CAMBRIDGE CARE CENTER

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on July 2, 2026 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a two (2) story, Type V (111) construction. This structure has a full basement that is attached to a one (2) story wood frame structure Type V (111). The facility is licensed for 110 beds and the census on the date of the survey was 90. The facility was constructed in 1964. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The facility is classified as fully sprinklered. The results of this survey were discussed with the Maintenance Director and the Facility Administrator/CEO during the exit conference.

Based on record review, observations, inspection, and interviews, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. The deficient practice affected 2 of 8 smoke compartments. The deficient practice could affect 24 of 90 residents, and an indeterminable number of staff and visitors. 1. The record review, observations, and interviews with the maintenance director revealed that there is a corroded fire sprinkler head located inside the Janitor Closet on the first floor, across from Room 108.2. The record review, observations, and interviews with the maintenance director revealed that there is a fire sprinkler head missing an escutcheon plate located in Room 401. NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. NFPA 25, 5.2.1.1.5 Escutcheons and coverplates for recessed, flush, and concealed sprinklers shall be replaced with their listed escutcheon or coverplate if found missing during the inspection. Deficient items were discussed with the Maintenance Director and the Facility Administrator/CEO during the exit interview.

Based on record review, observations, inspection, and interviews, it was determined that the facility failed to meet the protection requirements in accordance with the Utilities- gas and electric requirements in accordance with NFPA 101 and NFPA 54. The deficient practice affected 1 of 8 smoke compartments. The deficient practice could affect 12 of 90 residents, and an indeterminable number of staff and visitors. 1. Based on observation and staff interviews during the inspection, it was revealed that there are screws in the dryer vent duct work. NFPA 54, Section 10.4.4.2 Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system. Deficient items were discussed with the Maintenance Director and the Facility Administrator/CEO during the exit interview.

A survey with #CO3032071 was completed on 6/8/26 to 6/11/26. No deficiencies were cited.

A recertification survey with complaint #CO3032070, Incident #2631298, Incident #3029325, Incident #3029345, Incident #3029375, Incident #3029411 and Incident #3029463 was conducted on 6/8/26 to 6/11/26. Six deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/8/26 to 6/11/26. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure the resident’s right to self-determination and choice was honored for one (#4) of five residents out of 37 sample residents. Specifically, the facility failed to honor Resident #4’s preference for getting out of bed and sitting in a wheelchair. Findings include:I. Facility policy and procedureThe Resident Rights policy and procedure, dated 2001, was provided by the nursing home administrator (NHA) on 6/11/26 at 6:53 p.m. It read in pertinent part, “ Employees shall treat all residents with kindness, respect, and dignity.“Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident’s right to self-determination and access to people and services, both inside and outside the facility.”II. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on 7/10/25. According to the June 2026 computerized physician orders (CPO), diagnoses included coronary artery disease (CAD), congestive heart failure, diabetes mellitus, dementia, and schizophrenia. The 3/3/26 minimum data set (MDS) assessment revealed Resident #4 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment revealed the resident used a wheelchair for mobility and a walker, and required substantial and maximal support for activities of daily living (ADL), including bathing and dressing. The assessment indicated Resident #4 exhibited behaviors and rejected care one to three times per day during the assessment look-back period. B. Resident interviewResident #4 and her representative were interviewed together on 6/9/26 at 1:20 pm. Resident #4 said she preferred to get out of bed and into a wheelchair, but she had been staying in bed all day and all night. She said her previous wheelchair did not have foot pedals, which had left her feet dangling and had caused severe pain. Resident #4 said that because the facility was unable to provide a wheelchair that did not leave her feet dangling, she had refused to use the wheelchair they had provided her with, which had caused her to remain in bed all day and all night for several months. C. ObservationsOn 6/8/26 at 11:15 a.m Resident #4 was lying in her bed. Observation of Resident #4’s room revealed that a walker and/or a wheelchair were not present, stored, or accessible anywhere within her living space, including the resident’s bathroom. On 6/9/26 at 1:45 p.m Resident #4 was lying in her bed. Observation of the room revealed that a walker and/or a wheelchair were absent from her immediate environment. On 6/10/26 at 11:30 a.m. Resident #4 was lying in her bed. Observation of her living space revealed that there was no walker or wheelchair available or stored inside the resident’s room. D. Record reviewThe ADL care plan, revised 2/25/25, revealed Resident #4 had an ADL self-care performance deficit related to disease process. Interventions included providing the resident assistance with transfers. The mobility care plan, initiated 2/25/25, revealed that Resident #4 was independent in sit-to-stand transfers, shower transfers, and walking 10 feet, 50 feet, and 150 feet with a walker. -The ADL and mobility care plans failed to identify the resident used a wheelchair, despite the MDS assessment indicating the resident required one for mobility (see MDS assessment above). The 2/16/26 physical therapy (PT) evaluation indicated that Resident #4’s treatment approaches could include a moderate-complexity evaluation and therapeutic activities. The evaluation documented a treatment frequency of once daily for one week. Additionally, the evaluation documented that Resident #4's potential for achieving rehabilitation goals was poor at that time, due to significant agitation and violence toward staff when mobilization was attempted. The focus of the treatment plan was participation. -However, the plan of treatment was limited to "evaluation only" due to the resident's agitation and refusal, and did not explore ways to empower the resident or adapt interventions to her needs and choices by providing a wheelchair that provides support for her foot to prevent it from dangling and causing her pain. The June 2026 restorative nursing program documented zero days of participation with 20 documented refusals between 5/13/26 and 6/10/26.-There was no documentation in Resident #4’s electronic medical record (EMR) to indicate the facility attempted to identify the reason for the resident’s refusals of therapy of the restorative nursing program. III. Staff interviewsCertified nurse aide CNA) #2 was interviewed on 6/10/26 at 10:40 a.m. CNA #2 said she was familiar with Resident #4’s daily care. CNA #4 said that Resident #4 had been confined to her bed and had not been up or out of bed for a long time. CNA #2 said she documented all of the resident's refusals and reported them directly to the unit nurse. CNA #2 said she had not seen a wheelchair or walker in Resident #4's room for a long time. CNA #2 said that she had not noticed any recent changes in the resident's care plan regarding her mobility or equipment. Restorative nurse aide #1 was interviewed on 6/10/26 at 1:15 p.m. Restorative nurse aide #1 said she worked with Resident #4 and ran her restorative program. Restorative nurse aide #1 said the therapists developed the restorative therapy program for each resident and restorative aides were responsible for executing it. Restorative nurse aide #1 said she reported all refusals to the director of nursing (DON). Restorative nurse aide #1 said Resident #4 did not currently have a wheelchair in her room. Restorative nurse aide #1 said she would find a wheelchair when the resident decided to participate in the restorative nursing program. Restorative nurse aide #1 said there had been no new interventions that had been communicated to her for Resident #4. RNA #1 said Resident #4 refused to participate in the restorative program due to her leg pain. The director of rehabilitation was interviewed on 6/11/26 at 10:20 a.m. The director of rehabilitation said he was familiar with Resident #4’s care and her lack of participation with her restorative and ambulation programs. The director of rehabilitation said he was aware of Resident #4’s prolonged bed confinement due to complaints of leg pains. The director of rehabilitation said the rehabilitation department did not directly oversee the implementation and management of Resident #4’s restorative program. The director of rehabilitation said Resident #4 should have her assistive mobility devices available in her room and functioning appropriately at all times to support her care plan goals, self-determination, and choices. The director of rehabilitation said the absence of a walker and a wheelchair in the resident’s room could directly hinder the effectiveness of her restorative mobility program. The DON was interviewed on 6/11/26 at 3:00 p.m. The DON said she oversaw the restorative nursing program and was aware of Resident #4’s prolonged bed confinement due to the resident’s refusals. The DON said Resident #4 required transfer assistance with a mechanical lift, wheelchair, or walker. The DON said the wheelchair and the walker were removed from the resident’s room due to her refusals. The DON said she wrote a periodic update on the resident’s care refusals and documented it in the nursing progress notes.-However, there was no documentation to indicate the resident refused to get out of bed in Resident #4’s mobility care plan. IV. Facility’s follow-upOn 6/12/26 at 4:50 p.m., following the survey exit, the NHA provided a letter which documented the following:The letter identified that a wheelchair was not clinically or medically necessary for Resident #4’s care and daily needs and the resident was bed-bound by her own choice. The letter identified that Resident #4 regularly refused to participate in physical therapy, restorative transfer programs, and attempts to mobilize her due to knee pain and significant agitation.-However, the plan of treatment was limited to evaluation only due to the resident’s agitation and refusal. The plan did not address ways to encourage Resident #4 or adopt interventions to her needs and choices.-Additionally, there was no documentation to indicate the facility followed up to see if a different wheelchair would decrease the resident’s knee pain. The letter identified that Resident #4 was seen by PT every six months and as needed, to review her physical abilities and provided a copy of the 2/12/26 PT assessment. The PT assessment concluded that the resident was "not appropriate for skilled PT intervention at this time.”-However, the PT assessment did not identify that the resident would be re-evaluated in six months, or sooner if needed, for her mobility needs.

