff member attempted to write the open date on the insulin pen and it became illegible during use. RN #3 said since he could no longer confirm the opened date of the pen, it should have been replaced. RN #3 said he normally checked each of his insulin pens, but he did not notice the expired and mislabeled Lantus pens because they were only administered at bedtime by night shift. RN #3 notified the staff development coordinator who replaced each insulin pen.On 2/25/26 at 9:55 a.m., the #2 medication administration cart was observed with RN #2. The following medications were found:-An opened Novolog 100 units per ml injectable insulin pen for Resident #1, which did not have a cap and was not labeled with the date it was opened.RN #2 said without the cap for the pen, the nurse would have to clean it really well prior to each use. RN #2 said the open date was probably written on the cap which was lost. RN #2 said without an open date, she could not ensure if the insulin was safe to administer and the insulin pen should be replaced. IV. Additional staff interviewsThe director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 2/26/26 at 4:01 p.m. The DON said the staff development coordinator informed her of the mislabeled and expired insulin pens found in medication cart #1. The DON said RN #2 informed her of the insulin pen without a cap or open date in medication cart #2 and she ensured the insulin pen was replaced. The DON said each nurse should be checking the insulin pen's expiration and open dates prior to each administration. The DON said she planned to review the other medication carts in the facility to ensure no other residents were affected by mislabeled or expired medications.

Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for two out of five certified nurse aides (CNA) reviewed.Specifically, the facility failed to ensure CNA #3 and CNA #4 received 12 hours of continuing education annually.Findings include:I. Facility policy and procedureThe All Staff In-Service Training policy and procedure, undated, was provided by the regional corporate resource on 2/27/26 at 10:22 a.m. It read in pertinent part, All staff are required to participate in regular in-service education, including all new and existing personnel, individuals providing services under contractual agreements, and volunteers. Training requirements will be met prior to staff providing services to residents, annually, and as necessary based on the facility assessment. Based on the outcome of the assessment, additional training may be required.Completed training will be documented by the staff development coordinator, or his or her designee, which will include the date and time of training, the topic of the training, the method used for the training, a summary of the competency assessment, and the hours of training completed.The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the residents' quality of life and quality of care and can demonstrate competency in the topic areas of the training. The required training topics include resident rights and responsibilities, preventing abuse, neglect, exploitation, and misappropriation of resident property.II. Training record review and staff interviewsFive randomly selected CNA training records were reviewed on 2/25/26 at 5:18 p.m. Of the five CNAs reviewed, CNA #3 and CNA #4's training records did not include 12 hours of annual training. The staff development coordinator said she would review the employee's files and provide the required training records if found. The nursing home administrator (NHA) said CNA #3's (hired 8/1/21) employee file did not have 12 hours of training and CNA #4's (hired 4/25/25) employee file did not have records of the initial required training for dementia care, abuse, neglect and exploitation of residents.III. Additional staff interviewsThe staff development coordinator was interviewed on 2/26/26 at 2:40 p.m. The staff development coordinator said she was responsible for ensuring employees received the required hours of training before having contact with residents. The staff development coordinator said she was required to collaborate with the unit managers and the director of nursing (DON) to ensure CNAs completed the mandatory 12 hours of in-service training. The staff development coordinator said she would immediately begin checking regularly to ensure each staff member complied with the policy.The NHA was interviewed on 2/26/26 at 3:30 p.m. The NHA said performance reviews should be completed annually based on the CNAs date of hire. The NHA said performance reviews were not completed for CNA #3 and CNA #4. The NHA said she was not sure why the CNAs training was not completed. She said most of the department managers were recent hires, including herself. The NHA said she would immediately establish a system to ensure the mandatory 12-hour CNA annual training and in-service training were provided for all CNAs.

Based on observations, record review and interviews, the facility failed to ensure four (#3, #4, #7 and #8) of eight residents out of 10 sample residents were free from abuse.Specifically, the facility failed to:-Prevent physical abuse between Resident #3 and Resident #4;- Protect Resident #7 from physical abuse by Resident #9; and,- Protect Resident #8 from physical abuse by Resident #4. Findings include: I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention policy, last revised April 2021, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: facility staff; other residents; develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents; and, ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.II. Incident of physical abuse between Resident #4 and Resident #3 on 5/8/25A. Facility investigationThe facility investigation was provided by the nursing home administrator (NHA) on 7/23/25 at 9:28 a.m. The investigation documented on 5/8/25 at 4:05 p.m. Resident #3 leaned over Resident #4's wheelchair, held the arms of the wheelchair and shook it. Resident #4 grabbed Resident #3's forearm and caused a small abrasion. The event was witnessed by staff and the two residents were separated immediately. Resident #3 was assessed by licensed practical nurse (LPN) #1 and was found to have a small open area on her forearm with a small amount of bleeding requiring a bandage. The investigation documented both residents had severe cognitive impairments and could not recall the incident. The investigation documented increased supervision of residents to keep residents safe since Resident #3 wandered around the unit. The facility investigation indicated the facility substantiated that abuse occurred. B. Resident #3 (assailant and victim)1. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included generalized anxiety and disorder dementia and unspecified severity with other behavioral disturbances.The 5/16/25 minimum data set (MDS) assessment identified Resident #3 had severe cognitive impairments with short-term and long-term memory deficits, per staff assessment. The resident had behaviors of yelling, refusal of care, grabbing and pushing. She required assistance with dressing, bathing and incontinence care. The MDS assessment indicated the resident wandered frequently and had other behavioral symptoms not directed toward others, including throwing or smearing food or bodily waste.2. Record review-Review of Resident #3's electronic medical record (EMR) did not reveal documentation regarding the physical abuse incident on 5/8/25.C. Resident #4 (assailant and victim) 1. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included anxiety, restlessness and agitation and dementia with other behavioral disturbances.The 5/20/25 MDS assessment documented Resident #4 had severe cognitive impairments with short-term and long-term memory deficits and had communication deficits, per staff assessment. Resident #4's speech was rarely or never understood by others and he had severely impaired vision. Resident #4 was dependent on staff for bathing, dressing, eating and toileting. The MDS assessment indicated the resident exhibited verbal behaviors (yelling, cursing, or threats) and physical behaviors (hitting, kicking, pushing, or grabbing) towards others. The resident had other behavioral symptoms not directed toward others of disruptive sounds or screaming not directed at others.2. Resident #4's representative interviewResident #4's representative was interviewed on 7/23/25 at 11:03 a.m. The representative said Resident #4 frequently grabbed at other people and did not understand how hard he was squeezing. She said she had observed the behavior and was informed one time he scratched another resident. She said she did not think the behavior was aggressive, but instead it was related to his dementia, anxiety and impaired vision. 3. Record reviewResident #4's behavior care plan, initiated 12/2/24 and revised 6/22/25, indicated Resident #4 had behaviors that included tapping his legs and reaching out to hold the staff or resident's arm for comfort if he was anxious. The care plan documented the resident had aggressive behaviors that included exit seeking, pacing and grabbing others. Pertinent interventions included identifying patterns of wandering, providing structured activities and providing visits with the resident's spouse. -Review of Resident #4's EMR did not reveal documentation regarding the physical abuse incident on 5/8/25.Review of the certified nurse aide (CNA) behavior tracking task for Resident #4 from 6/24/25 through 7/22/25, revealed it was documented that Resident #4 displayed the behavior of grabbing at others 17 times.III. Incident of physical abuse by Resident #9 towards Resident #7 on 7/7/25A. Facility investigationThe 7/7/25 facility investigation was provided by the NHA on 7/23/25 at 9:28 a.m. The investigation documented on 7/7/25 at 8:15 p.m. Resident #6 displayed agitated and exit seeking behaviors. CNA #5 and LPN #4 were called as additional staff from other halls due to Resident #6's exit seeking behavior as Resident #6 pulled the fire alarm twice that evening. Resident #9 was awakened by the fire alarms and ambulated out of his room and down to the common area. CNA #1 was assisting Resident #9 back to his room and Resident #7 stood in the hallway observing the commotion caused by Resident #6's behavior. While CNA #1 and Resident #9 walked back to Resident #9's room, Resident #6 ran past them attempting to leave the secure unit. The investigation documented the behavior of Resident #6 startled Resident #9 who then struck Resident #7 in the arm. LPN #6 assessed Resident #7 and did not find any injuries. Resident #9 and Resident #7 were interviewed, but did not remember the event. The investigation documented the changes made to prevent a recurrence were to keep residents separate to reduce stimuli if Resident #6 continued to display exit seeking behavior. The facility investigation indicated the facility substantiated the abuse occurred.B. Resident #7 (victim)1. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included dementia, depression and anxiety. The 6/18/25 MDS assessment documented Resident #7 had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. Resident #7 was dependent on staff for dressing, bathing and hygiene. 2. Record reviewResident #7's behavior care plan, initiated 11/29/23 and revised 6/19/25, indicated Resident #7 had behaviors related to confusion and was at risk for resident-to-resident altercations. Interventions included if Resident #7 was ever triggered by something that might make her appear fearful, staff were to use a calm soothing voice tone with strong reassuring words that she was safe and protected. The care plan interventions documented when Resident #7 appeared or stated she was confused, staff were to provide answers to her questions and guidance to a stable setting.-Review of Resident #7's EMR did not include documentation regarding the incident on 7/7/25.C. Resident #9 (assailant)1. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included dementia, depression and history of cerebral infarction (stroke). The 5/21/25 MDS assessment documented Resident #9 had severe cognitive impairments with short-term and long-term memory deficits per staff assessment. Resident #9 was dependent on staff for bathing, dressing, toileting, and hygiene. Resident #9 required supervision and verbal cues from staff with ambulating and transferring.The MDS assessment indicated Resident #9 had the behavior of wandering four to six days during the assessment look back period.2. Record reviewResident #9's behavior care plan, initiated 12/10/24 and revised 1/6/25, indicated Resident #9 had verbally abusive behavior related to his dementia. Interventions included anticipating needs by asking about food, water, toileting needs and pain and allowing Resident #9 to express his understanding of the situation and feelings toward the situation.-Review of Resident #9's EMR did not include documentation regarding the incident on 7/7/25.IV. Incident of physical abuse by Resident #4 towards Resident #8 on 7/22/25 A. Observations During a continuous observation of the secured unit on 7/22/25, beginning at 3:43 p.m. and ending at 5:19 p.m., the following was observed:At 4:40 p.m. Resident #4 returned to the common area of the unit. Within a few minutes Resident #4 began to hit the table with his hands repeatedly and call out. Resident #4 was unable to communicate his needs to the CNA who asked if he was hungry. Resident #4 was offered a fidget blanket as a distraction at this time.At 4:50 p.m. Resident #8 was wandering in the common area. Resident #8 walked up to Resident #4's wheelchair. Resident #4 grabbed Resident #8 by the left elbow. Resident #8 yelled ow. Activities assistant (AS) #1 stopped her activity in the common area to intervene upon hearing Resident #8. AS #1 separated the two resident and redirected Resident #4. LPN #2 assessed Resident #8's elbow and did not find any injuries at this time. B. Resident #8 (victim)1. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included vascular dementia with other behavioral disturbances.The 5/5/25 MDS assessment documented Resident #8 had severe cognitive impairments with short-term and long-term memory deficits and communication deficits per staff assessment. Resident #8's speech was rarely or never understood by others and Resident #8 rarely understood the speech of others. Resident #8 required assistance with toileting, hygiene, dressing and footwear and was dependent on others for bathing.The MDS assessment documented Resident #8 had wandered frequently, but did not have aggressive behavior directed toward others.V. Staff interviewsAS #2 was interviewed on 7/23/25 at 2:06 p.m. AS #2 said Resident #4 frequently grabbed at people around him. She said she did one-to-one activities with Resident #4 because he could not participate in many activities. AS #2 said some residents knew Resident #4 would grab at them if they put their hands out near him, but not all residents on the secured unit were able to remember. She said she kept her eyes on the residents that wandered around the unit since they were at risk of getting grabbed by Resident #4. AS #2 said when Resident #4 grabbed a resident, she was usually able to get him to let go by speaking in a low calm voice. She said she would also use the word please as it prompted Resident #4 to let go. CNA #1 was interviewed on 7/23/25 at 3:07 p.m. CNA #1 said she was working on the unit the day Resident #6 was admitted to the facility. She said Resident #6 was agitated upon arrival to the facility and when his behaviors escalated to pulling fire alarms and banging on doors, she called for additional staff assistance on the walkie-talkies used by staff. She said she had to wait for additional staff to arrive and by the time they were on the unit, multiple residents were overstimulated and having behaviors. She said Resident #6's behaviors lead to the altercation between Resident #9 and Resident #7. LPN # 1 was interviewed on 7/23/25 at 3:15 p.m. LPN #1 said Resident #4 used to ambulate more often and used to walk up to people and grab them. LPN #1 said she remembered Resident #4 ambulated up to residents and grabbed them on both 6/6/25 and 6/20/25. LPN #1 said it was very difficult to keep wandering residents away from Resident #4. She said many times there was only one CNA and one nurse on the unit. LPN #1 said some of the residents required two people for cares and it was difficult to to keep residents who wandered, like Resident #8 and Resident #9 away from Resident #4. CNA #4 was interviewed on 7/23/25 at 3:20 p.m. CNA #4 said Resident #4 would grab anything around him including peoples' hands or arms. She said according to the CNA charting, the resident had physical aggression towards staff and would grab at others. CNA #4 said she said had not seen Resident #4 grabbing at other residents but had observed the resident display physical aggression towards staff when there was loud noises. CNA #3 was interviewed on 7/23/25 at 4:07 p.m. CNA #3 said Resident #4 grabbed at multiple people, but it did not appear that he targeted specific residents. CNA #3 said Resident #4 would grab at anyone he could see and was close enough to him. CNA #3 said she often had Resident #4 grab and hold his own hand so Resident #4 did not grab or pinch her while she fed him.The NHA was interviewed on 7/23/25 at 5:12 p.m. The NHA said he recently started as the abuse coordinator in July 2025. He said physical abuse could have occurred any time a resident expressed they did not feel safe and staff should report all potential allegations to the DON within two hours of the incident. The DON was interviewed on 7/23/25 at 5:41 p.m. The DON said the facility staff had reviewed Resident #4's behaviors in interdisciplinary meetings. The DON said she thought Resident #4 was no longer grabbing at people because he had become mostly wheelchair bound due to his disease progression. She said she not aware of the behaviors observed on the unit on 7/22/25 or the other incidents of Resident #4 grabbing others found in the progress notes that were not investigated. Cross-reference F610 for failure to investigate allegations of physical abuse.The DON said now that she knew Resident #4 continued to grab at people while he was in his wheelchair, she planned to discuss new interventions to manage his behavior in the next interdisciplinary team meeting on 7/24/25.

