AMBERWOOD POST ACUTE

A complaint survey, prompted by #CO3018033 and CO#3018186 was conducted on 6/15/26 to 6/17/26. No deficiencies were cited.

A survey with #CO3018034 was completed on 6/15/26 to 6/17/26. No deficiencies were cited.

A complaint survey, prompted by #CO2694996, #CO2806187, #CO2806232, #CO2806267, #CO2972092, #CO2974880 and Incident #2809067 was completed on 4/21/26 to 4/23/26. Three deficiencies were cited.

Based on interviews and record review, the facility failed to ensure the resident's representative was informed of changes in condition for one (#1) of three residents out of 17 sample residents. Specifically, the facility failed to:-Inform Resident #1’s physician-appointed healthcare proxy when the resident had a change in condition, including when the resident started on an antibiotic medication; and,-Return phone calls to Resident #1’s healthcare proxy’s voice messages requesting information about the resident’s condition in a timely manner. Findings include:I. Facility policy and procedureThe Notification of Changes policy, revised 2025, was provided by the nursing home administrator (NHA) on 4/23/26 at 1:21 p.m. It read in pertinent part, "The facility must inform the resident, consult with the resident’s physician and/or notify the resident’s family member or legal representative when there is a change requiring such notification. When residents are incapable of making their own decisions the representative will make any decisions that have to be made.”II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 12/12/25. According to the April 2026 computerized physician orders (CPO), diagnoses included paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit and encephalopathy. According to the 3/23/26 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. B. Resident #1’s representatives interviewsResident #1’s designated health care proxy was interviewed on 4/21/26 at 2:55 p.m. The health care proxy said the facility made it very difficult to contact Resident #1. She said facility staff did not return calls for days, making her worry about Resident #1 because she lived so far away and could not just drive over to check on the resident. The health care proxy said the resident was started on antibiotic treatment and she was not informed that Resident #1 had an infection and needed antibiotics until after the resident started on the medication. She said she had several questions about the medication and was not consulted on the medical decision prior to the start of the medication. Another one of Resident #1’s representatives was interviewed on 4/21/26 at 2:55 p.m. The representative said she had called the facility several times; however, the facility never answered the phone. She said phone calls went to a general voice mailbox. The representative said her voicemail message requests for a return call were either not answered or took several days for someone from the facility to respond to the messages. C. Record review Grievances filed on behalf of Resident #1 were requested and provided by the NHA on 4/21/26 at 2:17?p.m. The grievances revealed there were several concerns regarding delays in the facility’s response to the Resident #1’s representatives requests for information about the resident and the delays in reporting changes in the resident’s condition. The grievances revealed the following:A grievance, dated 12/30/25, revealed Resident #1’s representative had concerns related to the representative’s inability to get to speak to Resident #1 over the phone in a timely manner. The resident’s representative called the facility to speak to Resident #1 on 12/28/25 but the call was not returned until three days later (on 12/31/25). The documented facility’s response to the concerns was that a return call was placed to the resident’s representative on 12/31/25 and the call went to the representative’s voicemail. -There was no other documentation to indicate that the facility took further actions to resolve the communication delays. A grievance, dated 1/8/26 and filed by Resident #1’s health care proxy revealed the resident's health care proxy wanted weekly calls since she said it was too hard to contact the nurses in the facility. The facility’s response to the grievance documented that weekly follow-up calls would be completed in response to the concern, and that the resident’s health care proxy was satisfied with the follow-up. A grievance, dated 2/1/26 and filed by Resident #1’s health care proxy revealed the resident's health care proxy called to express concern over lack of notification for new medication the resident was started on but she was not informed of. The facility followed up by conducting in-services with their staff on 2/1/26, 2/3/26 and 2/5/26, regarding notifying residents’ responsible parties about medication changes, as well as which staff members were responsible for the notifications. Additionally, the facility ensured Resident #1’s health care proxy was listed correctly in their resident information. -The grievance failed to reveal information on whether or not the resident’s health care proxy was satisfied with the facility’s response to the concern. A grievance, dated 3/28/26 and filed by Resident #1’s health care proxy revealed the resident's health care proxy expressed concern over a scheduled video call where she was unable to connect with staff. The health care proxy said she was upset about the lack of communication from the facility. The resident’s health care proxy was called back on 3/31/26 by the activities director, who apologized for the miscommunication regarding the video call. The activities director said the health care proxy could call her if she needed anything from them. -The grievance failed to reveal information on whether or not the resident’s health care proxy was satisfied with the facility’s response to the concern. III. Other residents’ representatives interviewsResident #10’s representative was interviewed on 4/21/26 at 3:19 p.m. Resident 10’s representative said Resident 10 was newly admitted to the facility. He said he called to check on the resident's status and the call was sent to the facility’s voicemail. Resident #10’s representative said it took the facility two days to return his call. Resident #6’s representative and a secondary witness were interviewed together on 4/22/26 at 1:27 p.m. They said they attempted to contact the facility to report a suspected instance of verbal abuse that they over heard while on the phone with Resident #6 but the call was sent to the facility’s voicemail. They said they tried to call the social services director (SSD) and were again sent to voicemail. They said they never received a return call. IV. Staff interviewsThe SSD was interviewed on 4/22/26 at 3:15 p.m. The SSD said she was not entirely sure where the concerns about the communication with Resident #1’s representatives were coming from. She said all calls to the facility first went to the front desk receptionist and were then transferred to the nurses’ stations for direct contact with nursing staff. The SSD said Resident #1’s representatives had her cell phone number as well as the cell phone number for the director of nursing (DON), whom they could call if she was unable to get through to the nurses’ station. Licensed practical nurse (LPN) #1 was interviewed on 4/23/26 at 11:09 a.m. LPN #1 said one of Resident #1’s representatives often called his personal cell phone multiple times a day. The DON, the NHA, and the corporate nurse consultant were interviewed together on 4/28/26 at 12:34 p.m. The NHA said the Resident #1’s healthcare proxy wanted a call from the facility staff every single day. The NHA said the facility was aware several of the resident’s representatives’ phone calls went to voicemail when the nurses were unable to pick up the phone calls. The corporate nurse consultant said that voicemail messages left in the facility's voicemail message system should be returned within 24 hours. The NHA said she did not think it was accurate that Resident #1’s healthcare proxy was not getting called back and that the assistant director of nursing (ADON) was texting the health care proxy on a weekly basis to provide information. -However, there was no documentation for the weekly calls provided by the facility. The NHA said Resident #1’s representative and health care proxy had her cell phone number as well as the cell phone number for the SSD and the DON. The representatives could have called any of them directly if they were unable to get through to the nurses’ station. The NHA said Resident #1’s representatives often called during shift change when it was harder to get through to the nurse on duty. The NHA said if the nurse was unable to answer the phone call, the call went directly to voicemail where it was later picked up and returned.