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#80) of five residents reviewed for grievances out of 37 sample residents. Specifically, the facility failed to ensure Resident #80’s grievance concerning a lost personal item was documented and followed up on in a timely manner. Findings include:I. Facility policy and procedure The Grievances policy and procedure, dated 5/8/23, was provided by the nursing home administrator (NHA) on 6/11/26 at 6:56 p.m. It read in pertinent part, “To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded to promptly and in written form. “A resident, family member, staff member, or visitor may file a grievance at any time with an appropriate staff member or supervisor, regardless of cognitive status, mental health diagnosis, or physical disability. They have the right to file a grievance in writing or orally, to file it anonymously, and to obtain a written review. “The resident, or person acting on behalf of the resident, will be informed of the investigation's findings and any corrective actions recommended, within five (5) working days of filing the grievance or complaint.” II. Resident #80A. Resident status Resident #80, age less than 65, was admitted on 8/2/19. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), obesity class 3, schizoaffective disorder, personal history of traumatic brain injury, hypertensive heart disease without heart failure, obstructive sleep apnea, major depressive disorder, and anxiety disorder. The 4/27/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. He was dependent with toileting and personal hygiene, and independent with eating and transfer. Resident #80 exhibited no behaviors and did not reject care. B. Resident interviewResident #80 was interviewed on 6/9/26 at 1:15 p.m. Resident #80 said he reported a missing laptop charger to social services assistant #2 several weeks ago. Resident #80 said that no one had helped him to find the charger since he made the report. He said the issue was causing him significant frustration because he was unable to use his laptop to stay in touch with his friends and family due to the missing charger. Resident #80 said that social services assistant #2 had taken a picture of the laptop's charging port when he first reported the issue, but he had heard no feedback or updates from her since his initial report of the missing item. Resident #80 said that no formal grievance form was completed at the time of the initial report or during the subsequent weeks. C. Record review-A review of the facility’s Grievance Log, from 6/9/25 through 6/9/26, revealed that no entry had been documented regarding Resident #80’s reported missing computer charger. III. Staff interviewsSocial services assistant #2 was interviewed on 6/11/26 at 11:40 a.m. Social services assistant #2 said she remembered Resident #80 reported a missing computer charger a few weeks ago, but she did not remember the exact date and time. Social services assistant #2 said she informed the housekeeping manager to look for the resident’s charger but did not follow up to ensure that the charger was found. She said a grievance form was not completed and that the report and her actions were not documented in Resident #80’s electronic medical record (EMR). Social services assistant #2 said she understood the facility’s obligation to residents regarding grievances and that the issue should have been handled in accordance with the facility’s policy and procedure for grievance resolution. Social services assistant #2 said she could not find a charger that could fit the resident’s computer and she did not resolve the issue with Resident #80. The social services director (SSD) was interviewed on 6/11/26 at 12:05 p.m. The SSD said she was the grievance official for the facility. The SSD said that the grievance process required completing the grievance form for all grievances and forwarding it to the appropriate department for prompt action. She said when a grievance was resolved, the NHA would review the resolution, ensure that the resident or the resident’s representative were satisfied with the outcome, and sign the grievance form. The SSD said social services assistant #2 should have completed and documented Resident #80's reported missing computer charger. The NHA was interviewed on 6/11/26 at 1:30 p.m. The NHA said staff members filled out a grievance form whenever a resident reported that a personal item was missing and could not complete a grievance form on their own. The NHA said he did not know the reason the staff did not follow the facility’s grievance processes for Resident #80’s report of the missing computer charger. The NHA said missing personal items needed to be addressed immediately, but at most. within a few days. The NHA said a grievance form would be completed for Resident #80 and an education would be provided immediately to the social services assistant on the importance of following the facility’s grievance process. IV. Facility’s follow-upOn 6/12/26 at 4:50 p.m., following the survey exit, the NHA provided a letter which documented the following:The facility acknowledged there was an administrative delay in following up and securing the new cord for the resident. The letter indicated the facility completed a grievance form and provided Resident #80 with a replacement computer cord.-However, the grievance was not followed up on until it was brought to the attention of the facility during the survey. The letter additionally indicated the facility reviewed Resident #80’s routine and identified that Resident #80 participated in other activities of interest while waiting for the replacement computer cord.-However, per the resident’s interview during the survey, he had experienced significant frustration because he was unable to use his laptop to stay in touch with his friends and family due to the missing computer charger (see resident interview above).

Based on observations, record review and interviews, the facility failed to ensure one (#39) of four residents reviewed out of 37 sample residents were kept free from resident-to-resident physical abuse. Specifically, the facility failed to protect Resident #39 from physical abuse by Resident #58. Findings include:I. Facility policy and procedureThe Community Standard Operating Abuse policy and procedure, dated February 2024, was provided by the nursing home administrator (NHA) on 6/11/26 at 7:12 p.m. It read in pertinent part, “The community does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals.“Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being.“Willful means the individual must have acted deliberately, not that he or she must have intended to inflict injury, or harm. “Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident’s symptoms.” II. Incident of physical abuse by Resident #58 towards Resident #39 on 4/28/26A. Facility investigationThe facility abuse investigation report was provided by the NHA on 6/10/26 at 9:45 a.m. The investigation documented the incident occurred on 4/28/26 at 9:30 a.m. The investigation revealed that Resident #58 went to visit Resident #39’s roommate. Resident #39 grabbed Resident #58 and told him to leave. Resident #58 hit Resident #39 in the face. This took place in the hallway in front of Resident #39’s bedroom door. Resident #58 was verbally redirected away from the location. The residents were placed on frequent checks by the facility. The local police, the physician and all appropriate parties were notified. Resident #39 did not want his emergency contact notified. The investigation documented Resident #39 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #39 had no history of behaviors and had a visible injury of a swollen cheek following the incident. The investigation documented Resident #58 was cognitively intact with a BIMS score of 15 out of 15 and had a history of behavior issues related to entering others residents’ rooms to steal items. Resident #58 was alert and oriented to person, place, situation and time. Resident #58 was mobile without the use of assistive devices. The investigation documented that the incident was witnessed by staff. The victim (Resident #39) and the assailant (Resident #58) were assessed by a nurse on 4/28/26. Resident #39 sustained a swollen cheek and facial pain. Resident #39 declined over-the-counter pain medication. The investigation documented that Resident #39 was interviewed by social services assistant #1. Resident #39 said Resident #58 went to visit Resident #39's roommate for a cigarette. Resident #39 requested that Resident #58 not enter his room. Resident #39 then grabbed Resident #58's shirt, was hit in the face by Resident #58, and then Resident #58 left the scene. The investigation documented that licensed practical nurse (LPN) #5 interviewed Resident #58 on 4/28/26. Resident #58 said he went downstairs to see a guy, heard someone yell, and swing at him, so he hit back and left. The investigation documented Resident #58 was placed on frequent checks. Resident #39's roommate was being moved, so Resident #39 had no reason to be around the assailant. Resident #58 had been educated not to enter other residents’ rooms and not to ask for or buy cigarettes from other residents. Resident #39's roommate had also been educated not to sell or hand out cigarettes to anyone. The social services director (SSD) interviewed seven facility residents and six facility staff members. The interviewed residents said they had no concerns about physical abuse. The facility staff members said they felt they were sufficiently trained to handle situations of physical abuse.-However there were no updates to Resident #58’s behavioral care plan to prevent further recurrence (see record review below). The investigation documented contact between the residents but concluded that the outcome was inconclusive and the abuse allegation was unsubstantiated.-However, abuse occurred because Resident #58 hit Resident #39 in the face, which resulted in a swollen cheek and facial pain for Resident #39. B. Resident #58 (assailant) 1. Resident statusResident #58, age greater than 65, was admitted on 4/27/06. According to the June 2026 computerized physician orders (CPO), diagnoses included peripheral arterial disease (a circulatory condition in which narrowed arteries reduce blood flow to your limbs), hyperlipidemia (high cholesterol), anxiety disorder, schizophrenia, chronic obstructive pulmonary disease (COPD), and chronic bronchitis. The 3/31/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He was dependent on staff assistance for toileting hygiene and personal hygiene and was independent with eating and mobility. The assessment revealed Resident #58 had no behaviors towards himself or others during the assessment look-back period. 2. Resident interviewResident #58 was interviewed on 6/9/26 at 4:40 p.m. Resident #58 said he went downstairs to visit a friend. Resident #58 said that while he was downstairs, another resident, identified as Resident #39, began shouting at him and then swung at him. Resident #58 said he hit Resident #39's face and left the area. 3. Record reviewResident #58’s behavior care plan, initiated 12/27/24 and revised 12/1/25, revealed the resident had a tendency to wander into other resident’s rooms and use their bathrooms. Interventions included providing the resident with redirection when he wandered/roamed into other resident’s rooms/bathrooms, providing the resident with an alternate activity when he was aimlessly roaming and social services was to provide one-to-one supervision when the resident was unable to be redirected. -However, the care plan failed to include interventions to address Resident #58's documented history of entering other residents' rooms in search of cigarettes and taking their personal items. The 5/4/26 at 3:47 p.m. interdisciplinary team (IDT) behavioral note revealed the root cause of Resident #58's physical aggression was a disease process related to a personality disorder. No treatment was recommended, and the interventions put in place were encouraging the resident to avoid entering his peers’ rooms uninvited, monitoring the resident’s behavior episodes and attempting to determine the underlying cause, considering location, time of day, persons involved, and situations, documenting behavior and potential causes, and frequent checks as needed. -However the IDT note interventions were not updated in Resident #58’s care plan (see care plan above). C. Resident #39 (victim) 1. Resident statusResident #39, age 65, was admitted on 1/26/24. According to the June 2026 CPO, diagnoses included multiple sclerosis, narcolepsy without cataplexy (a chronic neurological sleep disorder), nicotine dependence, dermatitis, a history of falling, and hypertension (high blood pressure). The 5/11/26 MDS assessment revealed Resident #39 was cognitively intact with a BIMS score of 15 out of 15. He was independent with eating, personal hygiene, toileting, transfers and use of a manual wheelchair. The assessment revealed Resident #39 had no behavioral symptoms, rejection of care or wandering behaviors. 2. Resident interviewResident #39 was interviewed on 6/8/26 at 5:34 p.m. Resident #39 said another resident, identified as Resident #58, attempted to enter his room without invitation. Resident #39 said that he immediately held Resident #58's shirt to prevent him from entering the room and asked him to leave. Upon receiving the request to leave, Resident #58 struck Resident #39 directly in the right eye. Resident #39 said that the physical altercation resulted in a visible injury, specifically a black eye. 3. Record reviewResident #39’s behavioral care plan, revised 4/30/26, revealed he had a preference for questioning other residents if, according to his perception, they were doing things out of the ordinary. Interventions included educating the resident to avoid confrontation with other residents and notifying staff of any misunderstandings with other residents. The 5/4/26 at 4:08 p.m. IDT risk management note revealed Resident #39 was a victim of physical aggression, which required treatment with no referrals made. The proposed interventions included educating the resident to notify staff of any misunderstandings with other residents, educating the resident to avoid confrontation with other residents, and conducting frequent checks as needed. A physician’s note, dated 5/4/26 at 10:16 a.m., revealed Resident #39 was seen by a physician. The physician's note revealed that Resident #39 reported a physical altercation with another resident (Resident #58) after the other resident entered his room uninvited. The other resident then punched him in the right eye. Resident #39 developed ecchymoses (bruising) under the right eye. III. Staff interviewsSocial services assistant #1 was interviewed on 6/11/26 at 12:25 p.m. Social services assistant #1 said she was informed Resident #39 was hit in the face by Resident #58 (on 4/28/26). Social services assistant #1 said she was involved in the investigation of the incident. Social services assistant #1 said she reviewed the documentation for both residents, gathered statements regarding the physical altercation, and ensured that necessary safety interventions were implemented immediately following the incident. Social services assistant #1 said she did not determine the conclusion of the investigation. The SSD was interviewed on 6/11/26 at 12:35 p.m. The SSD said following the resident-to-resident altercation between Resident #39 and Resident #58 on 4/28/26, staff informed management immediately so an investigation could begin. The SSD said the NHA was out of the facility and asked her to initiate and complete the facility investigation. The SSD said because the incident involved physical aggression, the facility interviewed the staff present and other residents, and worked to identify the root cause of the incident. The SSD said the facility staff initiated frequent checks of Resident #58 and Resident #39 following the incident. The SSD said the incident of abuse was unsubstantiated due to inconclusive evidence. The SSD said the NHA, who was the facility’s abuse coordinator, determined the outcome of the investigation. The NHA was interviewed on 6/11/26 at 1:15 p.m. The NHA said that in his role as the facility's designated abuse coordinator, he was responsible for reviewing and determining the outcome of any allegations of abuse. The NHA said that he unsubstantiated the allegation of abuse following the investigation of the incident between Resident #58 and Resident #39. He said that while the evidence confirmed physical contact took place between the two residents, it was his clinical and administrative opinion that Resident #58 lacked the willful intent to harm Resident #39. The NHA said abuse required a determination of willful intent, and because he determined the physical contact resulted from a reactive behavioral escalation rather than an intentional act of abuse, the allegation did not meet thecriteria for substantiated abuse. IV. Facility follow-upOn 6/11/26 at 5:31 p.m. the NHA provided a Past Noncompliance Form related to the 4/28/26 incident between Resident #58 and Resident #39. The form documented the following:The staff development coordinator completed education with staff on 5/1/26 regarding stepping in and intervening when residents were entering other residents’ rooms uninvited. Additionally, the form documented the chief executive officer or a designee would make two observations a week for one week, one observation weekly for three weeks and then one observation monthly for two months to ensure staff intervened when residents entered other residents’ rooms. The audit would be documented on a written log.-However, the facility did not provide documentation of the education, including staff signatures and there was no documentation provided by the facility of the ongoing audits and results.