Based on observations, record review and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#4 and #6) of seven residents reviewed out of 10 sample residents.Specifically, the facility failed to:-Effectively implement person-centered approaches for dementia care to prevent resident-to-resident altercations for Resident #4; and, -Effectively implement person-centered approaches for dementia care to prevent verbal and physical aggressive behavior as well as wandering/elopement behavior for Resident #6.Findings include: I. Facility policy and procedureThe Dementia Clinical Protocol policy and procedure, revised November 2018, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. The policy read in pertinent part, For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life.The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT.The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician.The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.II. ObservationsDuring a continuous observation of the secured unit on 7/22/25, beginning at 3:43 p.m. and ending at 5:19 p.m. the following was observed:At 4:40 p.m. Resident #4 returned to the secured unit after visiting with his spouse. At that time, Resident #4 began to bang his hands on the table. Certified nurse assistant (CNA) #2 asked Resident #4 if he was hungry and assisted Resident #4 with putting on a clothing protector before dinner. At 4:44 p.m. Resident #4 resumed banging his hands on the table. CNA #2 attempted to redirect Resident #4 again, this time with a sensory fidget blanket. Resident #4 called out, but could not be understood by others. At 4:50 p.m. Resident #4 grabbed Resident #8 by the left arm and activities assistant (AS) #1 separated the two residents. After completing the assessment of the left arm of Resident #8, licensed practical nurse (LPN) #2 asked Resident #4 about his needs including pain, hunger, thirst and toileting. Resident #4 responded but could not be understood due to his impaired speech. At 5:02 p.m. Resident #4 grabbed Resident #6. Facility staff separated the two residents again and no injuries were present.At 5:09 p.m. Resident #6 told LPN #2 that he wanted to leave. LPN #2 attempted to redirect Resident #6 by telling him he could not go anywhere without eating dinner. Resident #6 remained upset and walked down the hallway. LPN #2 attempted to walk and talk with Resident #6 until Resident #6 stopped walking and stood by the entrance doors to the unit. At 5:19 p.m. an unidentified staff member walked through the entrance doors to the unit. Resident #6 attempted to push past the staff member and leave the unit.III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted [DATE]. According to the July 2025 computerized physician's orders (CPO), diagnoses included anxiety, restlessness and agitation and dementia with other behavioral disturbances.The 5/20/25 minimum data set (MDS) assessment documented Resident #4 had severe cognitive impairments with short-term and long-term memory deficit and had communication deficits per staff assessment. Resident #4's speech was rarely or never understood by others and he had severely impaired vision. The assessment indicated the resident exhibited verbal behaviors (yelling, cursing, or threats) and physical behaviors (hitting, kicking, pushing, or grabbing) towards others. The assessment indicated the resident had other behavioral symptoms not directed toward others of disruptive sounds or screaming not directed at others.The assessment documented Resident #4 was dependent on staff for bathing, dressing, eating, and toileting.B. Record reviewResident #4's care plan, initiated on 12/2/24 and last revised on 6/22/25, indicated Resident #4 displayed behaviors of tapping his legs and reaching out to hold the staff or resident's arm for comfort if he was anxious. The care plan also documented Resident #4 was at risk for being the victim of resident-to-resident altercations due to his impaired speech and inability to recognize the personal space of other people. Pertinent The interventions included documented in the care plan was to speaking softly and gently to Resident #4 in order to redirect Resident #4 to more desirable activities or location. -Review of the resident's care plan did not include person-centered interventions to prevent Resident #4 from grabbing other residents multiple times (5/8/25 and 7/22/25). Cross reference F600: failure to protect residents from physical abuse. The July 2025 treatment administration record (TAR) (7/1/25 to 7/21/205) revealed the resident was on documented behavior monitoring for anxiety medication. The behaviors that were tracked included grabbing others, banging on walls or doors with his fist, and hitting or kicking during care. The TAR documented Resident #4 had these behaviors seven times. from 7/1/25 through 7/21/25-However, review of the resident's electronic medical record (EMR) did not include documentation indicating person-centered interventions were implemented when the resident displayed behaviors.The CNA behavior tracking task for Resident #4 (from 6/24/25 through 7/22/25), documented Resident #4 had the behavior of grabbing at others 17 times.C. Resident #4's representatives interviewResident #4's representative was interviewed on 7/23/25 at 11:03 a.m. She said when the facility first opened the memory care unit, it did not appear to her that the facility was adequately prepared for dementia residents. She said Resident #4 frequently grabbed at other people and did not understand how hard he was squeezing. She said his behavior did not seem aggressive or directed toward anyone, but related to his dementia and impaired vision and speech. 3. Resident #6A. Resident statusResident #6, age less than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included, traumatic brain injury, history of alcohol dependence with alcohol-induced persisting dementia, insomnia and epilepsy (a seizure disorder) .The 7/17/25 MDS assessment was not complete as Resident #6 had seizure activity requiring hospitalization 7/8/25 and returning to the facility 7/17/25. The nursing admission note, dated 7/19/25, documented Resident #6 was confused with short-term memory loss. The assessment also Resident #6 wandered frequently, was a high risk for elopement and was independent with most activities of daily living, but occasionally incontinent of bowel and bladder. The facility restorative nursing evaluation, dated 7/17/25, documented Resident #6 was able to ambulate independently and perform most activities of daily living independently. B. Record reviewResident #6's baseline care plan, initiated on 7/2/25, indicated Resident #6 displayed behaviors of wandering and elopement attempts with impaired safety awareness. Pertinent interventions included distracting the resident with pleasant activities including structured activities, food, conversation, television, or books, The July 2025 treatment administration record (TAR) documented behavior monitoring for antipsychotic medication. This excluded dates 7/10/25 through 7/17/25 due to a hospitalization. The behavior monitoring documented in the TAR included exit seeking, removing windows, physical aggression, and attempting to break into the nurses station to take items or food. The behavior tracking in the TAR documented Resident #6 with multiple listed behaviors each shift from 7/5/25 through 7/9/25 and on 7/18/25, 7/19/25, 7/21/25 and 7/23/25. The behavior tracking documentation for 7/22/25 (date of the observed elopement attempt) was incomplete.The CNA behavior tracking task for Resident #6 (7/2/25 to 7/9/25 and 7/18/25 to 7/22/25) documented Resident #6 was wandering seven times, yelling four times, grabbing or pushing others 10 times. -However, review of the resident's EMR did not include documentation indicating person-centered interventions were implemented when the resident displayed behaviors.IV. Staff interviewsAS #2 was interviewed on 7/23/25 at 2:06 p.m. AS #2 said Resident #4 frequently grabbed at people around him. She said she did one-to-one activities with Resident #4 because he could not participate in many group activities. AS #2 said she turned Resident #4's wheelchair to face everyone so he felt included even if he was not able to participate. AS #2 said she remembered the globe mirror (a mirror placed on the ceiling that allowed staff to look on the other side of the door) was installed while Resident #6 was in the hospital. She said she remembered there was communication sent to staff that they should contact the memory care unit staff via radio and to check the mirror to make sure the door was clear prior to entering the unit. LPN #1 was interviewed on 7/23/25 at 3:15 p.m. LPN #1 said the globe mirror near the entrance to the unit was installed around the time Resident #6 returned from the hospital. LPN #1 said she was not sure if there was official communication with staff about checking the mirror prior to entering the unit, but she did remember staff were supposed to call on the radio prior to entering the unit. She said not all staff members called but she felt safer doing so because she was not always able to tell if Resident #6 was in the corner near the door by only checking the mirror. CNA #3 was interviewed on 7/23/25 at 4:07 p.m. CNA #4 said she remembered doing computer training for dementia care and attending in person training but could not remember when. CNA #3 said she tried to keep the residents who wander away from Resident #4 to prevent Resident #4 from grabbing them. She said she had not worked much with Resident #6 since he returned from the hospital but she knew they installed a globe mirror near the entrance to the memory care unit so staff could see the other side of the door before opening it. She said she was not aware staff were supposed to call ahead on the radio prior to entering to make sure the door was clear and she said most staff did not. Registered nurse (RN) #1 was interviewed on 7/23/25 at 2:13 p.m. RN #1 said she recently started at the MDS coordinator for the facility, but was working as the unit nurse for the memory care unit on 7/23/25. She said she remembered the globe mirror was discussed in a safety meeting recently but did not remember if there was education or communication sent to all staff to check the mirror prior to entering the unit. RN #1 said she was not sure if staff were supposed to call on the radio prior to entering the unit since she did not regularly work on the unit, but most of the staff had not so far this shift. She said all forms of aggressive behavior needed to be documented to accurately manage residents behavior and make changes to the care plan with the goal of avoiding abuse or injuries. The DON was interviewed on 7/23/25 at 5:41 p.m. The DON said the staff were supposed to communicate with unit staff via radio to make sure the door was clear prior to entering the unit. The DON said she was not aware Resident #4 continued to grab people now that he was mostly confined to a wheelchair and she was not aware how frequently Resident #6 was yelling or physically aggressive toward others. The DON said she planned to discuss new interventions to manage his behavior in the next interdisciplinary team meeting on 7/24/25. The DON said regarding Resident #6, she was working with social worker and unit manager directly to complete Resident #6's care plan since the process was disrupted due to his hospitalization. The DON said many of Resident #6's behavior prior to his hospitalization was related to improper medication management and lack of communication from the previous facility about changes made to his medication prior to admission. The DON said she was not aware of the CNA documentation of Resident #6's aggressive behavior and planned to make corrections to his care plan.

Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for one (#4) of seven residents out of 10 sample residents.Specifically, the facility failed to thoroughly investigate two allegations of physical abuse by Resident #4. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation-Investigating and Reporting policy, revised September 2022, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. The policy read in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. All allegations are thoroughly investigated. The administrator initiates investigations.Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. The individual conducting the investigation as a minimum: reviews the documentation and evidence; reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his or her interactions with staff and other residents; interviews the person(s) reporting the incident; interviews any witnesses to the incident; interviews the resident (as medically appropriate) or the resident's representative; interviews the resident's attending physician as needed to determine the resident's condition; interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interviews the resident's roommate, family members, and visitors; interviews other residents to whom the accused employee provides care or services; reviews all events leading up to the alleged incident; and documents the investigation completely and thoroughly.II. Resident #4 1. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician's orders (CPO), diagnoses included anxiety, restlessness and agitation and dementia with other behavioral disturbances.The 5/20/25 minimum data set (MDS) assessment documented Resident #4 had severe cognitive impairments with short-term and long-term memory deficits and had communication deficits per staff assessment. Resident #4's speech was rarely or never understood by others and he had severely impaired vision. The assessment documented Resident #4 was dependent on staff for bathing, dressing, eating and toileting.The assessment indicated the resident exhibited verbal behaviors (yelling, cursing, or threats) and physical behaviors (hitting, kicking, pushing, or grabbing) towards others. The assessment indicated the resident had other behavioral symptoms not directed toward others of disruptive sounds or screaming not directed at others. 2. Record reviewThe progress noted, dated 6/6/25 at 4:50 p.m., documented Resident #4 reached out and firmly grabbed and held three residents within an hour. The other unidentified residents tried to get him to let go and each time Resident #4's hand had to be pried off of the other resident by staff. The action resulted in return aggression from one of the unidentified residents. The note documented no injuries were sustained.The progress note, dated 6/20/25 at 10:25 a.m., documented Resident #4 walked up behind an unidentified resident in their wheelchair, grabbed the resident by the shoulders and squeezed them. Licensed practical nurse (LPN) #1 documented the unidentified resident was irritated by this behavior.A request was made on 7/23/25 for an investigation into the abuse allegations in the resident's electronic medical record (EMR). -The facility was unable to provide documentation to indicate an investigation was conducted related to the 6/6/25 and the 6/20/25 progress notes regarding Resident #4's physically aggressive behaviors. V. Staff interviewsLPN # 1 was interviewed on 7/23/25 at 3:15 p.m. LPN #1 said Resident #4 used to ambulate more often and used to walk up to people and grab them. LPN #1 said she remembered that Resident #4 grabbed other residents on both 6/6/25 and 6/20/25. She said she did not remember which residents he grabbed and she did not remember which residents became upset due to Resident #4's behavior. LPN #1 said she did not recall speaking with the DON about either altercation. LPN #1 said Resident #4 frequently grabbed out at people near him and the behavior did not appear targeted to anyone. She said residents who wandered should be directed away from Resident #4 to prevent them from being grabbed.The nursing home administrator (NHA) was interviewed on 7/23/25 at 5:12 p.m. The NHA said he recently began as the abuse coordinator in July 2025. He said anytime a resident made an allegation of hitting, kicking, slapping, or grabbing residents without consent it should be investigated. He said physical abuse could have occurred any time a resident expressed they did not feel safe and staff should report all potential allegations to the DON within two hours of the incident. The NHA said the DON also reviewed documentation and if she noted anything suspicious, she contacted the NHA to investigate. The NHA said he was not aware of the 6/6/25 or the 6/20/25 progress notes describing resident-to-resident altercations with Resident #4 because they occurred prior to when he began as the abuse coordinator. The DON was interviewed on 7/23/25 at 5:41 p.m. The DON said she had not seen either progress note describing Resident #4's resident-to-resident altercations until the time of the interview. The DON said she thought Resident #4 was no longer grabbing at people because he had become mostly wheelchair-bound due to his disease progression. The DON said after reading the progress notes, she would have investigated the allegations described if she had known about them earlier. The DON said now that she was aware of the allegations of Resident #4's continued grabbing of other residents, she planned to discuss with the interdisciplinary team to prevent Resident #4 from grabbing other wandering residents.

Based on observations, record review and interviews, the facility failed to ensure one (#1) of three residents out of three sample residents received treatment and care for optimal skin condition of a pressure wound, in accordance with professional standards. Specifically, the facility failed to: -Develop and implement a care plan for Resident #1's pressure ulcers; and, -Ensure interventions were implemented timely to prevent the development and worsening of a pressure injury for Resident #1. Findings include: I. Professional reference According to the All [NAME] Tissue Viability Nurse Forum, Best Practice Statement on the Prevention and Management of Moisture Lesions, September 2023, retrieved online 4/4/25 from:chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.wwic.[NAME]/uploads/files/documents/Professionals/Clinical%20Partners/AWTVNF/All_Wales-Moisture_Lesions_final_final.pdf Individuals with incontinence may also have problems with mobility and, as a result, be at risk of developing pressure ulcers as well as moisture lesions. Consequently, when inspecting an individual's skin, it may be difficult to tell if the damage to the skin is caused by moisture alone or moisture in combination with pressure. If the skin is subjected to moisture and pressure, then the treatment strategy will have to overcome both of these insults to the skin. Therefore, along with guidance on how to prevent and manage moisture on the skin, pressure relief will be an important part of care for the individual. Repositioning together with the use of pressure-relieving equipment are the main methods of preventing pressure damage caused by extended periods of localized pressure on the skin. The use of repositioning should be considered in all at-risk individuals as a prevention strategy and should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body. The repositioning schedule should take into account the daily activities of the individual, their ability to tolerate pressure when in the seated and lying positions and the support surfaces in use. If a moisture lesion does not respond to interventions to minimize the effects of moisture alone, then the clinician should consider whether pressure is contributing to the damage and introduce repositioning and pressure relief into the individual's care. II. Resident #1 A. Resident status Resident #1, age greater than age 65, was admitted on [DATE] and discharged on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included acute kidney failure, malignant neoplasm of the prostate (prostate cancer), cognitive communication deficit, weakness and need for personal care. The 2/25/25 minimum data set (MDS) assessment indicated Resident #1 had severe cognitive impairments with a staff assessment for mental status. The resident required staff assistance for most of his activities of daily living (ADLs) and used a wheelchair for mobility. B. Record review The pressure ulcer care plan, initiated 11/2/24, documented Resident #1 had the potential for a pressure ulcer/injury to his coccyx or potential for pressure ulcer development related to dehydration, and immobility. The care directed staff to document the resident's treatment weekly. According to the care plan, the documentation should include the measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. -The pressure ulcer care plan did not identify interventions to prevent the development of a pressure ulcer to his coccyx were identified on his care plan. The skin impairment care plan, initiated 12/20/24, documented Resident #1 had the potential impairment to his skin integrity due to his fragile skin. The care plan indicated the resident had a stage 2 and stage 3 pressure ulcer/injury. According to the care plan, the resident was anticipated to have a decline in his skin condition and would have interventions to help maintain his comfort. The following interventions were put in place after Resident #1 developed pressure injuries: specialty bed air mattress, initiated 12/20/24; pressure relieving bed mattress, initiated 12/27/24; avoid scratching and keep his hands and body parts away from excessive moisture and keep his fingernails short, initiated 12/27/24; and, encourage good nutrition and hydration in order to promote healthier skin, initiated 12/27/24. The 10/22/24 admission data collection assessment did not identify Resident #1 had any issues or indications of a pressure injury on his admission to the facility. According to the assessment, the resident had no history of skin issues. The October 2024 CPO revealed a physician's order that directed staff to treat Resident #1's coccyx with soap and water and cover it with bordered foam sacral dressing, ordered on 10/29/24 and discontinued on 12/15/24. -The EMR did identify documentation of a coccyx wound found on 10/29/24 requiring treatment or if coccyx was treated as directed by the physician. Review of the November 2024 and December 2024 medication administration record (MAR) and treatment administration record (TAR) did not identify Resident #1's coccyx was cleansed with soap and water and covered with bordered foam sacral dressing per the physician's order. The 10/29/24 Braden Scale assessment (a tool for predicting pressure ulcer risk) identified Resident #1 was at moderate risk for developing pressure sores. -Review of the resident's electronic medical record (EMR) did not reveal the reason the nurse requested treatment on 10/28/24 (see interviews below). The 10/29/24 skilled charting assessment documented Resident #1's skin was pale, warm and dry. -The skilled charting assessment did not identify concerns with the resident's skin. The 10/29/24 skin and wound total body assessment documented the resident had no new wounds. The 11/10/24 nursing progress note identified Resident #1's resident representative was told the resident had a wound on his coccyx. According to the note, the resident's coccyx would be looked at during wound care on the following morning (11/11/24). -Review of Resident #1's electronic medical record (EMR) did not reveal the resident was assessed by the wound care team on 11/11/24. A 11/11/24 general note documented Resident #1 did not have an open area or a wound but had a dressing over his sacral area to prevent skin breakdown due to his bony prominence. According to the note, the resident's representative felt the resident was not being assisted out of bed. The note documented the resident was given a choice to get out of bed and he wanted to eat in his room. The note documented the staff could encourage Resident #1 to spend time out of bed. -Review of the pressure ulcer risk care plan, dated 11/2/24, did not identify staff were directed to encourage the resident to spend time out of bed or interventions for the resident to offload pressure off his bony prominences. The 10/29/24 skin and wound total body assessment documented the resident had no new wounds. Review of Resident #1's skin and wound total body assessment on 11/5/24, 11/12/24, 11/19/24 and 11/26/24 did not document the resident had new wounds. The 11/28/24 progress note documented a certified nursing assistant (CNA) notified the nurse of an open area to Resident #1's sacrum when she was changing his brief. The open area measured 1.9 centimeters (cm) length by 1.9 cm width. According to the note, the area was cleansed and hydrocolloid dressing (moist dressing designed to absorb fluids) was applied to the area. The physician was notified. Review of the November 2024 and December 2024 CPO did not reveal a physician's order for hydrocolloid dressing or how often the open area should be cleansed and covered with hydrocolloid dressing. Review of the November 2024 and December 2024 MAR and TAR between 11/28/24 and 12/15/24, did not identify Resident #1's open area to his sacrum was cleansed and treated hydrocolloid dressing with coccyx was cleansed with soap and water and covered with bordered foam sacral dressing. The 11/28/24 situation background assessment and recommendation (SBAR) summary for providers note identified Resident #1 had a change of condition related to a skin wound or ulcer. According to the note, the resident did not like to lay on his side so a pillow was placed behind him to help him offload pressure from his back. -The intervention to place a pillow behind Resident #1 to help him offload pressure was not included on the resident's above care plan. The 12/10/24 nursing progress note documented Resident #1 had two more open areas to his buttocks. According to note, the open areas were cleansed and re-dressed. The note did not identify the location of the open areas on his buttocks, the condition, the appearance or the causation of the two additional open areas to his buttocks. Review of the resident's EMR did not identify the nurse assessed and documented measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate on 12/10/24 or shortly after the identification of the new wounds. The 12/13/24 nutrition note documented Resident #1 was not interested in eating but he requested to walk to the dining room because he still felt he had pep. The registered dietitian (RD) increased his oral nutritional supplement to three times a day with meals. The RD recommended Resident #1 be encouraged to get out of bed for repositioning/off-loading due to his stage 2 pressure injury to his coccyx. -The review of the resident's care plan did not direct staff to encourage and assist the resident to get out of bed