Based on record review and interviews, the facility failed to investigate an allegation of verbal abuse involving one (#6) of seven residents of 17 sample residents. Specifically, the facility failed to investigate an allegation of verbal threats overhead by a family member between Resident #6 and Resident #15. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised April 2021, was provided by the nursing home administrator (NHA) on 4/22/26 at approximately 9:20 a.m. It read in pertinent part, “Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents’ symptoms.“Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: other residents.“The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements and protect residents from any further harm during investigations.“Investigate and report any allegations within timeframes required by federal requirements.”The Identifying Types of Abuse policy and procedure, revised September 2022, was provided by the NHA on 4/22/26 at 9:20 a.m. It read in pertinent part:“As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents.“Examples of mental and verbal abuse include but are not limited to: yelling or hovering over a resident, with the intent to intimidate.”II. Resident #6 (alleged victim)A. Resident statusResident #6, aged less than 65, was admitted on 12/11/25. According to the April 2026 computerized physician’s orders (CPO), diagnoses included dysphagia, hemiplegia of the left side (paralysis of the left due to a stroke), attention and concentration deficit, delusional disorder, and major depressive disorder. According to the 3/20/26 minimum data set (MDS) assessment, Resident #6 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The MDS assessment indicated Resident #6 used a wheelchair for mobility and was dependent on staff for most of his activities of daily living (ADL). B. Resident #6 interviewResident #6 was interviewed on 4/21/26 at 2:23 p.m. Resident #6 said he did not think the arguing back and forth between Resident #15 and himself was a big deal. He said his roommate (Resident #15) said to shut the (explicative), and then they were both yelling back-and-forth at each other. He said he could not remember what they each yelled towards each other. He said there was no pushing, shoving or anything like that. C. Resident #6’s representatives interviewsResident #6’s guardian was interviewed over the phone on 4/22/26 at 11:55 a.m. She said that Resident #6 called her after the incident and she went to the facility to see what was going on. She said the staff had separated residents because they were yelling at each other. The guardian said apparently threats were made by Resident #15 towards Resident #6. She said Resident #6 told her that he was fearful of Resident #15. Resident #6’s representative was interviewed on 4/22/26 at 1:27 p.m. The representative said while she was talking to Resident #6 on the phone on 3/15/26, she heard Resident #15 yelling loudly and making threats towards Resident #6. She then heard the nurse enter the room to calm down the situation. The representative said that she tried to call the facility to report the yelling and threatening behavior, but wassent to voicemail and no one called her back. She said she was worried about the situation, so she called the police and reported the threatening behavior. The representative provided a police report number during the call (see emergency services interview below). III. Resident #15 (alleged assailant) A. Resident statusResident #15, age greater than 65, was admitted on 8/28/25. According to the April 2026 CPO, diagnoses included dementia, cognitive communication deficit, depression, and insomnia. According to the 3/2/26 MDS assessment, Resident #15 had moderate cognitive impairment with a BIMS score of eight out of 15. The MDS assessment revealed Resident #15 used a walker for mobility dependent on staff for most of his ADL. The MDS assessment indicated the resident did not have any behaviors. B. Resident interviewResident #15 was interviewed on 4/21/26 at 2:55 p.m. He said that he did not remember the incident between him and Resident #6. C. Resident #15’s representative interviewResident #15’s representative was interviewed on 4/23/26 at 10:45 a.m. The representative said Resident #15 did not remember the incident. Resident #15’s representative said she was made aware of the incident the day after it happened. She said she was told Resident #6 was talking too loud on the phone and Resident #15 started yelling at Resident #6 to be quiet. She said she was told that because of the yelling the facility initiated a room move that night (3/16/26) to separate the two from being roommates. Resident #15’s representative said she agreed to the room change. She said she had asked for the room change prior to 3/15/26 due the behaviors of Resident #6 when she visited Resident #15. She said that Resident #6 would masturbate on the other side of his privacy curtain and would yell racial slurs. She said that she told the director of nursing (DON). IV. Record reviewA request was made for an investigation regarding the allegations of verbal threats by Resident #6 towards Resident #15 (see staff interviews below). Review of