Based on observations, record review and interviews, the facility failed to ensure that residents received proper treatment and assistive devices to maintain hearing abilities for one (#34) of two residents reviewed for hearing services out of 37 sample residents. Specifically, the facility failed to ensure Resident #34’s broken hearing aids were replaced in a timely manner. Findings include:I. Facility policy and procedureThe Ancillary Services policy, dated 11/4/13 was provided by the nursing home administrator (NHA) on 6/11/26 at 6:56 p.m. It read in pertinent part,“Ancillary services, including, but not limited to, dental, vision, audiology and podiatry will be provided to the resident per state and federal regulatory guidelines; at the resident/responsible family member’s request; and as needed.“Any resident needing or requesting ancillary services such as dental, vision, audiology and podiatry will have their needs met in a timely manner. The facility will keep a provider for ancillary services available and/or assist the resident in utilizing the provider of their choice. The facility staff designee will coordinate transportation and appointments with all other pertinent parties to ensure ancillary service appointments are met.“Records of ancillary services care will be kept in the resident’s medical record for a period of one year.“All orders for the treatment of the resident’s ancillary services must be in writing and the resident’s attending physician must be made aware of any treatments or medications ordered by an ancillary service provider.”II. Resident #34A. Resident statusResident #34, age greater than 65, was admitted on 1/27/25. According to the June 2026 computerized physician orders (CPO), diagnoses included pleural effusion (an abnormal buildup of fluid in the pleural space between the lungs and chest wall), dilated cardiomyopathy (a disease where the heart's main pumping chamber becomes enlarged, thinned, and weakened), unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 4/29/26 minimum data set (MDS) assessment revealed Resident #34 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment revealed that the resident used a wheelchair for mobility and required substantial and maximal support for activities of daily living (ADL), including bathing and dressing. The MDS assessment revealed that Resident #34’s ability to hear was highly impaired (absence of useful hearing) and the resident required a hearing aid. B. Resident interview and observationResident #34 was interviewed in his room on 6/8/26 at 2:53 p.m. in his room. Resident #34 said his hearing aids were broken and that it was extremely difficult to hear. Resident #34 said that the absence of working hearing aids had made it difficult for him to communicate with facility staff, family, and peers. Resident #34 said he had previously reported this issue to the facility staff, but nothing had been done to help him fix the device or obtain a new one. Resident #34 said he had been waiting for assistance with obtaining a hearing aid for several months. Resident #34 said he had completed an audiology appointment several months ago, during which the audiologist recommended a new hearing aid. Resident #34 said he became frustrated and angry when he could not hear what others were saying around him. He said it had become difficult to hold a conversation unless people spoke louder. Resident #34 said he was not offered any accessories to facilitate better communication with others while he waited for his hearing aid. During the interview, Resident #34 was sitting on his bed. Throughout the interview, the resident maintained eye contact and frequently pointed to his ears to signal he did not catch what was said. Resident #34 would react by lowering his chin in frustration and verbalize that he could not hear. C. Resident’s representative interviewResident #34’s representative was interviewed on 6/9/26 at 11:40 a.m. Resident #34’s representative said the resident had ongoing hearing issues, prompting him to obtain over-the-counter hearing aids for the resident. The representative said that the resident's current hearing aids were purchased by him. The representative said it remained difficult to hold phone conversations with Resident #34 due to issues with his hearing aids. The representative said that because the hearing aids were not functioning, he often drove to the facility to talk to Resident #34. The representative said that even face-to-face conversations had proven difficult, with a lot of frustration on Resident #34's part. D. Record reviewThe communication care plan, initiated 2/9/25 and revised 4/13/26, revealed Resident #34 had a communication problem related to a hearing deficit. Interventions included using alternative communication tools as needed, monitoring, documenting and reporting as needed any changes in ability to communicate, potential contributing factors for communication problems, and assessing the resident’s need for adaptive devices as indicated. The activity progress note, dated 1/24/26 at 2:53 p.m., indicated that Resident #34 required adaptations to participate in activities due to his hearing limitations. The value-based weekly nursing progress note, dated 12/29/25 at 5:21 p.m., documented that Resident #34 had a mild-to-moderate hearing impairment, with difficulty hearing in some environments, and that the speaker may need to increase volume or speak more distinctly. The note documented that Resident #34 used a hearing device. The 8/11/25 audiology patient visit note revealed Resident #34’s pure-tone testing, bilateral (a hearing assessment that measures the softest sounds a person can hear), showed symmetric, moderate-to-severe sensorineural sloping hearing loss in both ears. The visit revealed Resident #34’s word recognition scores were 50% at 85 dBHL (Decibels Hearing Level) in the right ear and 60% at 85 dBHL in the left ear, and a repeat audiologist evaluation was recommended in one year, or sooner if there was any new onset or change in hearing status, vertigo, aural pressure, otalgia, or tinnitus.-Review of Resident #34’s electronic medical record (EMR) did not reveal any further documentation regarding the replacement of Resident #34’s hearing aids. III. Staff interviewsSocial services assistant #1 was interviewed on 6/11/26 at 12:25 p.m. Social services assistant #1 said Resident #34’s last audiology visit was on 8/11/25. She said she reviewed the audiology visit’s recommendation in April 2026 and realized the resident’s PETI (post-eligibility treatment of income) was denied in September 2025 and was not acted upon by the previous social services assistant. Social services assistant #1 said she informed the business office manager concerning the resident’s PETI denial from several months back. She said she could not speak to why the hearing aids were not purchased when it was discovered that the resident had not received his hearing aid. Social services assistant #1 said the facility was still working on getting Resident #34’s hearing aids. The social services director (SSD) and the regional clinical resource were interviewed together on 6/11/26 at 12:35 p.m. The SSD said Resident #34’s previous audiology appointment on 8/11/25 recommended new hearing aids for the resident and a PETI application was filed. The SSD said the previous social services assistant who had handled the application no longer worked at the facility. The SSD said she did not know why the PETI for Resident #34’s hearing aids was not resubmitted after the facility realized it had not been acted upon. The regional clinical resource said it was the facility’s protocol to purchase an alternative device for a resident if it contributed to the well-being of the resident’s day to day life. The regional clinical resource said the facility was working on obtaining the hearing aids for Resident #34. IV. Facility follow-upOn 6/11/26 at 1:35 p.m. the regional clinical resource provided a performance improvement plan (PIP) related to the facility’s failure to follow–up on the process to obtain Resident #34’s hearing aids for several months. The PIP, which was initiated on 4/2/26, documented that it was identified that a resident who had been requesting hearing aids for quite some time had not yet received them. The PIP documented that the failure had resulted in the resident refusing to eat, weight loss and decreased participation in community activities.-However, Resident #34 had still not received new hearing aids by the time of the survey (from 6/8/26 to 6/11/26), despite the facility’s PIP which documented the concern had been identified on 4/2/26, over two months prior to the survey.-The facility did not provide documentation to indicate the facility had resubmitted a PETI for the resident’s new hearing aids in April 2026 or offered the resident an alternative functional hearing device while he waited for his hearing aids to be obtained.

Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards for one (#92) of four residents out of 37 sample residents. Specifically, the facility failed to ensure oxygen was administered according to the physician’s orders for Resident #92. Findings include:I. Professional referenceAccording to Nursing Skills, Open Resources for Nursing (Open RN), Ernstmeyer K, Christman E, editors. Eau Claire (WI): Chippewa Valley Technical College; published 11/11/21, retrieved on 6/17/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/,“Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. (Chapter 11)“Devices such as high flow oximetry masks, CPAP (continuous positive airway pressure), BiPAP (bilevel positive airway pressure), or mechanical ventilation may be initiated by the respiratory therapist or provider to deliver higher amounts of inspired oxygen. (Chapter 11)“Manage oxygen therapy and equipment: If the patient is already on supplemental oxygen, ensure the equipment is turned on, set at the required flow rate, correctly positioned on the patient, and properly connected to an oxygen supply source. If a portable tank is being used, check the oxygen level in the tank. Ensure the connecting oxygen tubing is not kinked, as this could obstruct oxygen flow. Feel for the flow of oxygen from the exit ports on the oxygen equipment.” II. Facility policy and procedure The Oxygen Administration policy, undated, was provided by the nursing home administrator (NHA) on 6/11/26 at 6:56 p.m. It read in pertinent part,“Oxygen is administered and stored to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the resident’s goals and preferences.“Oxygen is administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.“Staff shall document the initial and ongoing assessment of the resident’s condition warranting oxygen and the response to oxygen therapy.“The resident’s care plan shall identify the interventions for oxygen therapy, based upon the resident’s assessment and orders, such as, but not limited to: the type of oxygen delivery system, when to administer, such as continuous or intermittent and/or when to discontinue, equipment setting for the prescribed flow rates and monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.”III. Resident #92A. Resident statusResident #92, age greater than 65, was admitted on 4/20/23. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), schizoaffective disorder, hypertensive heart disease, personality disorder, generalized anxiety disorder, and dependence on supplemental oxygen. The 3/23/26 minimum data set (MDS) assessment revealed Resident #92 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The MDS assessment revealed the resident used a walker and was independent with transfers and activities of daily living. The assessment indicated the resident had shortness of breath with exertion and when lying flat. The assessment indicated Resident #92 was receiving oxygen therapy. B. ObservationsOn 6/8/26 at 1:39 p.m. Resident #92 was lying on his bed. Resident #92 was wearing a nasal cannula connected to an oxygen concentrator. The flow rate on the oxygen concentrator was set to 4 liters per minute (LPM) of oxygen. On 6/9/26 at 5:12 p.m. Resident #92 was lying down on his bed wearing his nasal cannula and resting. The resident’s oxygen concentrator was set to 4 LPM.On 6/10/26 at 3:06 p.m. Resident #92’s oxygen concentrator was set to 4 LPM and the nasal cannula was in the resident’s nose. On 6/11/26 at 10:50 a.m. Resident #92 was seated in the dining room with a portable oxygen canister and a nasal cannula in his nose. The portable oxygen canister was set to 4 LPM.C. Resident interviewResident #92 was interviewed on 6/9/26 at 2:25 p.m. He said his oxygen order was for 2 LPM. Resident #92 said he was able to turn the oxygen concentrator on and off; however, the facility staff regulated the oxygen liter flow rate. D. Record reviewA review of Resident #92’s June 2026 CPO revealed the following physician’s order:Oxygen via nasal cannula at 2 LPM, ordered 10/1/24.-However, observations on 6/8/26, 6/9/26, 6/10/26 and 6/11/26 revealed Resident #92’s oxygen flow rate on his oxygen concentrator and his portable oxygen canister was set to 4 LPM of oxygen (see observations above). The oxygen therapy care plan, initiated 4/21/23 and revised 2/15/26, revealed that Resident #92 had oxygen therapy related to disease process. The goal was for the resident’s risk of respiratory distress related to the disease process to be minimized by the review date. Interventions included administering medications as ordered, monitoring/documenting for side effects and effectiveness, and oxygen settings via nasal cannula at 2 LPM.Review of Resident #92’s vital signs record, from 6/2/26 to 6/10/26, revealed the following: On 6/2/26 Resident #92’s oxygen saturation was 96%. There was no LPM oxygen flow rate documented. On 6/3/26 Resident #92’s oxygen saturation was 97%. There was no LPM oxygen flow rate documented. On 6/4/26 documented Resident #92’s oxygen saturation was 97%. There was no LPM oxygen flow rate documented. On 6/5/26 Resident #92’s oxygen saturation was 97%. There was no LPM oxygen flow rate documented. On 6/6/26 Resident #92’s oxygen saturation was 96%. There was no LPM oxygen flow rate documented. On 6/7/26 Resident #92’s oxygen saturation was 96%. There was no LPM oxygen flow rate documented. On 6/8/26 Resident #92’s oxygen saturation was 96%. There was no LPM oxygen flow rate documented..On 6/9/26 Resident #92’s oxygen saturation was 97%. There was no LPM oxygen flow rate documented. On 6/10/26 Resident #92’s oxygen saturation was 98%. There was no LPM oxygen flow rate documented.-However, there was no documentation indicating the resident needed more oxygen based on the documented oxygen saturations (see observations above). IV. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 6/10/26 at 2:35 p.m. CNA #2 said oxygen was part of the resident's medication and required a physician’s order. CNA #2 said Resident #92’s physician’s order for oxygen was for 2 LPM and it was important to follow it. CNA #2 said Resident #92 would call for assistance when he needed help with his oxygen. CNA #2 said she was not aware that Resident #92’s oxygen order had been changed. CNA #2 said she did not verify the oxygen flow rate the concentrator was set to at the beginning of her shift. CNA #2 said she should have checked the oxygen settings during her morning vital signs rounding. Licensed practical nurse (LPN) #5 was interviewed on 6/10/26 at 2:45 p.m. LPN #5 said that oxygen was part of the resident's medication and required a physician’s order. LPN #5 said Resident #92’s physician’s order for oxygen was for 2 LPM and it was important to follow the order due to Resident #92’s diagnosis of COPD. LPN #5 said Resident #92 had a diagnosis of chronic respiratory failure and required staff to monitor the use of oxygen and signs and symptoms of any adverse effects and report to the physician. LPN #5 said she was not aware that Resident #92’s oxygen order had changed. LPN #5 said she did not verify the amount of oxygen the resident was receiving on her shift. The director of nursing (DON) was interviewed on 6/11/26 at 3:00 p.m. The DON said nursing staff were expected to monitor and document the oxygen liter flow rate of all residents receiving oxygen therapy. The DON said oxygen was considered a medication and required a physician's order to administer. The DON said she would immediately provide education to the nursing staff to ensure that residents receiving oxygen therapy were monitored and that any side effects and the effectiveness of the oxygen therapy were documented. The DON said she would implement an auditing process in which she would cross-reference active oxygen orders with the actual bedside oxygen flow-rate settings to ensure continuous compliance and resident safety. The DON said residents who had a tendency and a documented history of changing their oxygen settings should be documented, with interventions for staff to follow in the residents' care plans.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of four units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents’ rooms and high-frequency touched areas (call lights, door handles, light switches and bed controls); and,-Ensure housekeeping staff followed disinfectant dwell times (the amount of time required to ensure germs are eliminated) when cleaning residents’ rooms. Findings include:I. Facility policy and procedureThe Cleaning and Disinfecting Residents’ Rooms policy and procedure, revised August 2013, was provided by the nursing home administrator (NHA) on 6/11/26 at 6:56 p.m. It read in pertinent part, "The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents’ rooms."Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled."Environmental surfaces will be disinfected (or cleaned) on a regular basis (daily, three times per week) and when surfaces are visibly soiled."Manufacturers’ instructions will be followed for proper use of disinfecting (or detergent) products, including recommended use-dilution, material compatibility, storage, shelf-life, and safe use and disposal."Disinfecting (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently."The environmental services director and administrator, in conjunction with the infection preventionist, will select appropriate facility disinfectants."II. ObservationsDuring a continuous observation on 6/10/26, beginning at 10:35 a.m. and ending at 11:10 a.m., the following was observed:At 10:35 a.m. housekeeper (HK) #1 pushed her cleaning cart to the entrance of room #204, a double-occupancy room, and donned gloves. She knocked, but neither resident was in the room. HK #1 removed a spray bottle labeled Clorox disinfectant and a clean blue rag from her cart. The Clorox disinfectant spray bottle had a label on it that indicated the manufacturer's recommended dwell time was three to five minutes. At 10:39 a.m. HK #1 removed the toilet brush and a base container from the cart and placed them on the bathroom floor in room #204. She started cleaning the toilet with the brush, from the inside out and around the left and right corners of the toilet bowl. HK #1 sprayed the residents’ sink, faucet, and toilet with the Clorox disinfectant spray and started cleaning the counter surfaces of the sink. At 10:42 a.m. (less than a minute after spraying the disinfectant), HK #1 cleaned the faucet and sink area with the same wash towel she had used to clean the sink counter surfaces. HK #1 went to her cart and placed the Clorox disinfectant spray in it, and performed hand hygiene. HK #1 picked up a bottle of glass cleaner, sprayed it on the surfaces of the bathroom mirror and wiped it down. HK #1 returned the glass cleaner spray bottle and cleaning rag to the cart and removed her gloves. HK #1 performed hand hygiene, donned new gloves and removed the disinfectant spray bottle and a rag from the cart. She sprayed the rag with the disinfectant and, without waiting for the appropriate dwell time, wiped the top of the overbed table for bed B. She sprayed the rag again and continued to clean the top of the resident's bedside drawer. She placed the disinfectant spray bottle and rag back into the cart, removed her gloves and performed hand hygiene. HK #1 donned clean gloves and removed the disinfectant spray bottle and a rag from the cart. She sprayed the rag with the disinfectant and without waiting for the appropriate dwell time, wiped off the top and front of bed A's nightstand. She placed the disinfectant spray bottle and rag back into the cart and removed her gloves.-HK #1 failed to allow the disinfectant to remain on surfaces for the appropriate disinfectant dwell time while cleaning the residents’ toilet and the sink.-HK #1 failed to disinfect high-touch areas, such as the door knobs, light switches, grab bars and bed controller in the residents’ room.-HK #1 failed to disinfect the light switch and door knobs in the bathroom. -HK #1 failed to clean from the dirtiest to the cleanest by cleaning inside the toilet with the cleaning brush, beginning from inside the toilet bowl to the surface and around the corners of the toilet bowl.-HK #1 failed to clean from top to bottom or clean to dirty when cleaning the toilet. -HK #1 donned clean gloves and proceeded to sweep the room and empty the trash. She placed the broom and trash into the cart and removed her gloves. HK #1 performed hand hygiene and donned clean gloves. During a continuous observation on 6/10/26, beginning at 11:10 a.m. and ending at 11:28 a.m., the following was observed:At 11:10 a.m. HK #2 donned gloves and entered room #324, a double occupancy room. HK #2 sprayed the toilet seat and inside of the toilet bowl in room #324 with Clorox disinfectant and proceeded to wipe down the toilet with a wet toilet brush from the inside of the toilet, then the toilet seat and continued to clean the top of the toilet bowl and the surrounding corners behind the toilet bowl with the same brush. At 11:15 a.m. HK #2 left the bathroom, removed her gloves and performed hand hygiene. HK #2 donned gloves and began rearranging the surfaces of the bedside table of bed A of the room. At 11:18 a.m. HK #2 proceeded to bed B and started rearranging the items on the bedside table after she changed gloves, performed hand hygiene and donned clean gloves. At 11:25 a.m. HK #2 picked up a broom and swept the floor of room #324. At 11:28 a.m. HK #2 went back to the bathroom toilet with a clean blue cleaning rag and began wiping down the toilet sink, faucet and the surfaces around the sink. The Clorox disinfectant she had sprayed earlier had dried up. The sink surface was dry, with no visible signs of disinfectant. HK #2 turned on the faucet, wet the cleaning rag and used it to clean the mirror and the remaining areas of the sink.-HK #2 left the Clorox disinfectant spray for an extended period of time, rendering it ineffective. According to the manufacturer’s recommendations for Clorox disinfectant spray, as provided by the housekeeping supervisor, surfaces must remain visibly wet for the recommended dwell time (see interview below).-HK #2 allowed the surfaces to dry up and used the water from the faucet to clean the surfaces, which rendered the disinfectant ineffective.-HK #2 failed to clean high-frequency touched areas, such as the grab bar, toilet door handle, and toilet call light.-HK #2 failed to clean the toilet in room #324 from a cleaner area to a dirtier area.-HK #2 did not allow the disinfectant to remain on the surface of the sink for an extended period of time, prior to wiping it off with water from the faucet. III. Staff interviews HK #1 was interviewed on 6/10/26 at 12:08 p.m. HK #1 said she had been trained on the proper resident room cleaning procedures. She said the disinfectant needed to remain wet on surfaces for three to five minutes to kill microbes. She said the toilet brush could be used on the seat and the toilet bowl and that was how she always cleaned the toilet. She said the toilet should be cleaned from top to bottom to prevent dirt from being carried into cleaner areas and to prevent contamination. She said she understood the reason high-touch areas should be cleaned daily to avoid cross-contamination. She said she did receive training on cleaning residents’ rooms and it was important to disinfect and clean the rooms properly to prevent the spread of infections. HK #2 was interviewed on 6/10/26 at 12:30 p.m. HK #2 said she left the Clorox disinfectant spray on the surface for too long and should have reapplied it when she noticed it was dry, allowing it to sit for three to five minutes before cleaning it. HK #2 said she was aware of and understood the importance of keeping high-touch areas clean. The housekeeping supervisor was interviewed on 6/10/26 at 12:25 p.m. The housekeeping supervisor said residents’ rooms were cleaned daily. She said the Clorox disinfectant spray should be left wet on surfaces for three to five minutes and applied to all surfaces. The housekeeping supervisor said the toilet brush should be used only in the toilet bowl and nowhere else. She said the toilet should be disinfected and cleaned from top to bottom. The housekeeping supervisor said high-touch areas included the over-bed table, the television remote, the call light, the bed controller, the door knobs, and the light switches. She said high-touch surfaces should be disinfected daily. The housekeeping supervisor said the disinfectant should be sprayed directly on surfaces and allowed to sit for the recommended dwell time of three to five minutes. The housekeeping supervisor said all housekeepers had been trained to properly clean and disinfect residents' living spaces. The housekeeping supervisor said she would immediately provide education to the housekeeping staff on hand hygiene, the correct use of disinfectants and the proper room cleaning procedure. The infection preventionist was interviewed on 6/11/26 at 3:42 p.m. The infection preventionist said when disinfecting residents’ toilets, door handles, and every area of residents' spaces, all surfaces should remain visibly wet for the correct dwell time before being wiped. The infection preventionist said high-touch areas should be cleaned daily. She said the toilet brush should only be used in the toilet bowl. She said she would immediately provide education to the housekeepers for the areas of concern.