for repositioning and off-loading. The care plan did not direct staff to assist or encourage the resident to walk to the dining room for meals. The 12/13/24 skin and wound evaluation revealed Resident #1 had a stage 3 pressure ulcer with full thickness skin loss on medial sacrum (on the center of his sacrum bone). The stage 3 injury was identified as a new wound, facility acquired and deteriorating with 100% slough. The pressure injury measured 3.3 cm length by 2.2 cm width with fragile surrounding skin with risk for breakdown. The pressure injury was identified as healable. According to the evaluation, the wound was treated with generic wound cleanser and hydrocolloid foam dressing. The wound documented the resident had pain during the dressing application. The evaluation indicated the use of a low air loss air mattress, educating staff to turn and reposition the resident frequently and to get the resident up out of bed for meals. The evaluation documented the facility was waiting for the arrival of a low air loss air mattress. -The review of the December 2024 TAR revealed the pressure redistribution mattress/low air loss/alternating pressure mattress for prevention and pressure relief, was not in place for use until 12/21/24, seven days after it was identified as intervention to his pressure ulcer. -The evaluation did not identify a second open area to the resident's buttock as identified in the above 12/10/24 nursing note. Review of Resident #1's December 2024 CPO revealed the following physician's orders: Daily wound review on every shift for wound management of Resident #1's sacrum, ordered 12/15/24 and remained an active till his discharge. Daily wound review on every shift for wound management of Resident #1's left gluteus, ordered 12/15/24 and remained an active till his discharge. Left gluteal wound care: Cleanse with wound cleanser; apply 3 by 3 hydrocolloid and cover with bordered foam dressing; change every dressing on Monday, Wednesday and Friday, ordered 12/15/24 and discontinued 12/21/24. Sacral wound care: cleanse wound with wound cleanser; apply 3 by3 hydrocolloid; cover with bordered foam dressing; change every Monday, Wednesday and Friday, ordered 12/16/24 and discontinued 12/21/24. The 12/18/24 electronic medical administration record (EMAR) general note documented Resident #1 received a daily wound review on 12/18/24. The note identified Resident #1 had a wound on his sacrum and on his left gluteus. According to the note, staff should document every shift for his sacrum and left gluteus wound management document the condition of his wound bed, drainage amount, odor, surrounding skin and pain level and dressing situation. The 12/19/24 wound initial note identified Resident #1 had a consultation from a wound care physician (Physician #1) to review two pressure ulcers/injuries. The note documented Resident #1 had an unstageable pressure injury to his sacrococcyx and a stage 3 pressure injury to his left buttock. The wound note revealed the sacrococcyx unstageable pressure injury measured 3.5 cm by length 3.5 cm width by 0.4 cm depth with 100% slough. The stage three pressure injury to the resident's left buttock measured 2.5 cm length by 2.5 cm width x 0.1 cm depth with 100% granulation. According to the note, the treatment recommendations were identified as the following: clean the sacrococcyx with normal Saline (a salt water solution); apply Santyl (ointment to remove dead skin) and gauze; change the dressing daily and as needed if the dressing became dislodged, saturated or soiled. The wound initial note identified the wound care physician directed staff to implement pressure relieving measures and offloading as tolerated; prevent contact of his heels with the bed or other surface and TO consult with the RD to optimize nutrition per facility or dietary protocol to promote wound healing. The wound care note indicated the wound care physician would re-evaluate Resident #1 in one to two weeks. The 12/20/24 interdisciplinary note (IDT) note documented the Resident #1 was placed on weekly wound arounds as of 12/19/24 and was currently getting up for meals. Review of wound treatment notes between 1/2/25 and 2/13/25 identified the wound physician continued to evaluate Resident #1's wound and adjust the treatment plan. On 1/2/25 the unstageable Sacrococcyx pressure was documented as unavoidable. On 1/9/25 the pressure to his left buttock was resolved. III. Staff interviews The director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 4/15/25 at 4:29 p.m. The DON said the facility inspected the resident's skin weekly, applied lotion to the skin after bathing and changing the resident, encouraged food and fluid intake, encouraged them to spend time out of bed and had the RD assess the resident's nutritional needs for pressure injury prevention. The DON said the facility provided specialty cushions depending on the needs of the resident and air mattresses if the resident was at high risk for pressure injuries and or had current pressure injuries. She said the air mattresses were low air low mattresses that helped alternate pressure for residents that were not able or unable to reposition on their own. She said the staff repositioned the residents at least every two hours and that should be included on the resident's care plan. The DON said Resident #1 was identified a risk for pressure injuries and developed pressure injuries while admitted to the facility. Resident #1 was not placed on an alternating pressure air mattress when his risk for pressure injuries was identified because his discharge plan was to receive therapy and return to the community. She said the alternating pressure air mattress was usually reserved for long term residents with an actual pressure injury. The NHA said all residents were provided a pressure redistribution mattress. The DON said the facility did not have a wound care certified nurse. She said she was not sure if Resident #1 was seen by his physician after the resident was identified to have an open area to his sacrum on 11/28/24. She said the resident was seen by a wound care physician on 12/19/24. The DON said she reviewed the resident's EMR and said the physician was notified of the open area on 11/28/24 but she could not find documentation to show the resident's physician saw the wound or was updated on the status of the wound between 11/29/24 and 12/17/24. The nursing home administrator (NHA) and the DON were interviewed together on 4/16/25 at 11:00 a.m. The DON said the nurses were responsible for nursing care provided but she was responsible for the overall wound care of the facility residents. The DON said Resident #1's pressure injuries were facility acquired. The DON said the resident was provided the alternating pressure air mattress in December 2024 because he had an open area, he refused to get out of bed or reposition and had bony prominences. -However, review of the progress notes and care plan did not identify the resident refused to be repositioned. The review of the progress notes only documented the resident refused to get out of bed on 11/11/24 when his representative asked why was not out of bed and on 11/16/24 when he did not want to get out of bed to take a phone call at the nursing station. The DON said she did not know why the nurse on 10/28/24 requested a treatment order for Resident #'s coccyx on 10/28/24. The DON said she was not informed of a concern to his coccyx and an assessment was not completed to identify the resident would need treatment orders. The DON said she did not know why a nurse told the resident's representative on 11/10/24 that Resident #1 had a wound to his coccyx and he would be included in wound rounds. The DON said she thought there may have been some miscommunication to the nurse and the resident was not scheduled to be seen in wound rounds. She said wound rounds would be documented in the resident's medical record. The DON said the resident was not placed on wound rounds after an open area was identified on 11/28/24 because the nurses were doing the wound care. She said she conducted the wound wounds but all nurses were responsible for wound care. She said the wound on his sacrum worsened while he was admitted to the facility. The DON said the open area to the resident sacrum was a pressure injury due to lack of nutritional intake and refusal to get out of bed. She said staff would have repositioned him every two hours but the repositioning would not have been documented. The DON said the care plan should have included repositioning, encouraging him to get out of bed and that he refused. She said the care plan did not direct staff on what to do if the resident refused. She said the care plans needed improvement. The DON said she did not know why a nurse documented the resident had two more open areas on his buttocks or if one of the areas referenced the open area on his sacrum. She said if there were additional open areas then there should have been an assessment, new orders, interventions and tracking. The DON said she observed the resident's sacrum/coccyx on 12/17/24 and identified an open area with slough and determined the resident required mechanical debridement (the physical removal of unhealthy tissue). The DON said Resident #1 was seen by the wound physician through telehealth on 12/19/24 where he found two open areas. The DON and the NHA were interviewed again on 4/16/25 at 1:45 p.m. The DON said when a resident had a change in condition such as a change in the resident's skin, the facility would document the change and monitor the resident for 72 hours on every shift. The DON said a wound care specialist would not be involved in the resident's skin care if the facility nurse felt the management of Resident #1's wound could be handled by staff. The DON said there was no wound care documentation of Resident's sacrum wound and thinks he may have been missed or tracked. The DON said in December 2024 she did not know the resident should have had daily a wound review after a wound was identified. The DON said the nurses did not complete the weekly skin assessments for Resident #1. The DON said she assessed Resident #1 on 12/13/24 and the wound worsened from 1.9 cm by 1.9 cm to 3.3 cm by 2.2 cm with 100% slough. The DON said she continued the same intervention of hydrocolloid until the resident was seen on 12/19/24 with the wound physician. The DON said the facility needed to continue to improve on documentation, communication, showing refusals and interventions and tracking skin concerns. She said the facility needed to increase their education on wound care and she was in the beginning stages of working becoming wound care certified. The NHA said the facility would immediately start educating staff. She said in May 2025, a wound care physician would be able to see the resident's in person and not on telehealth. The NHA was interviewed on 4/16/25 at 2:25 p.m. The NHA said she spoke with the facility's clinical consultant and was directed to start a whole facility review of resident skin and wounds. She said based on the findings, new treatment and interventions would be implemented and the care plans would be updated.

Based on record review and interviews, the facility failed to ensure residents or their representative were aware of the nature and implications of the facility's arbitration agreement to inform their decision on whether or not to enter into such agreements for six residents (#21, #22, #36, #42, #43 and #46) of six out of 32 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure residents and/or resident representatives understood the agreement before signing the arbitration agreement; -Accurately inform residents and/or resident representatives when the agreement could be rescinded before the agreement was signed; and, -Ensure staff reviewing the arbitration agreement with residents and the residents' representatives understood the components of the agreement. Findings include: I. The Arbitration Agreement The Voluntarily Executed Mutual Arbitration Agreement, undated, was provided by the nursing home administrator (NHA) on 1/22/24. The agreement read in part: This document waives the right to a trial by judge or jury: read carefully. Your decision to enter this agreement is voluntary and not a condition of admission to the community. However, once executed, the agreement requires arbitration of claims as defined and explained below. Agreement to arbitrate. Arbitration is a cost effective, private and time saving alternative means of resolving disputes outside of the courts. The dispute is heard and decided by a neutral arbitrator selected by the parties, rather than a judge or jury. This agreement does not waive or limit any party's right to assert claims against the other party, but rather provides an alternative venue for those claims to be resolved. By executing this agreement, the resident and community agree that any and all actions, claims, controversies, or disputes of any kind whether in contract or tort, statutory or common law personal injury property damage, legal or equitable, or otherwise, either currently existing or arising in the future, arising out of or relating in any way to the to the provision of assisted living, skilled nursing or healthcare services or any other goods or services provided under the terms of any agreement between the parties, including disputes involving the scope of this agreement, or any other dispute involving acts or omissions that cause damage or injury to either party and including wrongful death and survival actions, and where the amount in controversy exceeds $25,000 (collectively,'Claims'), shall be resolved exclusively by binding arbitration and not by lawsuit or the judicial process (except to the extent that applicable law provides for judicial review of arbitration proceedings). The resident has the right to seek legal counsel concerning this agreement, and has the right to rescind this agreement by written notice to us within 90 days after the agreement has been signed and executed by both parties unless said agreement was signed in contemplation of the resident being hospitalized in which case the agreement may be rescinded by written notice to us within 90 days after release or discharge from the hospital or other health care institution. Both parties to this agreement, by entering it, have agreed the use of binding arbitration in lieu of having any such dispute decided in a court of law before a jury. The agreement shall continue in full force and effect beyond the residents' stay at the community and shall survive death of the resident and the existence or operation of the community. The agreement shall be binding on this and all subsequent admission/readmissions to, or transfers within, the community. If any provision, sentence, word, phrase, paragraph, or portion of this agreement is declared to be unlawful, invalid or unenforceable for any reason, the remaining terms and provisions of this agreement show remain in full force and effect. The parties acknowledge agree that: -The community has explained this agreement to the resident and his/her legal representative, if present and provided the resident and his or her legal representative with an opportunity to ask questions; -Each party has executed this agreement on their own free will and without corrosion or distress from the other; -The resident has been informed of the legal right to seek legal counsel concerning this agreement at his or her own cost; -Execution of the agreement is not a precondition of residency or to the receipt of services from the community; and, - The community has provided a copy of the fully executed agreement to the resident and or his legal representative. This agreement contains a binding arbitration provision which may be enforced by the parties. By signing this agreement, the parties understand and agree that they are relinquishing and waiving their right to have any claim decided in court of law before a judge or a jury. Instead, disputes between the parties shall be resolved by the binding arbitration agreement. By signing this agreement you are agreeing to have any issue of medical malpractice decided by neutral binding arbitration rather than by a jury or a court trial. II. Staff interview The NHA was interviewed on 1/24/24 at 2:10 p.m. The NHA said the facility asked residents and /or the residents' representatives to enter into an arbitration agreement. She said the agreement was included in the admission packet. The arbitration agreement was reviewed with residents and or the residents' family representatives on admissions with the social service director (SSD). The social service director (SSD) was interviewed on 1/24/23 at 2:25 p.m. The SSD identified herself as the family advisor and was responsible for reviewing new admission paperwork with residents and/or the resident's representative/family. She said she had been reviewing arbitration agreements with the new admission residents and/or their representatives for at least a couple of years. The SSD said the arbitration agreements were not a condition for admission to the facility. Resident #43's arbitration agreement was reviewed with the SSD. The resident signed his own arbitration agreement. The SSD said Resident #43 had a recent and significant increase in his confusion. She said when the resident was admitted to the facility in November 2023 he seemed cognitively intact. The SSD said the resident or the resident representative would sign the agreement based on the resident's cognition to determine who would sign the electronic documents. The SSD said during the admission process she did not review the hard copies of the arbitration agreement with the resident and/or the resident representative. The SSD said the agreement was on her computer. She said she would briefly explain the agreement and then had the resident or their representative sign the agreement electronically. The resident or their representative could have a copy of the agreement if they wanted one. The SSD said she reviewed the arbitration agreement with the residents and/or the residents representatives by telling them not to go to court. She said to let the facility know if there were any concerns so the facility could fix it. The SSD said her understanding of the arbitration agreement was to address grievances. She said she wanted the residents and their families to feel comfortable with telling the facility their concerns/complaints. The SSD said if the concerns were not able to be resolved in the facility, the residents and/or representatives were informed then the resident/representative and the facility would address the concerns in mediation. The SSD said the residents and/or the residents' representatives could rescind the agreement but she was not sure the details to rescind or the exact time period when the residents and/or the residents' representatives could rescind the agreement. She said she felt residents could complain at any time so she did not give them a timeline. She said when she reviewed the arbitration agreement, she reviewed it more as a grievance process. The SSD said residents and/or the resident's representatives may still go to court to settle a dispute with the facility after signing the agreement. The SSD said first there was meditation to attempt to resolve and then there would be an option to go to court. She said the residents and their representatives could still do what they want after signing the arbitration agreement. The SSD reviewed the arbitration agreement she provided the residents and/or the representatives. The SSD said she had been misinterpreting the arbitration agreement when reviewing it with the residents and/or their representatives. The SSD said she probably should read the agreement in detail. She said she thought the agreement was just about the resident's right to complain. She said she thought that if the resident and/or representative signed the agreement, they still had the right to sue. She said according to the arbitration agreement by signing the agreement, the right to court was waived. The SSD said she did not know residents and/or representatives had only 90 days to rescind the agreement. She said she did not tell the residents and/or representatives they had only 90 days to change their mind after signing the agreement. The SSD said she needed time to sit down and read the complete admissions packet the residents and/or representatives sign. She said she was not trained on all the admission paperwork including the arbitration agreement. She said she had another admission this afternoon (1/24/24) and now had a better idea on what to tell the admission about the arbitration agreement. The NHA was interviewed on 1/24/24 at 3:05 p.m. The NHA said all but one resident in the facility had a signed arbitration agreement in place. The NHA was interviewed again on 1/24/24 at 5:52 p.m. The NHA said she was only involved in the arbitration process if a resident requested to go into arbitration. She said her understanding of the agreement was a resident had 90 days to rescind the arbitration agreement after it was signed. The resident or resident representative would go into mediation to review the dispute between the facility and the resident or representative instead of first going through the court system. The NHA said the resident could still go to court with an arbitration agreement in place but she was not totally sure. The NHA said she was not aware of the amount of facility admission training the SSD had or who provided her with the training to complete admission paperwork but the SSD had been in role for a while. III. Record review The facility admission packet was provided by the NHA on 11/13/23. The admission packet included the binding arbitration agreement. Arbitration agreements for Resident #21, Resident #22, Resident #36, Resident #42, Resident #43 and Resident #46 were provided by the facility on 1/24/24. Two of the signed agreements were signed by the resident representative. Four of the arbitration agreements were signed by the resident. All the arbitration agreements were signed by the SSD as the facility representative. The following arbitration agreements were reviewed: Resident #21 was admitted to the facility on [DATE]. The arbitration agreement was signed by Resident #21's representative on 11/12/23. The arbitration agreement was signed by the SSD on 11/12/23. Resident #22 was admitted [DATE]. According to the 12/7/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for a mental status (BIMs) score of six out of 15. The arbitration agreement was signed by Resident #22 on 12/4/23. The arbitration agreement was signed by the SSD on 12/4/23. Resident #36 was admitted [DATE]. The arbitration agreement was signed by Resident #36's representative on 12/21/23. The arbitration agreement was signed by the SSD on 12/21/23. Resident #42 was admitted on [DATE] and readmitted to the facility 12/5/23 after a 11/27/23 discharge. According to the 11/15/23 MDS assessment, the resident was cognitively intact with a BIMs score of 15 out of 15. The arbitration agreement was signed by Resident #42 on 11/12/23 and again on 12/6/23. The arbitration agreement was signed by the SSD on 11/12/23 and again on 12/6/23. Resident #43 was admitted [DATE]. According to the 11/30/23 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The arbitration agreement was signed by the Resident #43 on 11/24/23. The arbitration agreement was signed by the SSD on 11/24/23. Resident #46 was admitted [DATE]. According to the 1/2/24 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The arbitration agreement was signed by the Resident #46 on 12/28/23. The arbitration agreement was signed by the SSD on 12/28/23. IV. Representative interviews The representative of Resident #36 was interviewed on 1/25/24 at 9:24 a.m. The terms of the arbitration agreement were not reviewed with him. The representative said was provided with a copy of the agreement but had not read it thoroughly yet. He said he had a basic understanding of what arbitration was but was not aware he had only 90 days to change his mind after signing the agreement. He said he signed the agreement in December 2023 and was happy to know about the deadline and still had to rescind the agreement if he chose to. The representative of Resident #21 was interviewed on 1/25/24 at 11:10 a.m. The representative said she did not remember the facility going over an arbitration agreement when she admitted Resident #21 to the facility. She said she agreed verbally to a lot of things during the admission process but she did not actually sign anything including an arbitration agreement. The representative said she did not get a copy of the arbitration agreement. She said if something happened to Resident #21 during his stay at the facility she would like the option to go to court. V. Resident interviews Resident #43 was interviewed on 1/22/24 at 10:46 a.m. The resident was able to make basic needs known during the interview but was not able to answer questions regarding his stay at the facility. Resident #46 was interviewed on 1/25/24 at 10:54 a.m. Resident #46 said he said he did not know what was going on when he admitted . He said he had health issues that led to some confusion when he was admitted to the facility. He said he signed paperwork but he was not sure what he signed. He said he did not know what arbitration was. He said he wanted to know he signed something he was not familiar with and to be able to change his mind. Resident #46 said he signed what the facility gave him to sign. The resident said he did not read anything he signed. He said he did not read or write well. Resident #22 was interviewed on 1/25/24 at 6:37 p.m. Resident #22 said she did know what an arbitration agreement was. She said she did not remember anyone explaining the agreement to her or that she had 90 days to cancel it. She said the facility could have told her when she was admitted but she was so emotional during that time, she did not remember signing it. Resident #42 was interviewed on 1/25/24 at 7:25 p.m. He said he did not know what an arbitration agreement was and did not think he signed the agreement. He said he did not remember anything explained about the 90 days. VI. Facility follow up The NHA and the corporate consultant (CC) were interviewed on 1/25/23 at 7:08 p.m. The NHA said the facility was changing the form to help improve the comprehension of the agreement and staff would be educated on the arbitration process. The CC said training would be provided throughout the corporation to nursing home administrators and the family advisors on the arbitration agreement. The CC said the facility would review all the current arbitration agreements and review the agreement with the residents and/or resident representatives.