A complaint survey, prompted by #CO2655336 and Incident #2659975 was completed on 11/3/25 to 12/8/25. No deficiencies were cited. The actual survey exit date was 11/4/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/8/25.

A complaint survey, prompted by #CO39907, #CO39909 and Incident #39937 was conducted on 6/16/25 to 6/17/25. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure three (#8, #6 and #1) of six residents reviewed for abuse out of 12 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #9 from physical abuse by Resident #2; -Protect Resident #6 from physical abuse by Resident #2; and, -Protect Resident #1 from physical abuse by Resident #2. Findings include: I. Incident of physical abuse by Resident #2 towards Resident #8 on 1/30/25 A. Facility investigation The facility investigation, dated 1/30/25, was provided by the nursing home administrator (NHA) on 6/17/25 at 11:45 a.m. The investigation revealed the following: On 1/30/25 Resident #2 pushed Resident #8 in the coffee area of the dining room. Resident #8 fell and landed on her bottom. Resident #8 did not have any signs of injury or pain. The residents were separated and assessed, and several staff members and nearby residents were interviewed. The incident was witnessed and reported by a facility staff member, who said Resident #2 was cleaning the coffee area when Resident #8 walked by. The staff member said Resident #2 then pushed Resident #8 and she fell onto her bottom. The staff member said an intervention that helped Resident #2 was to keep the coffee area clear of people. The investigation indicated Resident #2 did not have a history of behaviors and did not have a behavior care plan. The investigation indicated Resident #2 had been involved with a physical occurrence in July 2024. The investigation revealed Resident #8 was not fearful but said she was startled and confused as to why Resident #2 pushed her. An interview with Resident #8, conducted on 1/31/25, revealed Resident #8 was getting coffee and did not know what happened. Resident #8 said she was shaken up but okay. Resident #2 was interviewed on 1/31/25. Resident #2 said Resident #8 was in his way and he tried to get her out of the way. Resident #2 said he did not intend to hurt Resident #8. The facility concluded the allegation of physical abuse was unsubstantiated as there were no marks or signs of injury on Resident #8 and there was no intent to harm Resident #8 by Resident #2. Resident #8 and Resident #2's care plans were updated. -However, physical abuse occurred due to Resident #2 pushing Resident #8 to the ground. B. Resident #2 (assailant) 1. Resident status Resident #2, age 73, was admitted on 6/3/24. According to the June 2025 computerized physician orders (CPO), diagnoses included fracture of left femur, acute and chronic respiratory failure, unspecified symptoms and signs involving cognitive function and awareness and metabolic encephalopathy (a change in how the brain works due to an underlying medical condition). The 4/7/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. The resident was independent for most activities of daily living (ADL). The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Observations On 6/16/25 at 2:01 p.m. Resident #2 was sitting in his wheelchair in front of the coffee maker in the dining room. An unidentified resident walked past Resident #2 and began speaking with him. Resident #2 began to swing his arm out and gesture at the other resident. Resident #2 yelled at the resident to "put some expletive clothes on." The other resident told Resident #2 not to be jealous of him and walked away. -No staff members were present in the dining room at the time of observation. 3. Record review The behavior care plan, initiated 12/7/24 and revised 3/26/25, revealed Resident #2 had a behavior problem due to his disease process. Resident #2 had poor impulse control and may unintentionally become physical by what m

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 4/17/25 for all previous deficiencies cited on 2/12/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO38997, #CO39002, #CO39099, #CO39162 and Incident #39235 was conducted on 2/11/25 to 2/12/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#4) of three residents reviewed for dialysis out of 13 sample residents. Specifically, the facility failed to:-Follow the physician's dialysis orders for Resident #4;-Consistently get Resident #4 to his dialysis appointments at his scheduled time; and,-Consistently and thoroughly complete dialysis communication forms between the facility and the dialysis center for Resident #4. Findings include:I. Facility policy and procedureThe Hemodialysis Residents Policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 2/11/25 at 12:18 p.m. via email. It revealed in pertinent part,"The facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes in coordination/collaboration with (the) dialysis center."Review and ensure orders upon admission are received for follow-up dialysis center appointments, shunt care, no BP (blood pressure) in arm that has shunt, diet and fluid restriction (physician discretionary)."A dialysis communication record is initiated and sent to the dialysis center each appointment; ensure it is received upon return."Post Hemodialysis/ongoing care:"Check vital signs post dialysis or per physician's order. Do not take blood pressure on the arm with dialysis shunt. Monitor for signs of postural hypotension. Instruct the resident to change positions slowly for a short time to avoid dizziness and possible falls."Monitor resident for signs and symptoms of toxic or adverse medication reactions."Documentation:"Dialysis communication record"Key medical record documentation elements: vital signs, pertinent comments related to resident status and weight."II. Resident #4A. Resident statusResident #4, age less than 65, was admitted on 12/23/24. According to the February 2025 computerized physician orders (CPO), diagnoses included end stage renal disease, hepatitis C, venous hypertension, congestive heart failure (CHF), anemia in chronic kidney disease and hypertension (high blood pressure). The 12/29/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 12 out of 15. He was independent with oral hygiene, and toileting. He required set up or clean up assistance with eating, and showers or bathing. He did not reject care from staff. The MDS assessment indicated the resident received dialysis treatments. B. Resident interviewResident #4 was interviewed on 2/12/25 at 4:00 p.m. Resident #4 said he preferred to go to dialysis early in the morning. He said he felt the transportation service that the facility scheduled to pick him up for dialysis was often late, which made him late for his appointments. He said he gave his dialysis communication sheets to whoever was his nurse when he returned to the facility after his dialysis appointments. C. Record reviewReview of Resident #4's February 2025 CPO revealed the following physician's orders related to dialysis:Check port site to right chest for bleeding during the shift after the resident returns. If bleeding occurs, apply direct pressure until it is controlled. Notify medical provider if bleeding lasts longer than 30 minutes or is severe, ordered 1/21/25. Remove dialysis communication sheet from resident's bag. File the form in his dialysis binder at the nursing station after checking it for follow ups, ordered 1/21/25. File dialysis communication form in resident's dialysis binder at the nursing station after checking it for follow ups, ordered 2/4/25. Fill in dialysis communication form. Resident to go with it (communication form) at dialysis center, ordered 2/4/25. Review of Resident #4's dialysis care plan, initiated 12/23/24 revealed the resident needed hemodialysis for the disease process. -However, the care plan did not identify what disease process the hemodialysis was needed for. Interventions (initiated 12/23/24) included encouraging the resident to go for the scheduled dialysis appointments on (Tuesday, Thursday, Saturday, regular chair time was at 5:40 a.m. and the resident was to arrive at 5:20 a.m.), monitoring vital signs twice a shift after dialysis on dialysis days and notifying the physician of significant abnormalities. The following intervention was added to Resident #4's dialysis care plan on 2/12/25:Nursing staff was to complete the pre-dialysis communication form before the resident left for dialysis. The dialysis center was to complete the form while the resident was at dialysis. Nurses were to complete the post-dialysis form upon the resident's return from dialysis and review the dialysis part of the form. Any part of the dialysis form required follow-up, and the DON (director of nursing) needed to be notified of any concerns.-The intervention was not added to the care plan until 2/12/25, during the survey. The dialysis communication log books were provided by registered nurse (RN) #1 on 2/11/25 at 5:00 p.m. Each log had three sections on one sheet of paper which revealed the following:The pre-dialysis section was to be filled in by the facility with the date, and the resident's vital signs including, temperature, pulse, respirations, blood pressure and pain. The section also included if a meal or snack was given to the resident to take to the dialysis center. There was a section for additional information such as changes in condition, physician orders and new labs since the resident's last dialysis visit. A nurses' signature was required to validate the information was completed. The middle section of the log was to be filled out by the dialysis center staff. The same information was included as above in the pre-dialysis section. The dialysis center staff filled in the middle section with the current vital signs the resident had while at the dialysis center. A section for additional information included, changes in condition, medications administered, laboratory work (labs) drawn and lab results and other communication.) The middle section included a place for physician orders and recommendations, if any were given and a place for the dialysis nurses' signature. The post-dialysis section was to be completed by the facility when the resident returned after he received dialysis. The post-dialysis section repeated all the vital signs to be recorded again as in the pre-dialysis section. The facility was to fill in the resident's current vital signs and sign again with the nurses' signature, date and time that the post-dialysis information was obtained. Review of Resident #4's dialysis communication logs from 1/2/25 through 2/11/25 revealed the following:-On 1/2/25 Resident #4's dialysis communication form sheet was blank and all three sections of the form were not filled in; and,-The post-dialysis sections were not completed by the facility on 1/4/25, 1/9/25, 1/11/25, 1/14/25, 1/16/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25 and 2/4/25. Additionally, the dialysis communication forms (from 1/2/25 to 2/11/25) revealed the following communication from the dialysis center to the facility regarding Resident #4's late arrival times for dialysis:-On 1/21/25 the dialysis center communicated Resident #4 missed his make-up time;-On 1/25/25 the dialysis center communicated Resident #4 missed his make-up appointment yesterday (1/24/25);-On 1/28/25 the dialysis center communicated Resident #4 was one and a half hours late to his appointment and the dialysis center questioned how the facility could get the resident to the appointments on time; and,-On 2/4/25 the dialysis center communicated Resident #4 needed to arrive on time for his appointments. III. Staff interviewsThe dialysis center social worker (DCSW) was interviewed on 2/12/25 at 12:15 p.m. via the telephone. The DCSW said the dialysis center wrote on the communication forms several times for the facility to have Resident #4 be on time for dialysis. The DCSW said the dialysis center called and spoke to the facility's DON several times over the telephone about the facility getting Resident #4 to his dialysis appointments at his scheduled time. The DCSW said the DON told the dialysis center the situation would be fixed and Resident #4 would arrive on time for his appointments. The DCSW said there had been no negative outcomes as of yet, but she said Resident #4 could have physical complications if the facility did not send him to his appointments as the physician ordered. The DCSW said the resident was late to his appointments approximately four times in 2025. The DCSW said the facility had recently fixed whatever the problem was and the resident now arrived on time for his appointments. Registered nurse (RN) #1 was interviewed on 2/11/25 at 4:00 p.m. RN #1 said they were the nurse responsible for Resident #4's care for the day (2/11/25). RN #1 said they did not know whose job it was to complete Resident #4's post-dialysis section when he returned from his dialysis appointments, however, they said it was not their responsibility to complete it. The NHA and the corporate nurse (CN) were together interviewed on 2/12/25 at 3:30 p.m. The NHA said he was unaware that Resident #4 had been late to some of his dialysis appointments. The NHA said he had not been aware that the post-dialysis sections of the resident's dialysis communication forms were not filled in by the resident's nurse when he returned from dialysis appointments. The NHA said yesterday (2/11/25) he called the dialysis center and set up a meeting with them to remedy the situation and handle any other concerns. He said the problem was the facility nursing staff did not fill in the post-dialysis sections, therefore no one read the dialysis centers' communication notes. He said he asked the nursing staff if anyone remembered talking to the dialysis center, but no nursing staff remembered speaking to the dialysis center over the telephone about Resident #4. The CN provided the nursing staff signatures of attendees and education that had been implemented during the survey (beginning on 2/11/25) about dialysis residents. The CN said the education would be ongoing for the nursing staff about dialysis residents and processes. The NHA said to help correct the situation with the dialysis communication logs, he began a new process on 2/12/25. The NHA said every day when there was a morning meeting, the communication books for residents who went to dialysis the day prior would be reviewed for compliance by management staff. The NHA said the DON or designee would read all of the residents' dialysis binder books weekly to double check everything was handled correctly. The NHA said for the next quarter, the quality assurance and performance improvement (QAPI) meetings would monthly discuss the plan of action and its implementation for residents who received dialysis. The NHA said, moving forward from 2/12/25, whoever was the RN or LPN (licensed practical nurse) for the resident on dialysis days would be responsible for filling out the post-dialysis information when the resident returned from their dialysis appointment. The NHA said the facility also made a change to send residents with a dialysis binder, a book which contained their dialysis communication sheets, and not just a single sheet of paper which could be misplaced.