Based on observations, interviews and record review, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure: -The residents in the dining room did not have prolonged wait times of 30 minutes or longer for their meal to be served; and, -Room trays were delivered to all neighborhoods and served to the residents at the regular posted meal times. Finding include: I. Posted meal times Meal times were posted across the facility as the following: Breakfast at 8:00 a.m. Lunch at 12:00 p.m. Dinner at 5:00 p.m. II. Observations On 1/22/24 at 11:50 a.m., three residents were in the dining room waiting for lunch. -At 12:21 p.m. the first meal went to [NAME] Halls. -At 12:53 p.m. East Halls still had yet to be served their trays. -At 1:11 p.m. the meal cart was placed in the East Halls and the certified nurse aide (CNA) started serving C Wing first. -At 1:24 p.m. the meal cart went to the East Hall to serve D Wing. -At 1:35 p.m. all meals were served. -The meals were all served one hour and 35 minutes over the posted meal time. -There were activities scheduled for after lunch and residents arrived to them late because their lunch was served late. On 1/23/24 at 1:19 p.m. Resident #37 was in East Hall shaking his head and frowning. He said he had been waiting for his lunch. His meal arrived at 1:21 p.m. Resident #37 said he was not sure if he was going to be able to attend the resident group interview and physical therapy because his lunch was served late. He said he missed some appointments and activities because of late meals. On 1/24/24 at 4:41 p.m. the kitchen was finishing preparing the sides for dinner and making sure the food was up to serving temperature. -At 4:57 p.m. the kitchen staff waited to plate meals until CNAs were at the kitchen door to serve the plates. -At 5:02 p.m. the kitchen started plating the residents who ordered the alternative meal in the dining room. -At 5:10 p.m. a CNA asked the kitchen if they could plate Resident #21 because he was getting upset in the dining room. -At 5:11 p.m. Resident #21's plate had the wrong texture and the kitchen staff attempted to fix it but ran out of mechanical soft noodles and had to make more. -At 5:23 p.m. Resident #21's plate was sent to the dining room. -At 5:41 p.m. the dining room was served 41 minutes over the posted meal time and the kitchen staff began getting the meal cart ready for [NAME] Hall; Wing A and Wing B. -At 5:45 p.m. the [NAME] Hall meal cart was sent 45 minutes over the posted meal time and the kitchen staff prepared the meal cart for East Hall; Wing C and Wing D. -At 5:53 p.m. mechanical soft noodles were dropped on the floor and had to be remade. -At 6:11 p.m. the meal cart was sent to East Hall one hour and 11 minutes over the posted meal time. -At 6:14 p.m. Wing C was served one hour and 14 minutes over the posted meal time. -At 6:22 p.m. Wing D was served one hour and 22 minutes over the posted meal time. On 1/25/24 at 9:10 a.m. Resident #21 was self-propelling in his wheelchair and headed back to his room from the dining room. He said he was still waiting for his breakfast. He said all meals were late and most days he played a guessing game of which meal he would get first, breakfast or lunch. -The resident received his breakfast one hour and 10 minutes over the posted meal time. -At 12:53 p.m. East Halls still had yet to be served their trays. Resident #37 self-propelled in the hallway while waiting for his lunch. He said he was hungry and looked to see if the meal cart was leaving the kitchen yet. -The resident's lunch arrived at 1:09 p.m. one hour and nine minutes over the posted meal time. III. Resident interviews Resident #9 was interviewed on 1/22/24 at 2:34 p.m. She said she ate in her room and meals were getting served later and later. She said hot foods and cold foods were lukewarm by the time they were served to the halls. She said the dessert was usually an individual ice cream and was usually melted by the time it was served in the rooms. IV. Resident group interview The resident group was interviewed on 1/23/24 at 1:42 p.m. with Resident #6, Resident #9, Resident #4, Resident #17, Resident #12 and Resident #13. Resident #9 and Resident #13 arrived late due to being served their lunch late and needing to eat. The group said meals were late and foods were served cold and residents were not woken up for breakfast which made their food even colder. The group said when the residents told staff their food was cold the staff told them I am sorry there is nothing I can do. The group said when the meals were served late it affected their schedules and made them feel terrible. Resident #4 said it upset her because then she felt like it was her fault she was late for something she had scheduled because her meal was late. V. Staff interviews The dietary manager (DM) was interviewed on 1/24/24 at 6:58 p.m. He said the posted meal times were when he had the kitchen start plating the meals. The DM said it did not necessarily mean that was when the meals were to be served. He said meals were sometimes late because he had a new team in the kitchen and they were trying to get a better flow. CNA #3 was interviewed on 1/25/24 at 3:31 p.m. She said when dinner was posted for 5:00 p.m. she said plates should be served to the residents at 5:00 p.m. She said most of the time the halls did not get the meal carts until 6:30 p.m. She said the residents were really angry when they waited for their meals.

Based on interviews, observation, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure staff were prepared for a potential threat of fire. The lack of preparation resulted in residents scared, anxious, removed from their beds at night, placed outside in parking lots with smoke filled air, and for some, without supplemental oxygen as needed during a facility wide evacuation on 9/23/22. The lack in preparation for a potential emergent threat, included the failure to have a complete and thorough emergency preparedness training program, specifically fire training, to identify when residents should be evacuated and when residents should be placed behind closed fire doors. According to interviews with management the staff panicked and overreacted. The absence of adequate training, resulted in a chaotic situation as identified by a resident family member, referring to the evacuation on 9/23/22. The facility was also unprepared to handle residents' supplemental oxygen needs in an event of an emergency. The facility failed to establish an efficient oxygen management system in place to ensure residents who required supplemental oxygen and/or had [CONDITION(S)] ([CONDITION(S)]) with a need for continuous oxygen, had it available to them as required and on demand as needed. The facility did not routinely fill portable oxygen tanks or effectively monitor the oxygen levels in the portable tanks. Further investigation identified the portable oxygen tanks were difficult to fill, time consuming, and the liquid oxygen would often freeze up during the filling of the tanks. These failures resulted in some of the residents who needed the supplement oxygen, did not have it available to them for a for extended amount of time during the evacuation on 9/23/22, causing residents unnecessary physical and mental stress, specifically Resident #7. Resident #7 had a physician's order for the continuous use of oxygen related to acute and chronic respiratory failure with [CONDITION(S)]. The resident also had a long history of [CONDITION(S)] with acute exacerbation. (Cross-reference F695 respiratory care.) During the 9/23/22 evacuation, Resident #7, along with three other residents (Resident #20, #23, and #26) were assisted outside of the facility without means to obtain supplemental oxygen timely. Resident #7 had a portable oxygen tank attached to her walker during the evacuation; however, the portable oxygen tank was empty. The above identified accident hazard failures created the likelihood of a serious adverse outcome for all of the residents in the facility. Furthermore, Resident #12 was admitted on [DATE] to the facility. She had severe cognitive impairment with a score of two out of 15 for the brief interview of mental status. The resident was identified as a fall risk as she had falls prior to entering the facility. The intervention which was put into place was encouraged to use the call light. The resident experienced the first fall on 7/8/22 and the bed was put into the low position and fall mat, she fell a second time on 7/9/22 which resulted in a [CONDITION(S)]. The facility failed to timely initiate fall precautions for Resident #12. These failures contributed to her falling and fracturing her hip. Resident #1 had an unwitnessed fall on 9/28/22. Resident #1 was picked up off the floor and placed in her wheelchair before she was appropriately assessed. A registered nurse was not contacted or present for the resident's assessment for injury prior to the resident being moved by the licensed practical nurse and the certified nurse aide. Resident #30 had a history of falls and diagnosis of [CONDITION(S)] disease. He had two falls in just over a week apart. Resident #30 fell on [DATE] and again on 9/19/22. The fall documentation identified contributing factors to the falls included unsteadiness on his feet, weakness, and increased shuffling of gait. The last fall care planned intervention was on 4/25/22. The care plan was not updated to reflect new interventions to prevent potential future falls based on the assessment of the 9/11/22 and 9/19/22 falls. In addition, the facility failed to: -Consistently follow fall precautions and implement effective fall interventions for Resident #34; and, -Ensure the staff utilized two staff when utilizing a mechanical lift for Resident #3. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy A lack of a system in place to ensure the staff followed the facility emergency plan regarding evacuation procedures for potential fire. Staff reported and demonstrated a lack of training with the emergency preparedness plan which had a high likelihood to result in an accident hazard. On the night of 9/23/22, smoke entered the facility from outside of the facility. The source of smoke was off the property and fire was not an immediate threat to the facility. The staff, unprepared to handle an emergent situation, and not able to locate the fire or determine if the fire was inside the facility or outside the facility, contacted the director of nursing and reported fire was everywhere. The director of nursing instructed the staff to evacuate outside. As a result, residents were unnecessarily evacuated with several residents reporting they were scared and felt increased anxiety. One resident was reported as crying. At least four residents who required oxygen were evacuated without it. The cold air and smoke in the air with the lack of oxygen made breathing difficult. B. Imposition of Immediate Jeopardy Based on interviews and record review, which revealed policies and protocols were not followed to ensure staff were prepared for a potential threat of fire with comprehensive fire training and lack of training on required medical equipment, the nursing home administrator (NHA) was informed on 9/29/22 at 3:32 p.m. the facility failures above created the likelihood of serious harm for all of the residents in the facility if the failures were not corrected immediately. C. Facility plan to remove immediate jeopardy On 10/4/22 at 10:18 a.m. the facility submitted the final plan to remove immediate jeopardy. The plan read: 1. Staff education All staff scheduled to work beginning 9/29/22 were educated on the community's emergency plan to include fire procedures which includes RACE (rescue, alarm, contain, evacuate) and PASS (pull, aim, squeeze, sweep), evacuation procedures, central command, who directs the emergency and essential medical supplies and devices needed to ensure the safety of the residents. The training also included, who is central command during normal business hours and after hours, central command will call 911 and initiate the call to management, evacuation decision is in coordination of central command and first responders/fire department to determine if evacuation is needed based on each situation. The executive director was educated by the regional director of operations on 9/29/22, the maintenance director was educated by the regional environmental director on 9/29/22. The regional director of operations and the regional environmental director provided verbal reeducation after the evacuation on Friday 9/23/22 to the ED (executive director). Staff training included: -Fire alarm; -How to check the fire panel to ensure it is functioning properly and clearly identifies where the fire is located; -When to evacuate commanded by the appointed designee comand control who is the East station licensed nurse and first responders. The east station assumes command control until the highest ranking manager arrives. The East station licensed nurses have been educated on their duties as a command control; and, -When to be contained in the facility. Education was provided to all staff who were currently working in the facility, was provided in person, and written education was provided to all staff that were working in the community at the time the IJ was placed on 9/29/22 by executive director (ED) and maintenance director (MTD). Education was provided as follows: -On 9/29/22 at 5:30 p.m., at 6:40 p.m. to all staff present in the facility by the executive director. -On 9/29/22 at 10:00 p.m. prior to staff starting shift by the maintenance director. -On 9/30/22 at 5:30 a.m., 6:00 a.m., 7:00 a.m., 7:40 a.m. prior to staff starting shift by the executive director. -On 9/30/22 at 10:00 a.m. and 1:00 p.m. for staff not on duty that were called to come in for education and staff coming on shift prior to their shift by the maintenance director. -On 9/30/22 at 5:45pm for staff on duty at the time of second immediacy plan reeducation was provided by executive director. -On 9/30/22 at 6:40 p.m. prior to staff starting shift by executive director. -On 10/1/22 at 5:45 a.m., 6:05 a.m., 6:20 a.m., 6:40 a.m, 7:00 a.m., 1:00 p.m. prior to staff starting shift by executive director. -On 10/2/22 at 9:00 a.m., 2:00 p.m., by executive director. -On 10/2/22 at 5:45 p.m., 10:00 p.m. prior to starting shift by the maintenance director. -On 10/3/22 at 6:00 am prior to the starting shift by executive director. All staff that have not been educated were notified by their department managers to attend training sessions scheduled for 9/30/22 at 10:00 a.m. or 1:00 p.m. Staff who have not been trained, will not work their shift until completed the training from the ED or MTD. Newly hired staff will receive training on the day of hire during their orientation. Education attendance sheets will be reconciled by the Executive Director to ensure all staff had been trained on emergency preparedness. Education attendance reconciled as of today 10/3/22, education is continuing to ensure all staff are educated. 2. Education will be monitored for effectiveness Fire drill will be conducted on each shift by the maintenance director on Monday 10/3/22. -Fire drill conducted on 9/30/22 at 3:30pm; -Fire drills will be held monthly on different shifts, which equates to quarterly per shift; and, -Safety team who consists of maintenance director, business office manager, medical records director, director of nursing, head chef and executive director will evaluate at monthly safety meetings the drill response and staff competencies during drill to identify opportunities for improvement. 3. Communication during a emergency The facility will have walkie talkies available for use. They will be in effect on 10/7/22. The maintenance director is responsible to provide training and to ensure the walkie talkies are kept ready to use. The facility utilizes the resident report sheets and daily schedules to ensure all are accounted for by the incident command control at the time. 4. Competencies After the staff have been trained on the emergency preparedness, a test is administered on what was learned, and also return demonstrations and asking situational questions are asked to the staff by executive director or maintenance director. The interdisciplinary team (IDT) will review the drills (which validates individual competencies) for opportunities of improvement and continued education on opportunities identified. Drill checklist will be reviewed at the huddle right after the fire drill, and will be completed by the Maintenance Director. These reviews will be as follows: Drill Checklist Were fire alarms and strobes sounded? Were all exit doors checked to see if they released while in alarm, and did they release from magnets properly? Were residents moved to safety? Length of time from start of alarm to residents being secured? Were all resident room doors closed? Were all office and dining room doors closed? Was response time sufficient? Was the fire department notified? Was the fire properly announced? How long did it take to announce the fire? Were safety standards met? ie: no walking through smoke doors without fire extinguishers, swamp coolers turned off? How many staff members responded with fire extinguishers? 5. Procedure for any outside fires near the property will be to follow any guidance provided to us by the local fire department. 6. Medical supplies-oxygen Each resident has a portable oxygen tank assigned to them. The portable oxygen tank: -To be filled by night shift staff before each resident arises in the morning; -Oxygen portable tanks will be checked before and after each meal and filled if indicated; -Oxygen portable tanks will be checked at bedtime and filled if indicated; -Oxygen portable tanks will be checked PRN at resident request and filled if indicated; and, -The facility has a list of residents who require oxygen. Compliance will be monitored with random checks during meal times and nursing/administrative rounds five days a week. The director of nursing (DON)/NHA will designate staff members to complete random checks and any issues identified will be reported immediately to DON/NHA and re-educated as indicated. Any issues identified are addressed with retraining and education on the spot. C. Removal of immediate jeopardy On 10/4/22 at 11:00 p.m., the NHA and the DON were notified the immediate jeopardy was removed at 10:18 a.m., based on the plan above. However, deficient practice remained at an E level, a pattern with the potential for more than minimal harm. II. Facility policy The If You Discover A Fire In Your Area policy and procedure, dated June 2012, was provided by the nursing home administrator (NHA) on 10/4/22 at 8:49 a.m. The policy read in pertinent part: Remove anyone in the room while calling out 'Code red, location .' for assistance. Close the door to the fire room and any room connecting doors. Activate the fire alarm and make overhead page announcements of the fire location. Close all remaining doors and windows in the fire zone, placing residents into rooms. Evacuate remaining rooms in the smoke compartment if directed to do so by the person in charge. The Charge Nurse fire procedures were provided on 10/4/22 at 8:49 a.m. According to the procedures, the charge nurse was to initiate the following steps in a fire was on their unit they needed to ensure: -The fire room had been evacuated; -The door to the fire room had been closed and marked; -Fire alarm had been activated and a page announcement of the fire location made; -All residents had been removed from the corridor with doors and windows closed; and, -All equipment had been removed from the hallway. The charge nurse fire procedures directed the charge nurse to make a decision regarding further evacuation by using the following guidelines: -If the fire has been extinguished, no further evacuation is necessary. Instruct the staff to reassure residents while awaiting arrival of the fire department; -If the corridor smoke conditions would not be tolerable for residents, do not evacuate. Inform the fire department of smoke concerns upon their arrival. -If the fire had not been extinguished and the corridor conditions were tolerable begin evacuation by moving the residents from the fire compartment to the adjacent side of the fire/smoke doors as identified in the evacuation diagram. Instruct staff to evacuate rooms adjacent to the fire room first, followed by the room opposite of the fire room. The remaining rooms in the compartment should then be evacuated. -Mark the door to the room with a pillow in front of the door to indicate that the room had been evacuated. For this purpose the orange tape is stored in each medication room. -Account for residents and staff once all are relocated. Be prepared to report results to the control station. According to the charge nurse fire procedures, the charge nurse was responsible for: -Directing appropriate staff to respond to the fire area; -Directing remaining staff in securing unit by moving residents into rooms, closing windows and doors, and clearing corridors; -Directing staff to make rapid rounds, checking on and reassuring residents Once the unit was secured; - Directing staff in the preparation of receiving residents by clearing space for the arriving residents from the evacuated unit. Position one staff member at the entrance of the unit to direct staff arriving with evacuated residents to the appropriate areas of the receiving unit. -Ensure initial care of residents who have been evacuated if applicable. The charge nurse fire procedures identified the East nurses station charge nurse with activation of the fire alarm was to: -Check the fire alarm panel to determine location of alarm; -Make overhead page announcement of alarm location; and, -Place a backup call to the fire department (911). The Action Plan procedure pertaining to facility evacuations, dated July 2017, was provided by the NHA on 10/4/22 at 8:49 a.m. According to the policy, to evacuate the full building evacuation plan, the decision to evacuate should be made with input from emergency service agencies. The action plan identified agencies to be notified included emergency services (911), Delta County/ State Office of Emergency Management, and the Colorado Department of Public Health and Environment. III. Events of 9/23/22 1. Electrical panel fire A. Observations On 9/26/22 at 11:47 a.m. the hall lights went out of the B hall. At 11:49 a.m. the door alarm started to sound. A staff member walked down the hall towards the door and said the breaker was not working. The activity director (AD) following the staff member said it was not working last night either (9/25/22). B. Staff interview Licensed practical nurse (LPN) #3 was interviewed on 9/26/22 at 1:56 p.m. The LPN said the morning of 9/26/22 she was conducting a fire watch around the facility because the fire panel was not working again. She said the panel has now been fixed and she was no longer conducting a fire watch. The LPN said during the past weekend someone did a temporary fix on the panel and it was in working order so she did not conduct a fire watch over the weekend. The NHA was interviewed on 9/26/22 at 2:55 p.m. The NHA said on the morning of 9/23/22, the breaker to the electrical panel became too hot and wires were melted. An electrician was contacted and was able to temporarily repair the system but determined a new breaker had to be installed. She said the breaker was not in stock and had to be ordered for a 9/26/22 arrival and installation. She said some of the alarm systems had to be turned off momentarily during the installation. The maintenance director (MTD) was interviewed on 9/29/22 at 2:37 p.m. The MTD said the facility was old and recently had an electrical fire in the panel on the morning of 9/23/22. The electrician temporarily fixed it on 9/23/22. The electrical technician completed the repair process on 9/26/22 and 9/27/22 with new components. He said the fire panel was officially fixed on 9/27/22. The MTD said he had no issues with the panel before 9/23/22. He said the electric company said the breaker had burned up and fused itself. The electrical technician was going to send the breaker to a specialist to see why the breaker burned up. 2. Facility evacuation in response to a potential fire A. Staff interviews The DON was interviewed on 9/26/22 at 3:04 p.m. with the NHA. She said she received a call from a certified nurse aide (CNA) that there was a fire somewhere in the building. She said she saw smoking outside the backdoor. The DON said LPN #1 was the charge nurse on 9/23/22. The DON said by the time she arrived, the residents were evacuated. The fire department conducted three sweeps of the building before it was all clear. She said the alarm sounded just before 9:00 p.m. and residents were back inside and in bed by 11:00 p.m. She said residents were provided blankets and separated in small groups to be supervised by staff. The NHA and DON said they felt staff did well during the evacuation but should have sheltered the residents in place so they would educate the staff and review the policy with the staff. LPN #1 was interviewed on 9/28/22 at 7:45 p.m. The LPN said both her and LPN #4 were considered the charge nurses at the time of the evacuation on 9/23/22. The LPN said she was responsible for the west side of the facility and LPN #4 was responsible for the east side. She said a CNA told her that staff could smell smoke on the east side of the facility and staff saw smoke coming from the basement. The LPN said the staff believed the smoke was coming from the boiler area. LPN #1 said smoke alarms were not triggered/sounding at the time. She said earlier on the day of 9/23/22, fuses had burned and assumed it was smoke from the burned fuses. LPN #1 said LPN #4 decided to evacuate her residents on the east side outside, so she started evacuating her residents on the west side. The residents were divided up in two parking lots on different sides of the facility. She said the NHA was called but the residents were already being evacuated outside. She said the maintenance director (MTD) was called. She said she thought CNA #1 called 911 and then emergency vehicles arrived. CNA #1 was interviewed on 9/28/22 at 8:20 p.m. CNA #1 said she said the night of the evacuation she smelled smoke and saw thick smoke from the floor to the middle of the hallway. The CNA said she told the other staff they had to go outside. The other CNAs said they also saw smoke from the basement. CNA #1 said LPN #4 told the staff they were to evacuate the residents outside. The CNA said one other CNAs called 911. She said the other staff helped residents outside while she stayed with the residents who wandered until she could get more assistance. She said the air conditioner was drawing smoke inside the facility. She said the night of 9/23/22 she thought the facility had to evacuate because there were residents who had [CONDITION(S)] ([CONDITION(S)]). She said the alarm was going off and smoke was already in the facility so they evacuated. The director of nursing (DON) was interviewed on 9/29/22 at 11:03 a.m. The DON said she was contacted by staff on the night of 9/23/22 and was told there was a fire and the building and smoke was everywhere. The DON said that she had instructed the staff to evacuate the entire facility if there was fire and smoke inside and bring them to the parking lot. She directed the staff to evacuate the residents first then if possible go back inside the building to get oxygen and medication carts.The DON said she asked if the fire panel was checked and where the location of the fire was. She said they checked the fire panel but could not hear where the location of the fire was because she was in a bad phone service area. The DON said when she arrived at the facility at approximately 9:25 p.m. She said the smoke was not visible. The DON said if there was smoke outside it would not have been a good idea to take them outside. She said the smoke could make the residents sick. She said NHA was in charge of the facility and would normally be the one to make the call to evacuate. She said staff should have contained the residents to one area in the facility away from any identified smoke. She said if it happened again, staff should move residents to the other side of the building. CNA #5 was interviewed on 9/30/22 at 4:30 p.m. CNA #5 said he was present during the evacuation on 9/23/22. He said that he did not see smoke in the building, but he could smell a smoke odor in the building, but not too extreme. He said earlier in the day the circuit panel was not working properly, so he and CNA #9 went to look at the fire box outside of the building. He said while they were standing in the dark CNA #9 pointed toward the stairs and said she saw smoke. He said things went quick and they started to evacuate the building, he was not sure who had made the decision to evacuate. He said he was the muscle of the group, and he began to lift residents out of bed into wheelchairs, so the others could assist them outside. He said he remembered the oxygen portable for Resident #31 but that it was probably not a full tank. He said when outside, the residents had blankets and they waited for the fire department to direct them what to do. He said communication was hard, as he had no means to know what was happening outside, as he was inside. He said walkie talkies or some form of communication would help a lot. He said the NHA interviewed him last night about the evacuation, not any other time. CNA #9 was interviewed on 10/3/22 at 10:04 a.m. She said she started to smell smoke in the facility and went to the east side of the facility where LPN #4 was. She said she asked the LPN if she smelled smoke and they both proceeded to look for where it could be coming from. She said they checked near the electric panel and the boiler but the door was not hot. LPN #4 told CNA #9 to pull the fire alarm, shut all windows and doors and start evacuating. She said staff proceeded to evacuate all the walking residents, then the wheelchair resident and finished the evacuation with bed bound residents. The NHA was interviewed on 10/5/22 at 4:24 p.m. The NHA said she has not had a post incident review on the evacuation yet to review all that happened during the night of 9/23/22. She said she did not do the review because surveyors entered the facility on 9/26/22, the same day they were going to do the post-incident review. The NHA said the DON was told the building was on fire so they evacuated. She said she spoke with staff on the night of 9/23/22 while she was driving to the facility but was in a bad service area during the call and was not sure where the fire was located that prompted the evacuation. She said the facility had since discussed what to do when staff smell smoke, whether the source was inside the facility or coming in from the outside. She said the facility has also discussed when to evacuate the residents and when to contain the residents in their room. She said during the discussions she identified the failures as lack of training and fear. She said the facility had since learned the staff needed more fire training and they overreacted which inturn prompted the facility evacuation. B. Record review 1. Fire department report The fire chief's incident narrative and 9/23/22 incident report was provided by the NHA on 10/4/22 at 3:20 p.m. The 9/23/22 incident report identified the fire alarm record time as 9:05 p.m. The fire department arrived at 9:17 p.m. The fire department cleared the facility at 10:23 p.m. The fire chief's incident narrative identified events observed and conducted by the fire department at the facility on 9/23/22. The narrative read: Paged to (facility) for a report of a fire in the basement. Upon arrival we found no fire at the facility. There was smoke in the air from a nearby fire that we were unable to locate. We cleared the entire building using a TIC (thermal imaging camera). We were unable to locate any spot fires or heat. Staff had informed us that there had been a fire earlier in the electrical panel outside at around 11:00 a.m. They had called an electrician to fix the panel but didn't have time to properly do the job and did a fix that 'would get them through the weekend.' I advised the head of staff to contact the electrician and have them come out tonight (9/23/22) and look at the wiring within the box, as the previous fire had compromised multiple wires inside. We were unable to reset the alarm panel and advised the supervisor to do a firewatch throughout the night. They were going to try to reset the panel themselves. They evacuated all the residents of the facility during our arrival. They were allowed to enter the home once we were unable to locate any fire. 2. 9/23/22 incident notes The 9/23/22 incident notes with a staff attendance record were provided by the NHA on 10/3/22 at 10:40 a.m. The notes identified the fire panel was triggering an error message and could not be reset so the panel was taken offline. The notes also provided a timeline when management was contacted and when they arrived at the facility on 9/23/22. -At 8:58 p.m. the DON was called by staff; -At 8:59 p.m. the MTD was called; -At 9:00 p.m. the NHA was called; -At 9:30 p.m. the DON arrived onsite; and, -At 9:58 p.m. the NHA arrived onsite. IV. Resident impact A. Resident and family interviews Resident #7 was interviewed on 9/26/22 at 9:47 a.m. The resident said she needed to be on oxygen at all times because of her [CONDITION(S)]. She said her portable oxygen was usually empty and staff needed to fill it up (cross-reference F695 for respiratory needs). The resident stated staff often did not make sure her portable was filled at night which became a problem on 9/23/22. Resident #7 said she was assisted outside during a facility evacuation on 9/23/22 after she was told by staff they smelled smoke in the facility. She had her portable oxygen tank attached to her walker but the oxygen tank was empty. Resident #7 said the cold air outside made it even harder to breathe. She said she did not receive oxygen until the paramedics arrived and provided it to her. Resident #7 said she was outside for 45 minutes to an hour, much of the time she was outside without oxygen. She said she has had [CONDITION(S)] for years and knows when her oxygen saturation levels drop. She said during the evacuation and without continuous oxygen, she became light headed and started seeing fire works. The resident said she normally had some anxiety and she became very anxious without the needed oxygen during the evacuation. Resident #35 was interviewed with her family on 9/26/22 at 12:09 p.m. The family member said an electrical panel burned out on 9/23/22 during the day. Resident #35 said on the night of 9/23/22, the fire alarm sounded and staff slid her out of bed, placed into a wheelchair, and was taken outside. The resident said she was outside for about an hour. Resident #3 was interviewed on 9/27/22 at 9:34 a.m. The resident said the facility evacuated from the building on the previous Friday (9/23/22). He said he was in bed for the night when the CNA came in and told him they needed to evacuate the building. He said he was manually lifted out of bed with two certified nurse aides. He said he received a skin tear on his right elbow as they got him out of bed. He said he was usually transferred with a mechanical lift. He said it all went so fast. The resident's right elbow had a bandage on it. Resident #20 was interviewed on 9/28/22 at 11:45 a.m. The resident said that the facility evacuated from the building on Friday 9/23/22. She said that she was awoken from sleep and told that they needed to get her out of the building as they were evacuating the facility. She said that when she was assisted outside, she was taken outside without her oxygen. She said that she was having trouble breathing. She said the fire department provided her with oxygen 45 minutes later. Resident #20 was interviewed a second time on 9/28/22 at 1:35 p.m. The resident said when she was awoken from bed, she was told by the two CNAs to jump from her bed. She said she could not and that she was scared. She said the CNAs said they would catch her. She said the bed needed to be lowered, then she would have been able to step off of the bed easier. She said she had to jump from the bed, which was approximately ten inches from the floor. Resident #23 was interviewed again on 9/29/22 at 12:30 p.m. The resident said that on Friday (9/23/22) he was informed that the facility had to evacuate. He said he had been sleeping and he said he grabbed his hat and nothing else. He said he left the facility without his oxygen. He said he could not recall the length of time he went without his oxygen. He said without his oxygen he had grasped for his breath. He could not recall when he received oxygen. He said he was told someone was burning trash outside and the air conditioning sucked in the smoke. The family member of Resident #26 wa[TRUNCATED]

Based on observations, staff interviews, and record review the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#11 and #16) of two reviewed for catheter care out of three residents with catheters. The facility failed to ensure Resident #11's urinary catheter down drain bag was kept from dragging on the floor and the urinary catheter bag was kept below the bladder. There were no physician orders on how to clean the area around the suprapubic catheter site. Due to the facility's failures, Resident # 11 suprapubic urinary catheter line to drag on the floor and no order to cleanse the site, contributed to an infection as evidenced by the purulent (pus) drainage from the catheter exit site which caused pain to the resident. In addition, the facility failed to: -Ensure Resident #16 was provided catheter care assistance with emptying her catheter bag and monitoring catheter fluid level to ensure timely empting of her catheter bag; and, -Ensure Resident #16 had proper placement of her catheter bag. Findings include: I. Facility policy and procedure The Catheter Care, Urinary policy and procedure, revised September 2014, was provided by the director of nurses (DON) on 10/4/22 at 10:30 a.m. With instructions, be sure the catheter tubing and drainage bag are kept off the floor. Along with The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. II. Resident #11 A. Resident status Resident #11, older than age 60, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO) diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The7/12/22 minimum data set (MDS) assessment showed the resident had minimal cognitive impairment with a score of 13 out of 15 on the brief interview for mental status (BIMS). The MDS coded the resident as requiring no assistance with activities of daily living. The resident had a catheter. The MDS incorrectly coded the resident as always continent. B. Observations On 9/26/22 at 12:50 p.m. the resident was walking down the hall. The resident's catheter tubing was dragging on the floor. The catheter bag hung on the walker. On 9/28/22 at 8:05 a.m. the resident's suprapubic urinary catheter tubing was dragging on the floor as she walked in the hallway. On 10/3/22 at 10:37 a.m. the resident's suprapubic catheter insertion site was observed with the licensed practical nurse (LPN) #5. The insertion site was noted with greenish, thick colored drainage, the resident denied pain at this time. LPN #5 said the previous shift nurse reported that the site didn't look good. She said the insertion site had purulent drainage. There was no documentation noted in the chart of the findings and there was a failure to notify the doctor of the change of the resident's condition. LPN #5 reported that the leg drain bag should not be left on the resident's leg throughout the night. On 10/4/22 at 3:25 p.m. the resident's suprapubic catheter insertion site was observed with the LPN #5. The insertion site had thick, cream colored drainage. LPN #5 obtained a culture of the drainage, afterwards wiping the area with a tissue and cleaning with one [MEDICATION(S)] (antiseptic) swab, not allowing the [MEDICATION(S)] to dry, then placing resident's undergarment over the area, no dressing was placed over site. During the cleaning with the [MEDICATION(S)] swab, the resident pulled back and winced in pain. The resident said she had pain around the site. C. Record review The September 2022 CPO, a physician order was entered on 4/1/22, stating: cleanse stoma site twice daily, check skin for redness or drainage, and notify MD (medical doctor) of skin changes from baseline. The September 2022 treatment administration record (TAR) revealed, starting on 4/2/22, the stoma site was to be cleaned daily and as needed. Discontinue date of 9/23/22. On 9/23/22 a new treatment was added to cleanse stoma twice daily. -There was documentation that stoma site was being cleaned, but no documentation of how it was being cleaned. The care plan initiated on 4/1/22 identified the resident had impaired urinary elimination pattern and the need for a suprapubic catheter. Some days the resident may choose to use a leg bag and other days a larger drainage bag; their preference. -There was no documentation in the resident's chart showing that she was offered this preference and what the preference was daily. The goal added on 9/29/22 (during the survey), for the resident to have a decreased risk for developing complications associated with catheter usage such as a urinary tract infection. The care plan documented that the suprapubic catheter should maintain a position of the catheter bag and tubing below the level of the bladder. Interventions were added on 9/30/22 (during the survey) to the care plan to ask the resident if a leg bag or down drain foley catheter bag was to be used based on their preference, along with observing and reporting for s/s of an infection-strong odor, cloudy, and urgency. LPN #5 faxed the primary doctor the change of the resident's condition on 10/3/22, there was no documentation noted in the chart of this action. She reported that after no response she called at 2:00 p.m. and 3:30 p.m. both attempts went to an answering machine. There was no documentation of this in the chart. The resident had a urine culture lab test, collected on 10/4/22 at 3:12 p.m. the preliminary results on 10/5/22 9:56 a.m. noting an organism present: presumptive E. coli greater than 100,000 CFU/ml. D. Staff interviews Registered nurse (RN) #1 was interviewed on 9/29/22 at 10:30 a.m. RN #1 said the catheter tubing should not drag on the floor, as it could cause an infection. She said she would assess to determine if a leg bag could be used. RN #1 was interviewed a second time on 9/29/22 at 11:06 a.m. RN #1 said the resident agreed to try a leg bag. She said the leg bag was in place. Certified nurse aide (CNA) #3 was interviewed on 10/3/22 10:13 a.m. CNA #3 said the resident was using the leg bag, however, the leg bag was not being changed at night for a larger drain bag and it was staying on the resident's leg throughout the night, which could result in the leg bag not being below the bladder. LPN #5 was interviewed on 10/3/22 at 10:37 a.m. LPN #5 said the leg drain bag should not be left on the resident's leg throughout the night. LPN #5 confirmed nothing was documented in the resident's medical record and that she had forgotten. LPN #5 said she faxed the medical director the change of the resident's condition. She said after no response she called at 2:00 p.m. and 3:30 p.m. both attempts went to an answering machine. -However, there was no documentation of this in the resident's chart. LPN #5 was interviewed again on 10/4/22 at 10:12 a.m. She reported that she had forgotten to document notifying the physician. She reported that the nursing staff have been wiping the drainage from the site with a tissue, then cleaning the area around the suprapubic catheter with [MEDICATION(S)]. -However, no physician order was found for the [MEDICATION(S)]. She reported that the drainage is white in color and that the resident reported redness and pain at the site. LPN #5 said that she had forgotten to document any information about the infection. The DON was interviewed on 10/4/22 at 10:31 a.m. The DON said that the on-call doctor should have been called on 10/3/22 when the facility was unable to reach the resident's doctor. She said the leg bag should not have been left on the resident's leg through the night, it should have been changed to a larger drain bag hanging below the resident's bladder. She said that she would educate the nursing staff. III. Resident #16 A. Resident status Resident #16, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 7/28/22 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. The MDS assessment indicated the resident was independent in activities of daily living (ADLs). The MDS assessment identified the resident had a catheter. B. Resident interview and observation Resident #16 was interviewed on 9/27/22 at 9:04 a.m. She said staff did not assist her with the emptying of her bag. Resident #16 said they were often busy taking care of other residents. She said she had watched how they emptied her catheter bag before and then trained herself. The catheter bag was observed laying on the floor next to the resident's feet as she sat in her reclining chair in her room. The catheter bag was not hanging on her walker or another device to keep it off the floor and below her waist. The bag was not covered by a protective cover as it laid on the floor. The catheter bag was almost completely full with fluid. Resident #16 was observed on 9/29/22 at 9:26 a.m. Her catheter bag was attached to her walker. There was not a cover over her bag. The bag was more than half way full. The resident said she would have to empty the catheter bag in a little while. Resident #16 was interviewed on 10/4/22 at 3:20 p.m. She said it was hard to remember when to empty her catheter bag and when to check if the catheter bag needs to be emptied. She said she would like for more help from the staff to monitor her catheter and assist her in ensuring the bag was emptied timely. She said she was worried it might become too full and back up causing an infection. C. Record review The certified nurse aide (CNA) tasks sheet read Resident (#16) has a suprapubic catheter. Position bag and tubing below the level of the bladder. The CPO, initiated 4/6/22, directed staff to maintain Resident #16's suprapubic catheter site and clean as needed. The urinary catheter/[CONDITION(S)] care plan last revised on 4/19/22, indicated the resident had an impaired urinary elimination pattern and continuous incontinence of urine. According to the care plan, the resident should have a decreased risk for developing complications associated with catheter usage such as urinary tract infections (UTIs). The care plan directed staff to provide Resident #16 catheter care q (every) shift, and as needed. According to the care plan staff should also ensure her foley strap was in place, not pulling off the catheter, and the foley was properly draining. The CPO for [MEDICATION(S)] (antibiotic) at 500 milligrams (mg) capsule, started 10/2/22, was ordered for the resident. D. Staff interviews CNA #1 was interviewed on 9/28/22 at 8:15 p.m. The CNA said she was new to the facility but has been working with Resident #16. She said staff told her that Resident #16 emptied her own catheter bag. She said Resident #16 needs frequent reminders to empty it. She said she has seen the resident's bag sometimes full because the resident has not emptied it yet. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 10/4/22 at 3:05 p.m. The DON said all residents needed assistance with catheter care, including the emptying of the catheter bag and the monitoring of the fluid level. The NHA said some residents have been evaluated by therapy to determine if the resident could provide catheter care management such as emptying catheter bags themselves. She said the CNAs routinely monitor residents' catheter fluid level and would document the amount of fluid bag before it was emptied. The NHA reviewed Resident #16 medical record. The NHA said Resident #16 had not been evaluated or approved to empty her own catheter bag. She said the CNAs have not been charting the amount of urine output emptied from the resident's catheter bag. The NHA said staff should have been assisting Resident #16 with emptying her catheter bag and monitoring the resident's fluid level collected from her catheter. The NHA said staff should also ensure the catheter bag was properly positioned when the resident was sitting in her reclining chair in her room. The NHA said the bag should have been hung below the resident's bladder and never placed on the floor. The DON and NHA acknowledged placing the catheter bag directly on the floor could create a potential infection control concern. The NHA said staff needed to be responsible for the emptying and monitoring of the resident's catheter. She said would educate the staff to empty the resident's catheter bag, monitor and document the fluid level/output, and proper placement of the catheter bag when the resident was sitting in her room. Registered nurse (RN) #1 was interviewed on 10/5/22 at 3:39 p.m. She said Resident #16 had a new [CONDITION(S)], identified on 10/2/22. The RN said Resident #16 was now on antibiotics related to a [CONDITION(S)].

Based on observations, record review and interviews, the facility failed to ensure three (#12, #28 and #34) of six out of 26 sample residents received the care and services necessary to meet their nutritional needs and to maintain their highest level of physical well being. Resident #12 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was weighed on 5/3/22 and again on 5/4/22 at 2:33 p.m., at 100.7 pounds (lbs). Then the resident was not weighed again until 8/1/22 and she was 99.2 lbs, and the last recorded weight was on 9/2/22 at 9:58 a.m. at 92.5 lbs., a loss of 6.7 lbs, which was a 6.5% weight loss over one month considered significant. The resident did not receive a nutritional assessment either after admission or after she sustained a severe weight loss. An intervention of Ensure was recommended on 9/16/22, however the facility did not implement it, until 9/18/22. In addition, the facility failed to: -Address Resident #28's significant weight loss timely; -Follow RD interventions for Resident #28; -Perform a comprehensive nutritional assessment for Resident #34; and, -Assess and provide adequate hydration needs for Resident #34. Findings include: I. Resident #12 A. Resident status Resident #12, age 85, was admitted to the facility on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/3/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status (BIMS) score of two out of 15. She required extensive assistance of one person with bed mobility, dressing, eating, and personal hygiene. The resident was under hospice care. The resident was not coded for weight loss. B. Observations The resident was served her noon lunch tray on 9/28/22 at 12:39 p.m. The resident was offered meal assistance three times, however, the resident refused. However, throughout the meal, the resident was falling asleep, and no staff attempted to wake her up. She only consumed 25% of her meal. And no alternative meal was offered. C. Record review In the resident's care plan initiated 5/3/22, and revised on 7/8/22, a goal was established of not incurring weight loss, through a dietary consult for a nutritional regimen and ongoing monitoring. The care plan was not updated to include the recent weight loss or to include the interventions which were put into place. Resident #12's weights since admission: -On 5/3/22 the resident weighed 100.5 lbs. -On 5/4/22 the resident weighed 100.7 lbs. -On 8/1/22 the resident weighed 99.2 lbs. -On 9/2/22 the resident weighed 92.5 lbs., a loss of 6.7 lbs, which equals a 6.5% weight loss over one month. The September 2022 CPO revealed the following: -The resident was admitted into hospice 7/8/22. -Ordered 9/16/22, Ensure original formula two times a day, however no specific amount was included in the order. Review of the September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record failed to show that a initial nutritional assessment or a change of condition related to the weight loss was completed for Resident #12. There were no quarterly assessments completed since admission. The meal and supplement intake records from September 2022 revealed the following: -The resident typically consumed 51-100% of breakfast, lunch and dinner. -The resident was provided with Ensure twice daily but there was no documentation of intake percentages/amount. B. Staff interviews The hospice registered nurse was interviewed on 10/3/22 at 11:05 a.m. He stated that the resident has a review in thirty days and that a recommendation of discharge from hospice would be discussed as the resident was not meeting the criteria for hospice care. The registered dietician (RD) was interviewed on 10/4/22 at 4:40 p.m. The RD said she began employment at the facility on 9/16/22, and that her first meeting with the skin and weight team would be 10/7/22. Normally, she would come once a week to the facility for the meeting but has not been to the last two meetings, due to the fact that the director of nurses (DON) and the nursing home administrator (NHA) have been working on the floor. When she began employment at the facility she noticed that weights were not being charted on a regular basis, she stated, not having monthly weights hinders me. She reported the process that after entering an intervention, there should be a weekly progress note following up on the intervention. The RD reviewed the medical record and confirmed the resident had experienced a significant weight loss of over 6% in a month's time. She said it was her assumption that an Ensure consumption amount was 240 milliliters (ml), and that the intake amount should be tracked. She said when a resident eats less than 50% of the meal, alternatives need to be offered, and that the documentation needs to be accurate. The DON was interviewed on 10/4/22 at 5:37 p.m. The DON said when the resident ate less than 50% of her meal, then an alternative meal needed to be offered. She reported that the staff needed to return to check on the resident even if she refused the help, in order to monitor what the resident was eating. Her expectation was for an accurate meal percentage documentation so that the resident was accurately evaluated on what she was eating. She said she was aware of the resident's severe weight loss. II. Resident #28 A. Resident status Resident #28, age 78, was admitted to the facility on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/22/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. The MDS coded the resident as requiring supervision with eating. B. Record review Weights since admission revealed the following: -On 5/9/22 the resident weighed 148.5 lbs -On 7/8/22 the resident weighed 135.5 lbs, a loss of 13 lbs., which equals an 8.75% weight loss -On 9/1/22 the resident weighed 134 lbs -On 10/3/22 the resident weighed 133 lbs The care plan dated 5/9/22 identified the resident as a potential for losing weight secondary to social isolation. With an intervention initiated on 5/25/22 of encouraging the resident to eat a healthy well-balanced meal. The September 2022 CPO revealed the following: -A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . However, a review of the medical record showed the weights were not obtained according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Fortified foods added on 9/8/22. The 8/25/22 nutrition note documented the resident was on a general diet order, mechanical soft texture, and thin liquids. Meal intakes have been between 76-100% of food and only approximately 240 ml of fluid intake. An estimation of daily nutrition needs for the resident were determined with the goal of 1550-1900 caloric intake and approximately 1600ml of fluid intake. Also, noted by the RD was a request for fortified foods at meals, and for updated weights. The 9/30/22 progress note documented due to the resident's significant weight loss since admission, she recommended fortified foods with every meal. C. Observation On 10/3/22 at 5:35 p.m., observed the resident's dinner tray being delivered to her room. On the tray were the following items: pasta, peas, pears and ice cream. No fortified foods were noted on the resident's tray. D. Staff interview The RD was interviewed on 10/4/22 at 4:40 p.m. She agreed that the dinner tray the resident received for 10/3/22 was not a fortified meal. She said examples of fortified foods were butter, brown sugar, mashed potatoes and heavy cream. The RD said that the facility did not have a specific menu for a fortified meal and that mashed potatoes should not be served with every lunch and dinner meal. III. Resident #34 A. Resident status Resident #34, age 93, was admitted on [DATE]. According to the September 2022 computerized physician order, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/5/22 MDS assessment revealed the resident had had severe cognitive impairment with a score of two out of 15 on the brief interview for mental status. The resident was independent in walking and required limited assistance with all activities of daily living. It indicated the resident did not have a swallowing disorder. No dental abnormalities were noted. B. Observations 9/26/22 -8:30 a.m., the resident was at the dining room table awaiting her meal. The resident had a pitcher of water and a 120 milliliter (ml) cup on the resident table. However, she did not receive assistance to pour the water. -At 12:44 p.m., the resident received a total of 240 ml fluids (ice tea & water) however, drank approximately 120 cc tea. She did not consume or receive encouragement to drink the water. 9/27/22 -At 8:30 a.m., the resident drank coffee, approximately 50 ml of fluid. -At 12:30 p.m., the resident drank approximately 60 ml of ice tea. She was not encouraged to drink the remaining of the 120 ml of tea and did not have a glass of water. 9/28/22 At 12:30 p.m., the resident was served 120 ml of ice tea, however, she drank approximately 40 ml of the tea. She was not poured any water and received no encouragement to drink the remaining ice tea. 10/3/22 -At 8:18 a.m., the resident was served 120 ml of coffee, and although she was offered a second cup, she declined. She did not have any water poured from the water pitcher on the table. C. Record review The care plan last updated on 9/13/22 identified the resident was at risk for inability to maintain her nutrition. Pertinent interventions included, monitor intake and record each meal. -The care plan failed to include the amount of fluid the resident required each day. According to the RD interview, the resident did not have a nutritional assessment to indicate her daily fluid needs (see below). The hydration record for September 2022 was reviewed. The resident drank on average 240 ml at breakfast and 240 ml at afternoon meal. The dinner meal was not documented, only once at 100 ml. The snacks intake was not consistently entered with only 240 ml on five days. The observations and the documentation that the resident received less than 1500 ml a day (indicated by the RD, see below). D. Staff interview CNA#3 was interviewed on 10/2/22 at 4:40 p.m. The CNA said she assisted the resident to eat her food by showing her what was on her plate. She said she made conversation with the resident as she was eating, asking the resident what she liked to eat and if she liked to cook. She said the resident was more inclined to eat when she encouraged the resident. The RD was interviewed on 10/5/22 at 4:40 p.m. The RD reviewed the record and confirmed that a nutritional assessment had not been completed for Resident #34. The resident should have an assessment which documented the resident's fluid needs. She said that minimally the resident required 1500 ml, however, she preferred to calculate out what the resident's specific needs were. The RD said the resident should have the water poured while at the table and receive encouragement to eat and drink.