A revisit survey was completed on 9/30/24 for all previous deficiencies cited on 8/21/24. The facility is in compliance with all regulations surveyed.

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waivers. A plan of correction is not required.

A complaint survey, prompted by #CO37066, #CO37107 and #CO37240 was conducted on 8/20/24 to 8/21/24. One deficiency was cited.

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#1) of three residents reviewed for discharge planning out of 12 sample residents. Specifically, the facility failed to: -Ensure consistent efforts in the discharge planning process were made, which resulted in the potential delay in Resident #1's discharge to another facility;-Ensure Resident #1's representative received consistent communication regarding Resident #1's discharge planning process; and,-Ensure the discharge planning process was documented in Resident #1's electronic medical record (EMR). Findings include:I. Facility policy and procedureThe Social Service policy and procedure, dated 8/31/22, was provided by the corporate consultant (CC) on 7/21/24 at 7:30 p.m. via email. The policy read in pertinent part, "Social services members are responsible for planning, organizing, and directing all administrative and operational activities of the social services department in accordance with current federal, state, and local standards, guidelines and regulations, and the facility's established policies and procedures."Assisting residents in planning for discharge by coordinating service delivery with the nursing staff and by assessing availability and facilitating use of financial and social support services in the community."Coordinating transfers (other than medical transfers) within and out of the facility and assist residents in adjusting to intra-facility transfers."II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 6/24/21 and readmitted on 7/17/24. According to the August 2024 computerized physician orders (CPO), diagnoses included anoxic brain damage, acute respiratory failure with hypoxia, aphasia, unspecified intracranial injury without loss of consciousness and the need for assistance with personal care. The 7/19/24 minimum data set (MDS) assessment identified the resident had severe cognitive impairment. The staff assessment for mental status revealed the resident had short and long term memory problems. She was not identified to have inattention or disorganized thinking. Resident #1 had unclear speech and was rarely understood. According to the MDS assessment, she did not exhibit behaviors or rejections of care. She was dependent on staff for all of her activities of daily living (ADL). The MDS assessment did not identify the resident's overall goal for discharge was to discharge to another facility. According to the MDS assessment, there was not an active discharge plan in place to return to the community, however, the MDS assessment also indicated a referral to a local contact agency was made. -Review of of Resident #1's EMR identified the resident's representative wanted a discharge to another facility. -Provided records did not identify referrals and follow up were conducted between 2/26/24 and 6/6/24 when requested by the resident's representative (see below). III. Resident's representative interviewResident #1's representative was interviewed on 8/21/24 at 9:49 a.m. The resident's representative said Resident #1 was admitted to the facility in 2021 with the anticipation of discharging the resident to another facility within a year. She said she wanted Resident #1 to move closer to her so the representative could increase the frequency of family visitations. She said the distance of the resident to the representative was becoming a hardship. The resident's representative said Resident #1 had been denied admission by some facilities because of her age, payor status, and/or high care needs. She said she had declined a facility that accepted Resident #1 because she saw the facility and felt it was not clean and did not feel they could meet her needs. The resident's representative said she was concerned that efforts to pursue her request for transfer to another facility had been delayed because of inconsistent staff and lack of follow through from the facility. The resident's representative said she started working with the facility's corporate health plan liaison (HPL) who was in the process of helping her in the discharge/transfer process but she was told the HPL was no longer handling the facility's referrals. She said the position was left open for a while and no one was handling the referrals to other facilities. She said the facility's social service department had very little to do with the discharge and referrals process. She said the facility later hired an admissions coordinator (AC) who said she was going to help her with the discharge process. The resident's representative said she then found out the AC was no longer at the facility. She said the facility had very little communication with her on the status and/or efforts made to provide assistance with Resident #1's discharge plan. The resident's representative said last winter (2023/2024) there was a virtual meeting conducted with facility #3. She said the HPL said the meeting went well but the resident's representative said she did not hear anything more until she contacted facility #3 a couple of months ago and was told that facility #3 had staffing changes and did not have records of a request for a referral or documentation of the prior meeting. The resident's representative said the former AC at the resident's current facility did not know anything about the other facility referral so the resident's representative asked her to do another referral to that facility. The resident's representative said she provided the AC with a list of eight other facilities she wanted more information on as potential transfer facilities but she was not provided anymore information of the status of referrals. The resident's representative said no one was telling her if and why Resident #1 had been denied admission from the listed facilities or if all the referrals were sent out. She said she had not been provided communication or updates. She said she attended a care conference but the attendance was small and little was known about the status of Resident #1's discharge plan. She said the social service director (SSD) requested another list from her on potential facilities and he gave her a list of potential facilities but she said she was not aware of any other steps toward a discharge for Resident #1. IV. Record reviewResident #1's discharge care plan, initiated and revised on 7/17/24, documented Resident #1's representative wished for discharge in the future to a facility closer to the resident's representative. The care plan read the healthcare proxy denied possible transition to other communities that had accepted Resident #1. The discharge care plan intervention, initiated on 6/25/21 and revised on 5/16/23 directed the facility to establish a pre-discharge plan with the resident/family/caregivers and evaluate the progress and revise the plan .The discharge care planned intervention, initiated on 6/25/21 and revised on 5/16/23 directed the facility to prepare and give the resident, family member/caregiver contact numbers for allcommunity referrals. The discharge care plan intervention, initiated on 6/25/21 and revised on 7/17/24, directed the facility to review possible facilities with family and make referrals as necessary. A 11/6/23 text message between the resident's representative and the health plan liaison (HPL) was provided by the CC on 8/21/24 at 2:23 p.m. via email. The text read a virtual meeting would be conducted on 11/6/23 with facility #3. The following email chain between the former social service assistant (SSA) and the HPL on 1/30/24 was provided by the CC on 8/21/24 at 11:55 via email. The email read Resident #1's representative requested a transfer to facilities closer to the location where the resident's representative lived. The resident was very friendly, compliant, easy-going and dependant with all ADLs. According to the email, a referral was attached to the email and the resident's representative could be offered video greetings and an in-person meeting. A second 1/30/24 email between the director of care transitions (DCT), the HPL and the former SSA read the resident was accepted to facility #1 in the past but the resident's representative declined the facility because she did not like it. According to the email, the DCT asked if the resident's representative would be open to facility #1 again. The DCT said facility #6, facility #9, facility #2 and facility #10 could be an option. A follow up email on 1/30/24 between the former SSA, the DCT and the HPL read the former SSA did not think the resident's representative would be interested in facility #1 again. The SSA asked if the DCT and the HPL could send the referrals to the listed facilities or if that was something he should do. The DCT responded to the SSA that she sent the HPL Resident #1's information and would let the SSA know. A follow up email on 1/30/24 identified the senior director of care transitions (SDCT) requested the community director of care transitions (CDCT), the former SSA, the DCT, and the HPL to work on finding a facility for Resident #1. The 1/30/24 social service progress note documented the former SSA received an email from the DCT. The email stated a referral would be sent to a liaison in the resident representative's preferred area. A second 1/30/24 social service note read referrals were emailed to the facility's corporate community referrals. An email chain between 2/2/24 and 2/5/24 between facility #2, the HPL and the CDCT was provided by the CC on 8/21/24 at 11:55 a.m. via email. The email chain identified a referral was sent to facility #2 but the family declined and wanted to see if another facility was available to take Resident #1. A 2/2/24 text message between the resident's representative and the HPL was provided by the CC on 8/21/24 at 2:23 p.m. The text message read the resident's representative requested referrals for facility #5, facility #6, facility #8 and facility #9. A 2/5/24 email between the HPL and the CDCT was provided by the CC on 8/21/24 at 11:55 a.m. via email. According to the email, the CDCT requested the HPL to forward information to whichever facility she felt the family may be interested in. The follow up email, dated 2/5/24, read the HPL could assist with the request. A 2/7/24 and 2/8/24 text message between the resident's representative and the HPL read the resident's representative requested to find out what the status was of facility #4. A 2/8/24 follow up text message between the resident's representative and the HPL read the HPL would send a referral to facility #4. A 2/26/24 email between the HPL and the CDCT was provided by the CC on 8/21/24 at 11:55 a.m. via email. The email read the HPL was going to send an updated referral packet to the CDCT and requested community director of transition to send it to facility #3 and facility #8. The 2/26/24 social service note read a referral was sent to community transitions to request a referral be sent to facility #3 and facility #4. The facility #4 referral/discharge/admission spreadsheet was provided by the CC on 8/21/24 at 2:23 p.m. via email. The spreadsheet read Resident #1 was denied admission at facility #4 on 2/26/24 because the facility did not have enough mechanical lifts.-Review of the progress notes, provided text messages and emails between 2/26/24 and 6/6/24 did not identify any referral follow up with suggested or requested facilities. -Review of the progress notes, provided text messages and emails between 2/26/24 and 6/6/24 did not identify communication with the resident's representative on the status of the suggested and requested facilities for potential transfer. A 6/6/24 email between the HPL and the NHA was provided by the NHA on 8/21/24 at 12:41 p.m. via email. The HPL informed the NHA that the resident's representative was asking for a follow up. According to the email, the resident's representative wanted to know if the facility had sent out the referrals. A 6/6/24 email between the social service director (SSD) and the HPL was provided by the NHA on 8/21/24 at 12:41 p.m. via email. The SSD wrote he would talk to the admissions coordinator (AC) and find out what referrals could be sent out and he would also talk to Resident #1's representative the next time she was at the facility. The 6/24/24 care transitions note read Resident #1's representative had come in to the admissions office to discuss potentially moving Resident #1 to another facility closer to her. She said she had been asking for months and was tired of the back and forth drive between her location and the facility's location. According to the note, the AC would send out a referral to facility #3 and follow up in a day or two to see the status of the referral. The 7/19/24 social service note read the AC sent out a referral to facility #3 because it was too hard for the resident's representative to drive to the resident's current facility. According to the note, admissions would follow up. -Review of the progress notes and provided emails identified there was no documented follow up with the resident representative's request or referral status communicated regarding facility #3 between 6/24/24 and 7/19/24. The 7/22/24 social service note read admissions contacted facility #5 per the request of the resident's representative and would like to transfer Resident #1 to the facility. The note read the resident was denied admission due to the resident's payor status. -The 7/22/24 social service note did not identify the resident's representative was informed of the denial of admission by facility #5. A 7/25/24 to 7/27/24 text message chain between the resident's representative and the director of nursing (DON) was provided by the CC on 8/21/24 at 3:05 p.m. via email. The text chain identified that, on 7/25/24, the resident's representative texted the DON to ask if she had any information regarding the referral status of facility #3. The DON texted back and wrote she contacted the facility and the information was shared with the facility's DON. The resident's representative texted back that she contacted facility #3 on 7/26/24 and found out Resident #3 was denied admission but she did not know why. A 7/29/24 email was provided by the NHA on 8/21/24 at 12:41 p.m. between the NHA, the CDCT, the DCT and another corporate representative. The email read the resident's representative was looking for placement for Resident #1. The NHA requested assistance from the corporate representatives. According to the email, facility #3 denied admission of the resident. A 7/29/24 email was provided by the NHA on 8/21/24 at 12:41 p.m. between the AC and the NHA. The email read the resident's representative gave a list of facilities to the AC that she would like the AC to look into because two of the facilities could not accept Resident #1. According to the email, the AC was going to follow up with the facilities and follow up with the resident's representative. -Progress notes, facility provided text messages and emails did not identify additional follow up with the facilities or communication with the resident's representative between 7/29/24 and 8/13/24. The following 8/13/24 email chain was provided by the NHA on 8/21/24 at 12:41 p.m. A 8/13/24 email between the NHA, the SSD and the corporate representatives read the NHA asked if the team could help find placement for Resident #1. The 8/13/24 email between the SSD, the NHA, and the corporate representatives read the SSD had given a list of facilities in the resident representative's area. According to the email, the resident representative had not gotten back to him regarding the referral options. The SSD wrote the resident's representative told him at the last care conference that she had a list of referral options but had not provided a list to him. The 8/13/24 email between the NHA, the SSD and the corporate representatives read the NHA informed the SSD that the resident's representative provided the list of requested referrals to the AC. The NHA asked the SSD if he called the resident's representative to follow up and directed him to call her if he had not already done so. The 8/13/24 email between the SSD, the NHA and the corporate representatives read the SSD checked in the office of the AC and did not find the referral list and would contact the resident representative and ask her to send him the list so he could start sending out the referrals. The 8/13/24 social service note read Resident #1's representative would send a list of places she wanted social services to send referrals to for discharge. The 8/19/24 social service note read the (current) SSA contacted facility #6 and confirmed there were no open beds at that time. The SSA attempted to contact facility #7 but was not able to reach anyone. Facility #4 was contacted and a referral was sent.-Review social service notes between 8/19/24 and 8/21/24 did not identify additional attempts were made to contact facility #7. The 8/21/24 at 12:49 p.m social service note, documented during the survey, revealed the SSA contacted facility #2 to follow up with the referral sent on 8/19/24. According to the note, a voicemail was left and the facility was waiting for a response back. The 8/21/24 at 1:00 p.m social service note read the SSA received a call back from facility #7 on 8/21/24 (during survey) and obtained the facility's fax number and faxed the referral. V. Staff interviewsThe SSD and the NHA were interviewed together on 8/21 at 9:32 a.m. The SSD said the former AC handled the referrals over the past few months. He said the HPL handled the referrals prior to the AC and he documented what he was made aware of in the progress notes. The SSD said when a resident or their representative requested a transfer to another facility, a referral would be sent to the requested facility and other appropriate facilities if needed. The SSD said the facility would follow up with the potential admitting facility and inform the resident and/or their representative of the referral status. The SSD said he and his new SSA were handling referral requests for the past few weeks since the AC left her position. The NHA said the referral process for Resident #1 was started in 2021 when the resident's representative requested the resident to be transferred to another facility. The NHA said referrals were sent out and Resident #1 was either denied admission by the referral facilities or the family did not like the facility. The NHA said, in the last month, the resident's representative started to request again for Resident #1 to be transferred to another facility. The SSD said he provided the resident's representative with a list of potential facilities Resident #1 could be referred to but the resident representative did not respond right away. He said once she did respond, referrals were sent out last week (week of 8/12/24).-However, review of the provided emails identified the requested 8/13/24 referral list was the second list provided to the facility from the resident's representative in a month's time as identified in the above 7/29/24 and 8/13/24 emails. The known 7/29/24 facility referral list was not looked at to proceed with the referral process until 8/13/24, resulting in an additional delay. The CC was interviewed on 8/21/24 at 12:40 p.m. The CC said Resident #1 had been denied admission by some facilities because of her high care needs. The CC said the resident was accepted at facility #1 and facility #2 but the family declined. The CC said the facility should have done a better job documenting the discharge efforts but the facility was currently still sending out referrals. The CC and the NHA were interviewed together on 8/21/24 at 3:38 p.m. The CC said facility #3 denied admission for Resident #1. The CC said the facility did not have adequate documentation to show the denials and communication to the referral facilities and the resident's representative. The CC said the facility had reached out to facility #7 and facility #6 and they had a waiting list. She said the facility would try facility #4 again. The NHA said he would have the SSD contact the resident's representative to provide her an update. The NHA said the former AC was in her position between the end of April 2024 to the end of July 2024. He said the SSA who was assisting with some of the process was no longer at the facility and he was unsure when he left his position. The SSD was interviewed on 8/21/24 at approximately 6:30 p.m. The SSD said he contacted Resident #1's representative on 8/21/24. He said she was happy to have the follow up and that more referrals would be sent out.