Based on record review and family and staff interviews, the facility failed to provide supervision, assistance and equipment to prevent accidents for one (#3) of eight residents reviewed for falls, out of a total of 13 sample residents. Specifically: -The facility failed to prevent falls with injury for resident #3; -The facility failed to thoroughly investigate a fall that occurred for resident #3; and -The facility failed to ensure that an air mattress provided by hospice was equipped with bolsters to prevent falls for resident #3. The failures contributed to the resident suffering fractures, pain and hospitalization ; and experiencing an additional fall after her fractures. A. Facility Policy and Procedures 1. The facility policy titled "Quality Improvement Post Fall Investigation," dated [DATE], stated in pertinent part: "To be completed on all falls within 24 hours of incident ...The QA (Quality Assurance) review has identified when a resident has had an accident/fall the following had been established: -Identification of environment hazards and individual resident risk for an accident, including the need for supervision. -Evaluation/analyze the hazard and risk . . . -Implementation of interventions, including adequate supervision, consistent with the resident's needs, goals and plan of care and recognized standards of practice, to reduce the risk of an accident. -Monitor the effectiveness of the interventions and modify the approaches as necessary." 2. The facility policy titled "24 Hour Resident Report," dated [DATE], included in pertinent part: "The following conditions/events that should be documented on the 24-hour report sheet include, but not limited to the following: -Resident condition changes from baseline (include a brief assessment and notifications) -Incidents/accidents (include a brief assessment and notifications) ... -The resident's name, room number and condition/event will be documented on the form and indicate appropriate follow up completed (physician, family, chart, pharmacy, incident report, etc.) -Each shift will utilize the 24-hour report form to communicate resident information between shifts (licensed staff and certified nurse aides). -The Director of Nurses (or shift supervisor/designee) will assess each resident noted on the 24-hour report and check the chart to assure appropriate and follow up/documentation has been completed ..." B. Resident #3 Resident #3, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. The annual Minimum Data Set (MDS) assessment, dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 8, which indicated she was moderately impaired. She had no delirium, psychosis or rejection of care coded. She required limited assistance with bed mobility, toilet use and personal hygiene, and extensive assistance with transfers and dressing, with one person physical assist. She was frequently incontinent of urine and there was no toileting trial program that had been attempted. She used a walker and wheelchair for mobility. The resident's death certificate documented she died on [DATE]. The immediate causes of death included vascular dementia and hypertension (high blood pressure). The "other significant conditions contributing to death" included "femur fracture." 1. Fall on [DATE] Record Review: The resident's care plan, dated [DATE] and last reviewed [DATE], identified the following problems, goals and approaches: -"Resident has cognitive loss evidenced by short-term memory loss, long-term memory loss, decision-making deficits related to Alzheimer's dementia." -The goal was that "Risk of injury will be minimized with interventions and needs will be met every shift over the next 90 days." -The approaches included: "Approach in calm manner and assist with ADLs (activities of daily living) as needed ... Check frequently throughout the shift. Encourage to make safe choices and do ADLs independently if able to ..." The Monthly Nursing Summary dated [DATE] documented that the resident required supervision with the assist of one for toileting and personal hygiene. The "Incident Report Form" dated [DATE] documented that the resident had an unwitnessed fall in her room and included: "Resident had complained of left knee pain with night shift. Couldn't stand. Left knee significantly swollen. As time went on it was noticed left ankle swollen, left forearm bruise. Bruise right cheek. Resident started complaining of left hip pain. Daughter notified at 8:00 a.m ...To (local area emergency department) via ambulance [DATE] at 9:45 a.m." The form also included a hand-written note which read: "History of falls without telling staff." The resident's physician was documented as having been notified, but was void of the date and time this was completed. The "Signature/Title of person preparing report" was void of a signature. The form was signed by the director of nurses (DON), nursing home administrator (NHA), and medical director. The report did not note that the resident was found on the floor, the circumstances surrounding the fall, or at what time the resident was found. The "Quality Improvement Post Fall Investigation" form dated [DATE] was reviewed. The question "Last time resident was checked prior to fall" was void of documentation. The question "Last time resident was toileted" was void of documentation. The question "Is there a pattern noted with falls?" was void of documentation. The Nurse's Notes dated [DATE] at 4:30 a.m. were reviewed, which were written by the licensed practical nurse (LPN) #18 who was working that night. The note included, "Two assist to bathroom. Resident didn't use call light or want help. Complained of left knee and leg pain. Quick response to bedside alarm all shift. Very difficult to transfer. Resident grabbing furniture tightly stating 'You're going to make me fall, you're going to drop me.' Voided clear yellow urine and helped back to bed. Two assist, gait belt and wheel chair for transfers." The note did not include documentation of the fall. The Nurse's Notes dated [DATE] at 1:00 p.m., were written by LPN #17 and documented, "Resident's daughter called with results from resident's visit to emergency room . Resident broke leg above left knee and has a sprained ankle. Surgery tomorrow." Initial Staff Interviews: On [DATE] at 11:51 a.m., the certified nurse aide (CNA) #22 who was working the overnight shift on [DATE] was interviewed, and was asked what she recalled from that night. She stated, "I went in and checked on (resident #3) after midnight; probably between 1:00 a.m. and 2:00 a.m., and that's when I found her on the floor, and I asked her what she was doing. She told me in Spanish that she was going to the bathroom. I went and got the nurse because I'm not supposed to move them, and let them look her over. The nurse (LPN #18) went in with me to (resident #3's) room and the nurse told me that the leg had already been injured before, and she was always complaining about it. So she helped me get her up to the bathroom, and the nurse stood her up and did most of the lifting, and I just held her wheelchair and pushed her into the bathroom. Then the nurse again got her up from the wheelchair to put her on the toilet, and the nurse sat her down. Of course (resident #3) was already wet at that time. Then the nurse helped me put her back in bed." -The CNA stated "As far as I know, the nurse didn't even call the family that night. I know when a resident falls you are supposed to notify family and she didn't. She said she didn't want to bother with the paperwork and that it was 'too much of a bother.' And she didn't even chart it or anything, or let other people like the day shift nurse know. The nurse was (LPN #18)." -The CNA explained that resident #3 normally required the assistance of one person to help her "because you would get her up in a wheelchair and then take her to the bathroom." The CNA confirmed that the resident was not on a toileting program at that time, and explained that she would check on her often, and stated, "She was a fall risk, so I would check on her every half an hour, or constantly." -The CNA stated, "The next morning I did tell the morning aide that (resident #3) had fallen and that she might be kind of sleepy ...I reported it to my nurse and I reported it to the day shift." The CNA clarified that the staff member she gave report to on the morning of [DATE] was CNA #9. On [DATE] at 4:11 p.m., CNA #9, who received report from CNA #22 on the morning of [DATE], was interviewed, and stated, "She said that (resident #3) fell out of bed." She explained that when she'd first gone into resident #3's room that morning, "I saw she was complaining of pain ...You could see her knee was very, very swollen. It was bad. I don't know why something wasn't done before that. I went and got (LPN #17)." The CNA explained that LPN #17 was the nurse who came on shift at 5:30 a.m. on the morning of [DATE]. -CNA #9 explained that resident #3 was lying in bed and, "She had her knee under the blanket, and she grabbed my hand and said 'I hurt. I hurt.' I took the blankets off and it was already turning colors, and she was complaining that her hip was hurting too. It was a pretty good fall." -The CNA explained that LPN #17 was not aware that the resident had fallen during the night. On [DATE] at 12:51 p.m., LPN #17 was interviewed, and stated, "I wasn't made aware (resident #3) had fallen. In report that I got from (LPN #18), she said they went into her room at 4:00 a.m. and they tried to take her to the bathroom but she couldn't stand for them. When I started my shift, I went in and looked at her. I couldn't really see anything, so I went back in before breakfast, and she was complaining of hurting and she couldn't stand, so we got her a meal tray for breakfast." -LPN #17 said, "I went in during the breakfast and she was complaining of more pain ...We were in and out of there a lot that morning just to check on her because something wasn't right with her." The LPN explained that at that time, a CNA informed her that resident #3 had bruising on her ankle and stated, "I hadn't seen anything before. But then we saw that she had more swelling and she started to bruise." -LPN #17 explained that she called resident #3's family and told them, "I'm not sure what has happened," and arrangements were made to send resident #3 to the local emergency room for evaluation. The LPN stated, "The last time I was in there, (resident #3) was getting worse and was having more pain." -LPN #17 explained that she'd assessed resident #3's legs when she first went in her room that morning, and stated, "The first time (LPN #18) told me about it was when she checked her at 4:00 a.m. and (resident #3) had called for help. We assumed she had fallen. In report we talked about it and knew that something had happened. She said she didn't know if she'd fallen, so I filled out an incident report on it." This statement did not correlate with the documented nurse's note written by LPN #18, which stated the resident did not call for help. -LPN #17 confirmed that resident #3 did not require the assistance of two staff members prior to the fall on [DATE]. Previously she'd only required the assistance of one. On [DATE] at 1:00 p.m., LPN #18, who was resident #3's nurse on the night of [DATE], was interviewed, and was asked to recall the events of that shift. She stated, "We tried to get her up out of bed to take her to the restroom but she was hollering and crying saying it was too painful, so we stopped and I wrote a nurse's note about it." The LPN was asked how the resident was toileted, if she was unable to go to the restroom, and she stated, "We didn't. So that's what I had to pass on. She couldn't get out of bed to go to the restroom because it was hurting too bad." This statement contradicted the nurse's note LPN #18 wrote, which documented that the resident was assisted to the restroom and voided. -LPN #18 was asked when she was first made aware that resident #3 had fallen, and she stated, "I wasn't aware that she had fallen. She said something about it, but she used to say something about it all the time." The LPN was asked if the resident had been medicated for pain, and she stated, "I don't recall." -LPN #18 was asked if she'd reported to the day shift nurse that resident #3 had fallen, and she stated, "I reported that she was in pain and we couldn't get her out of bed. We tried to help her by moving her in bed and she would just cry out." LPN #18 was informed of the report by CNA #22 that resident #3 had fallen and that she'd been the one to assist the resident off the floor, and the LPN stated, "That is absolutely not true. No." -LPN #18 was asked when the first time was that she assessed resident #3's leg, and she stated, "I didn't. She was in pajamas. I just passed that on that we tried to move her and she cried out in pain. I told the day nurse that she doesn't seem to be in pain when she is just lying in bed, but when we try to get her up, she is in pain. If she'd been broken, I wouldn't think that would stop hurting when you are holding still. I had no idea she was broken." Family Interview: On [DATE] at 5:02 p.m., the resident's daughter was interviewed. She explained that she was informed around 7:00 a.m. on [DATE] that "her knee was really swollen and they didn't know what happened." She said the facility "thought she might have gotten out of bed because her bed alarm went off. They thought she might have bumped her knee or did something that made it swell." She said she had shared her concerns with the facility staff and stated, "I told them I was very disappointed at how my mom was taken care of there." Additional Record Review: The medication administration record for [DATE] was reviewed, and documented that no pain medication had been given to resident #3 on [DATE] or [DATE]. The dictated emergency room history and physical from the local area hospital dated [DATE] included: "...Has been feeling weak. Apparently fell a few times overnight. Last one she could not get up with complaints of hip pain and knee pain ..." The dictated consultation from the local area hospital dated [DATE] included, "Reason for consultation: left femur and left ankle fracture ... The patient lives at (name of facility) and has had several falls. She is, in general, wheelchair-bound and does not walk, but she will occasionally walk with a walker in her room and occasionally gets up without any assistance. She fell two weeks ago and was seen in the emergency room with a facial injury, but no head injury ...She fell today complaining of left leg pain ...Will plan to proceed with surgery tomorrow ..." The resident was readmitted to the facility on [DATE]. The "Post Fall Investigation" form, which was signed by the director of nurses (DON) on [DATE], included, "Fall has been evaluated/analyzed and interventions require additional input for the following reasons: Will evaluate fall risk when resident returns from hospital." On [DATE], the DON was asked if the "Post Fall Investigation" form was completed when the resident returned from the hospital, and she stated, "No, we just looked at what we needed and put it in place." She further explained that a perimeter-defining mattress was placed on the bed and a fall mat was placed on the floor. The resident was moved to a room which was closer to the nurse's station. Additional Staff Interview: On [DATE] at 2:02 p.m., the DON was interviewed. The incident reports and fall investigation forms were reviewed for the falls that occurred on [DATE] and [DATE] (see below). She explained that when she signed those forms, her signature did not indicate that she conducted an investigation for them. She explained that her signature was there "because we review it. The nurse does the incident report, then we address the lower portion (of the form) in the morning meeting." -The DON was asked how she conducted her investigation for the fall that occurred on [DATE], and she stated, "We did not do an investigation for this fall. I got called the morning of the fall. My expectation is that if anyone passes away or has to go to the hospital, I want to be notified. (LPN #17) explained to me they noticed more swelling, and then later she called and said the leg was broken. By the time I saw this, she was in the hospital. She has a history, over half of those falls, the resident reported she fell ." The DON explained that the resident would have a fall, get herself up, and then report to them later that she'd fallen. -The DON was asked how they would know what to do to prevent future falls if they didn't investigate it to see what caused the fall, and she said, "It is a team decision. When we review the notes, we bring in the nurses and we review the nurse notes. If it is real questionable to us, we will go out and investigate it. If we have questions, then we go back and question the staff involved." -The DON was asked if she had interviewed the night shift CNA, the LPN who worked the night of [DATE], or the CNAs who worked the day shift of [DATE], and she said "No." -The DON confirmed that LPN #18 should have offered the resident pain medication when she began complaining of left leg pain, and stated, "If someone is complaining of pain, I think they should offer (pain medication)." The DON confirmed that LPN #18 should have done a physical assessment of her leg and "should have checked and looked at it, yes." -The DON was asked if the change on the early morning of [DATE] when she'd previously required the assistance of one person to get up, to needing two staff members to assist her was a change that warranted more frequent observation, and the DON stated, "I think we get to know our residents. (Resident #3) would complain periodically of this or that. Sometimes she would let you assist, or fight assistance. Whether (LPN #18) went back in or not is not documented. I agree with that." -The DON was asked how often the facility staff should check on residents and she stated, "We go minimally every two hours. You can be in a room, and then two minutes later, after you leave, someone can fall. You cannot prevent them all." -The DON explained that their documentation could not show that resident #3 was checked on frequently on the night of [DATE], and stated, "It's not documented. I can't." She explained that the "Treatment Sheet" has the order "Nurse to visualize resident every two hours," but did not document the actual times the nursing staff was in the resident's room. -The DON was informed of the contradictory information obtained from CNA #22 and LPN #18. She stated, "I was told there was no report of a fall," and explained that CNA #22 "did not come to me and tell me that she knew she fell . I would hope that if she thought the nurse wasn't following through, they could come to me, but that was not the case either." The DON agreed that someone was not being truthful. -The DON agreed that LPN #18 failed to adequately assess resident #3 when she began to complain of left leg pain. The DON was asked if she felt LPN #18 had failed to notify the physician and family in a timely manner, and she stated, "If the resident fell . If she helped her up, I agree with that. I don't know that all that happened, and I think the best way to handle it is to bring them in face to face and figure it out." The DON confirmed that if LPN #18 knew that the resident fell , she should have reported it, and begun an investigation. -The DON stated, "We truly believed that the lady had a fall. I have never done that kind of an investigation." She stated, "I am going to do an investigation. I don't know how long it will take. I truly did not know." As of [DATE], no additional information had been provided by the facility. 2. Fall on [DATE] Record Review: The significant change MDS assessment, dated [DATE], included a BIMS score of 6, which indicated the resident was severely impaired. She now required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. She was always incontinent of urine and bowel, and there was no documented rejection of care. She had a new [DIAGNOSES REDACTED]." The Physician's Progress Notes dated [DATE] included, "Family has expressed anger and frustration to staff that we 'let her fall.'...I discussed with (name of family member) short of tying people in bed we cannot prevent falls, and she agreed that we can't. The NH (nursing home) will try other strategies as has been done in past to try to prevent falls." The Physician's Telephone Orders dated [DATE] included, "Admit to (name of local hospice provider) for hospice care at end of life; comfort care only. DNR (do not resuscitate) ..." The "Data Collection Tool" assessment dated [DATE] documented that the resident's functional status for transfers required two-person assistance. She required physical assistance for dressing, grooming, transfers, toilet use and bed mobility. She was currently incontinent of urine and used pads/briefs and bedside commode. A dictated hospice progress note dated [DATE] included, "Patient has had apparent stroke on [DATE]. Patient is unable to move left extremities and swallowing has become progressively more difficult over the weekend ... Alternating air mattress delivered [DATE] for skin breakdown increasing over coccyx and buttock areas due to immobility ..." An SBAR (Situation, Background, Assessment, Request) form dated [DATE] for a fall that occurred at 9:05 a.m. included: "(Resident #3) had rolled out of bed and landed on her left side. Alert but with a recent history of a stroke is unable to speak. She has left sided weakness. She was last checked at 8:50 a.m. and was in bed ... She is currently a hospice patient. The POA (power of attorney), (name of POA), wanted her mother sent to the emergency room via ambulance to be 'checked out.' ...Resident has a noted skin sheer on bottom that is currently being treated. Reported to emergency room nurse." A Nurse's Note dated [DATE] at 11:15 a.m. included, "Resident back via ambulance. No new orders. I was told by ER (emergency room ) personnel that they were sending (resident #3) back, no changes, no injuries." The Incident Report Form dated [DATE] included, "Resident rolled out of bed, landed on her left side ... Sent to (local emergency room ) [DATE] at 9:31 a.m. ...Final Outcome/Disposition: (Name of air mattress supplier) placed bolsters on bed [DATE]." The "Quality Improvement Post Fall Investigation" form was reviewed. The question "Previous falls" was void of documentation. The question "Injuries" was void of documentation. The question "Have the resident's medications been evaluated?" was check-marked "Yes," but the date was void of documentation. The question "Change in medical condition" was void of documentation. The form was signed by the DON. A dictated hospice progress note dated [DATE] included, "Patient rolled out of bed on [DATE] to floor mat. I ordered bolster mattress for her bed, education done with staff to use pillows to prop her away from open side of bed." On [DATE], the DON was asked to provide a list of all the dates of falls the resident had while she was a resident at the facility. The DON provided the following list: -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] The resident had a total of 10 falls while she was a resident at the facility. Staff Interviews: On [DATE] at 4:11 p.m., CNA #9, who was working the day shift on [DATE], explained that resident #3 fell out of bed and "she didn't hurt anything." She explained that she had been placing a long body pillow on the edge of the air mattress and said, "It was one of those big body pillows that we put on the outside to keep her in. I started doing that and (family member's name) loved it and said to keep doing it." The CNA said the resident was on an air mattress at that time, "But not the bolsters on the sides, and that's when she got the bolsters." On [DATE] at 1:10 p.m., the hospice nurse was interviewed, and was asked who was responsible for ordering air mattresses and bolsters for beds. She said, "Once hospice is informed that the resident needs an air mattress, hospice will order it." She thought the bolsters were ordered separately, in addition to the regular air mattresses. On [DATE] at 2:02 p.m., the DON was interviewed, and said, "Our nurses can tell hospice they want something." The DON was asked why bolsters were not placed on the bed at the same time the alternating air mattress was placed, and she stated, "They did not get bolsters for it. She wasn't doing a lot of moving or getting out of bed. And (the family member) wanted us to keep her in bed. Then she rolled out of bed, so I told hospice I want bolsters on that bed. I didn't even think about it at that time, to be honest with you. I didn't know she'd had 10 falls until I put the list together." On [DATE] at 1:03 p.m., the medical director was interviewed, and she confirmed that she would expect the facility staff to do a thorough investigation after they learn about a fall. Family Interview: On [DATE] at 5:02 p.m., the resident's daughter was interviewed. She confirmed that the bolsters were not placed on the bed at the same time the alternating air mattress was placed, and she stated, "No, they did not. They did it after she fell ." She explained that when the resident was placed on the air mattress, she did not have any concerns that she would fall out of bed "because she was paralyzed on the left side. What concerns could I have had? She wasn't moving around anymore." In summary, the resident experienced ten falls during her stay at the facility, culminating in a fall with fractures and an additional fall out of bed after her fractures. The facility failed to thoroughly investigate the circumstances surrounding the falls. The DON stated (see interview above) that she had never done that kind of an investigation for falls, and did not plan to do so until the complaint investigation was initiated.

Based on facility and hospital record review and staff and family interview, the facility failed to ensure one of 27 sample residents (#70) received sufficient fluids to maintain proper hydration and health. Resident #70 was admitted to the facility 2/1/13 with a history of [MEDICAL CONDITIONS], slurred speech, poor dentition, and swallowing problems. The resident lost his ability to swallow and lost 8% percent of his body weight during his two week facility stay. He was hospitalized [DATE] with mental status changes and severe dehydration. The facility failed to promptly intervene to address the resident's known risk factors for dehydration. The findings included: 1. Closed record review revealed resident #70, an [AGE] year-old male, was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the facility after hip surgery for [REDACTED]. The resident signed an advance directive on admission stating he wanted cardiopulmonary resuscitation and full medical treatment including artificially administered nutrition and hydration by tube, if medically indicated. 2. Resident #70's Status on Admission - Risk Factors for Dehydration Interviews and record review revealed the resident was identified on admission to have difficulty swallowing and to be at risk for declines in nutrition, weight, and fluid intake, all factors impacting hydration status and health. Interviews: A Licensed Practical Nurse (LPN) who provided care for the resident approximately once a week, was interviewed on 3/20/13 at 1:08 p.m. She said she recalled resident #70 "had swallowing problems. I think he had them when he got here. He refused a lot of food, drink, and supplements." The Registered Nurse (RN), who completed the resident's admission assessment, and provided care for him five evenings per week, was interviewed on 3/20/13 at 3:48 p.m. She said, "He did have swallowing problems upon admit ... I noticed a lot of coughing and he always had extra secretions." A RN who provided care for the resident on the day shift was interviewed on 3/21/13 at 9:45 a.m. She said resident #70 "did have difficulty swallowing - I think it was right off the bat. When I gave him his meds I had to take my time, give him one pill at a time. He didn't like to eat ... I remember him having really poor dentition." Record Review: According to the Nursing Admission Assessment, the resident was noted on 2/1/13 to need assist under "eating/nutrition." He was noted to have a fair appetite, and to eat a mechanical soft diet with thin liquids; his dentition was noted as "poor." Review of the resident's care plans revealed the following problems were identified shortly after admission: -Eating/nutrition issues were addressed on an acute care plan on 2/2/13, due to the resident's intake of less than body requirements. Goals were to maintain usual weight, and to provide foods the resident enjoyed and was familiar with. Approaches included RD (registered dietitian) assessment of caloric needs, therapy provided as ordered, food/fluid consumption monitored daily. -Hydration/Alteration in fluid volume deficit related to not drinking was addressed on a care plan 2/2/13. The goal was for the resident to drink an adequate amount of liquids throughout the day. The approaches were: Monitor [MEDICAL CONDITION]; monitor for decreased appetite/decreased fluid intake/dry mucus membranes/decreased urinary output, constipation, and diarrhea; monitor weight and inform MD of weight loss/gain of 3 pounds or as directed by MD; encourage fluid intake with med pass/snacks; provide fluids based on resident choice per interview; hydration risk review tool will be completed as directed; dietary consult. Review of nurses' notes 2/1 - 2/13/13 documented [MEDICAL CONDITION] (1-2+) to lower extremities; however, this was not care planned. 3. Documented declines in food and fluid intake after admission. a. Assessments The resident's admission Minimum Data Set assessment dated [DATE] documented the resident had loss of liquids/solids from mouth when eating or drinking, coughing or choking during meals or when swallowing medications, complaints of difficulty or pain with swallowing. The resident was care planned on this date for "risk for weight loss due to [DIAGNOSES REDACTED]." The goal was for stable weight at 180 pounds (+ or - 10 pounds) and approaches included diet as ordered, fortified foods, monitoring intakes and skin and honoring preferences. The resident's nutritional assessment also was completed 2/6/13. It noted the resident's diet (mechanical soft), his weight (183.7) and ideal weight range (143 - 175), and body mass index (26.5), as well as PO intake (50%). Other than the resident's mechanical soft diet (ordered on admission), there was no specific reference or intervention in the care plan above to address the resident's swallowing difficulties that had been identified by staff on admission. Likewise, there was no reference to the resident's swallowing difficulties in the registered dietitian's assessment. b. Progress Notes Nurses' notes and therapy notes 2/1 - 2/13 documented meal refusals or "bites" only (2/5/13, 2/9/13) gagging and difficulty swallowing (2/8/13, 2/9/13, 2/11/13, and 2/13/13) and weight loss (2/10/13). Per dietary communication 2/11/13, the resident was placed on a 3 day trial of pureed food, secondary to swallowing difficulty. c. Specific Nutritional Documentation Nutritional records (in pertinent part) revealed declines in food and fluid intake after admission and failure to meet estimated fluid needs at any time after admission. -The resident's nutritional assessment 2/6/13, documented "PO intake about 50% of meals at that time. A Nutritional Progress Note dated 2/13/13, a week later, documented "PO intakes about 18% of meals..." - The resident's Meal & Fluid Detail Report revealed that between 2/1 and 2/14/13, the resident consumed: (1) During breakfasts 76% to 100% twice, on 2/2 and 2/4; 25% to 50% once on 2/6; 25% or less six times on 2/3, 2/5, 2/8, 2/9, 2/10 and 2/11; and refused four times 2/7, 2/12, 2/13 and 2/14. The most he was ever documented to drink at breakfast was 360ccs three times, but he typically drank 240ccs or less, and refused to drink fluids at breakfast twice. (2) During lunches 76% to 100% twice, 25-50% once, less than 25% seven times, refused twice, and was out of the facility once. The most he ever drank at lunch was 400ccs once, and otherwise drank 300ccs or less. (3) During dinners - 76% to 100% once, 51-75% once, 25% or less twice, and refused nine times. The most he ever drank at dinner was 350ccs twice, but otherwise no more than 240ccs, and 0-10ccs four times. (4) During HS (Bedtime) Snacks - offered and accepted seven times, otherwise refused. Snack fluids were noted only once, 350ccs on 2/2/13. According to the Meal & Fluid Detail Reports above, resident #70 consumed zero (on 2/14) to 2175ccs of fluids per day. He was noted to consume less than half his required fluids on five out of 14 days: 2/1 (480ccs), 2/7 (1090ccs), 2/12 (890ccs), 2/13 (440ccs) and 2/14/13 (zero). The resident never met his estimated fluid needs of 2500cc's per the 2/6/13 nutritional assessment. (One certified nurse aide/CNA documented on four occasions that resident #70 had consumed large amounts of fluids - 800ccs on 2/3 at 8:44 p.m., 800ccs on 2/5 at 8:52 p.m., 800 ccs on 2/9 at 8:40 p.m.; and 900ccs on 2/11/13 at 9:19 p.m. However, see below, the resident was assessed on 2/11/13 as being unable to swallow anything but small sips of ice water.) 4. Failure of Facility to Promptly Intervene to Address Known Risk Factors for Dehydration. a. See Hydration care plan above. There was no evidence a hydration risk review tool was completed to identify the resident's specific hydration risks, the severity of these risks, and whether monitoring and encouragement, as care planned, were sufficient to reduce the resident's risk for dehydration. b. Although interviews with staff (see above) identified swallowing difficulties "right off the bat," this issue was not care planned until 2/11/13, 10 days after admission and at least 5 days after declines in intake were noted. c. There was no documentation that the resident's swallowing difficulties, inadequate food and fluid intake and weight loss, as noted by staff and as documented in the record, were timely reported to the resident's physician. While review of a nurses' note 2/9/13 documented that nursing spoke with the physician 2/9/13 and requested medication for secretions and a "speech eval," there was no documentation in the notes prior to this that staff had reported the difficulties evident to staff on admission. Moreover, there was no documentation in the 2/9/13 note regarding what information was communicated to the physician about the changes observed and documented by staff. There was no evidence the physician was notified of the extent of the resident's condition until the resident went to a scheduled appointment on 2/14/13 and from which he was sent directly to the hospital. (While a nurses' note 2/10/13 documented the physician's office was contacted to see if the resident could see the physician before his scheduled appointment 2/14/13, when staff was told there was no earlier appointment earlier, there was no documentation staff pursued an earlier appointment or physician visit to the facility based on the resident's condition). d. Although a 2/10/13 note documented the resident's weight loss of 8% (10 pounds) since admission, there was no evidence the registered dietitian was notified or that the resident's weight loss care plan (see above) was reviewed and/or revised. e. The speech evaluation, requested 2/9/13, was not obtained until 2/11/13. The speech therapy (ST) assessment showed the resident had "severe impairment (75-99% impairment). The resident's swallowing posture was "inadequate for PO intake." The resident's swallowing initiation was "severe (10+ seconds)" with "significant pocketing noted." -The goal was, "The patient will tolerate a mechanical soft diet with the use of compensatory strategies 100% of the time without signs/symptoms of aspiration to optimize nutrition and hydration." The goal date was 2/24/13. Rehab potential was "good" due to "Pt follows 2 step commands and has strong family support." The frequency/duration recommended was "two times a week for two weeks." -The ST treatment on 2/11/13 was documented as follows: "Trialed thermal gustatory stimulation to elicit a swallow. Pt had absent swallow reflex. Given cold ice-water from a small cup, he was able to swallow 4 sips ... It is recommended that he have a neurology consult or CT scan as he demonstrates several signs of a [MEDICAL CONDITION] severe dysarthria (slurred speech) and severe dysphagia (inability to swallow or difficulty with swallowing) with an absent swallow reflex." The speech therapist (ST) was interviewed at 11:00 a.m. on 3/21/13. -She said, "I'm only here a couple days a week ... (resident #70) has almost an absent swallow reflex. We tried puree and he'd just hold and hold it - then I'd ask him if he wanted to spit it out. Nothing worked for him until I got him in his room - he was able to swallow a few sips of very cold water. I asked him to practice swallowing every chance he got. I gave him a paper, typed it out and left him a paper. -I would have liked to have been involved before - I told them he needed more than just me one day a week ... -He had a swallow reflex with ice water - I told them to make sure he had a lightweight cup of ice water to increase his hydration. He was at risk for dehydration and [MEDICAL CONDITION]. -It wouldn't have been a bad idea to call me in sooner ... I did wonder why they continued to (feed him) when he couldn't swallow solid food." In a follow-up interview on 3/21/13 at 12 noon, the ST stated she had reported her findings to nursing, the registered dietitian, and the therapy director, as well as the resident's daughter. She said, "That sensation of ice water was the only thing that was triggering his swallow - if that's his only source of hydration, I'm not going to take that away from him." (1) There was no evidence that the resident's physician was notified of the ST's findings that the resident was unable to swallow. (2) While the ST evaluation and recommendations were obtained the same date the resident was care planned for "risk of choking or weight loss," the speech therapist's recommendations were not incorporated into this care plan. 5. Documentation of Further Declines - Hospital Admission a. Facility nurses' notes -On 2/13/13 evening shift nurse documented, "Seems to be having more difficulty with speech... Refused to eat, only taking few bites ..." Night shift noted, "Pt still points and needs sit to stand lift secondary to weakness and doesn't try to put wt (weight) on feet ..." -On 2/14/13 day shift nurse, "This a.m. he is unable to hold his head up. He has no c/o pain. MD appt. this am and a note re: this was made for her to eval resident as well as his continued difficulty swallowing ..." (The resident was transported to his appointment and from there transported directly to the hospital.) b. Hospital Records The 2/14/13 hospital emergency room physician report noted in pertinent part the following: -"[AGE] year-old male sent over by (PCP) after she had evaluated him in the office today. He had been sent from (LTC facility) with decreasing level of consciousness, noisy breathing and confusion. He had a recent surgery on his left hip at the end of January ... He's at (LTC facility) since he's been having difficulty swallowing. Recently had decreased oral intake. Today in the office (PCP) found him to be hypoxic and hypotensive with an irregular heart rate. He was also slumped in a chair and was not interacting appropriately. It was thought that he might have developed [MEDICAL CONDITION] and perhaps a stroke." -Review of systems revealed "difficulty swallowing. Emesis after liquids on occasion. Dry lips ... Respiratory: Reports: cough, short of breath (low sat), Gastrointestinal/Abdominal: Reports: vomiting ... Skin: Reports: other (pallor), Neurological: Reports: other (decreased responsiveness)." -Physical Exam: "General Appearance ... thin ... dry lips and dry mucous membranes with food matter in the posterior pharynx ... decreased breath sounds, rhonchi (rhonchi bilaterally), Cardiovascular/Chest: Reports: irregularly irregular (appears to be sinus with frequent PACs) ... somnolent but arousable on arrival ... disheveled ... gargled speech with mumbling." -Progress Note: "Sodium markedly elevated at 165 ... BUN/creatinine markedly elevated at 56 and 3.4. This is a new finding ... I discussed his presentation with (physician name) the hospitalist on call. The patient has [MEDICAL CONDITION] with severe dehydration and [MEDICAL CONDITION]. He has also developed a right lower lobe infiltrate consistent with pneumonia. He'll be admitted to the intensive care unit and will continue with fluid hydration and [MEDICATION NAME] antibiotics." -Discharge Problem: [MEDICAL CONDITION] with severe dehydration, [MEDICAL CONDITION], right lower lobe pneumonia, difficulty swallowing ... Condition: Serious." The hospitalist physician's report documented in pertinent part "Some mental status changes ... He was initially doing well (following hip surgery) until this past Thursday (approximately 7 days prior to hospital admission - 2/7/13) when he was having some difficulty swallowing. Daughter noted that he was somewhat difficult to understand because of dry mouth. He became weak." "He was seen by Speech Therapy (2/11/13) who noted he had some difficulty swallowing (per the patient's daughter), and was not taking much in way of p.o. of either food or water. He went to follow up with (PCP) today in the office. He was noted to have an irregular heart rhythm and then was slumped over and essentially obtunded, and he was transferred to the emergency room ." Basic metabolic profile noted sodium of 165, potassium 3.5, chloride 119, CO2 of 28, BUN and creatinine 55 and 3.4, respectively. Urinalysis was ordered, however, he has not been able to void ... Also a chest x-ray was obtained, which noted low lung volumes with bibasilar infiltrates, suspect right lower lobe pneumonia. The patient was subsequently given IV fluids and admitted for further workup and evaluation. He was also placed on [MEDICATION NAME] and [MEDICATION NAME]." Physical examination: "Patient is very slow with responses and currently not oriented ... Currently temperature 97.5, pulse of 79, respiratory rate of 20, blood pressure of 112/48, saturation 82% on 4 liters nasal cannula ... Mucous membranes are extremely dry ... Discharge [DIAGNOSES REDACTED]. 6. Interviews A LPN interviewed on 3/20/13 at 1:08 p.m. said, "He refused a lot of food, drink and supplements. He didn't choke when he drank, but a lot of times we crushed his meds, and we'd think he'd swallowed it, but he was keeping it in his mouth and he'd spit it out later ... We'd try to encourage fluids a lot, but he usually wouldn't take them. I'd offer him water and things ... His mouth, he had a lot of dryness ... I think he was pocketing and it was just coating in his mouth. It was hard to get it out ... It was just because he held the fluids in his mouth." The facility medical director was interviewed on 3/20/13 at 1:30 p.m. Although not resident #70's physician, she had reviewed his chart. She said, with regard to the resident's swallowing problems and weight loss, "That we missed on him ...We were recording his intake but when he first got sick, that was when (his weight) dropped. Looking at his record, I didn't see that going on ...The main thing I looked at was, did we miss his dehydration? Weight loss can be an indicator of dehydration ..." A RN interviewed on 3/20/13 at 3:48 p.m., said, "He wouldn't drink anything but thin (liquids) ... I'd turn and he'd spit it in a cup or on the floor." A CNA who regularly provided care for the resident was interviewed on 3/21/13 at 10 a.m. She said, "At the end before he left, he'd spit out everything we gave him. He'd take a gob of napkins and spit out everything. In the beginning he was okay with drinking, but it tapered off and he just quit drinking." The director of nurses (DON) interviewed at 11:30 a.m. on 3/21/13 said, "I was told that he was spitting out food - but I was told this after he went to the hospital, not before. I didn't know about spitting out the liquids there at the end." She acknowledged that given the resident's poor dentition, slurred speech and other therapies, it would have made sense to provide speech therapy as well upon admit. The resident's family member/power of attorney (POA) was interviewed by phone on 3/26/13 at 10 a.m. She said, in pertinent part: -"After those first couple of days, I recall only once being there around a mealtime, and he was in his room with a tray. Nobody was in there with him. This was roughly (2/7 or 2/8/13). The tray was sitting in his room on one of those bedside tables. Everything was covered, he hadn't even touched it. It was about 5:30 p.m. One lady came in and asked him if he was going to eat. He said no, and (she) took the tray away." -"I tried to give him water whenever I was there, and he was just kind of getting weaker. I don't know how much water they attempted to give him. They did a swallowing test on him and he'd pretty much lost his ability to swallow. They had called for a swallow test because he wasn't getting anything down ..." -"I did try to give him water when I was there and he was just kind getting weaker. I don't know how much water they attempted to give him ...I did try to give him water when I was there. He could no longer suck it up through the straw so I'd put the cup up to his mouth. He'd get a little, but most of it went back out. I'd have to go get him a cup, because he couldn't drink from a straw. What I saw there was a larger container with ice and a straw; even after the ST saw him. Like I said, I'd go down and ask if I could get a cup, because I knew he couldn't drink through the straw and that thing (large container in room) was way too big for him to drink out of."