both resident’s electronic medical record revealed no documentation of the resident to resident verbal altercation or related concerns. A room change form in Resident # dated 3/16/26 revealed the reason for the resident's room change was Resident #15 and his roommate did not get along. Family requested he be moved. IV. Emergency services interviewA non-emergency dispatcher was interviewed on 4/22/26 at 5:26 p.m. The non-emergency dispatcher said there was an incident reported from Resident #6’s representative. The non-emergency dispatcher said emergency medical services (EMS) responded to the call and not the police. V. Staff interviewsRegistered nurse (RN) #1 was interviewed on 4/23/26 at 10:00 a.m. RN #1 said she did not remember the verbal altercation between Resident #6 and Resident #15 all that well, since it occurred a while ago. She said that she did remember that there was loud yelling and arguing between Resident #6 and Resident #15. She said she did not hear the exact words exchanged and did not know if any threats were made by either resident. RN #1 said she could not remember exactly, but it was either the police or EMS who responded to the facility related to the resident’s yelling. RN #1 said she reported the yelling to the DON that evening, but did not tell the DON about EMS responding to the facility for the residents yelling at each other. RN #1 said she talked to a family member or friend of Resident #6’s regarding the verbal altercation. She said she could not remember who she talked to or the relationship to Resident #6. RN #1 said she had helped Resident #15 to change rooms, due to the resident-to-resident incident on 3/15/26. The social service director (SSD) and the corporate nurse consultant were interviewed together on 4/23/26 at 9:40 a.m. The SSD said she did not know much about the incident that took place between Resident #6 and Resident #15 on 3/16/26. The SSD said it was just an argument between two individuals and there were no threats, or anything else that would rise to the occasion of an allegation. She said it was a back and forth between two residents and nothing else.-However the incident was not investigated and the SSD was not present during the incident. Additionally, both residents had cognitive deficits and there was no documented interview with either resident at the time of the incident. The NHA, the DON and the corporate nurse consultant were interviewed on 4/23/26 at 12:30 p.m. The NHA and the DON said RN #1 had called the DON after the incident to initiate a room change for Resident #15 due to worsening dementia. The DON said that Resident #15’s representative had asked for a room change prior to the incident that took place due to Resident #6 behaviors. The DON said that she was not made aware that the police or EMS were called about the incident and was not told that EMS had arrived in response to the resident-to-resident verbal alteration. The NHA said she did not report the resident’s verbal exchange to the State Agency as abuse of a resident, because there were no threats made by either resident. She said the two residents were just having a disagreement and yelling at each other. The NHA said neither resident called the police or EMS. -However, no facility staff inquired how EMS showed up in response to the resident-to-resident verbal altercation where RN #1 believed it was necessary to initiate an immediate room move to separate the resident permanently. The DON and the NHA said that they followed up to prevent anything from happening in the future, by moving Resident #15 to another room and having compatible roommates.

Based on observations, interviews and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases in four of four units. Specifically, the facility failed to:-Ensure staff performed hand hygiene before and after providing resident care; and,-Ensure staff followed enhanced barrier precautions (EBP) while providing direct resident care for residents who were identified as being on EBP. Findings include:I. Professional referenceAccording to the Center for Disease Control and Prevention (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, (2/27/24), retrieved on 5/4/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html,“Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with, handwashing with water and soap, antiseptic hand rub, or surgical hand antisepsis.”According to the CDC’s Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO), (4/2/24), retrieved on 5/4/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html,"Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities."EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO."Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing)."II. Facility policy and procedureThe Enhanced Barrier Precautions policy, revised December 2024, was provided by the nursing home administrator (NHA) on 4/23/26 1:21 p.m. It read in pertinent part, “EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.”The Hand Hygiene policy, undated, was provided by the NHA on 4/23/26 1:21 p.m. It read in pertinent part, “hand hygiene will be done by all employees, volunteers and contract staff to reduce transfer of microbes to patients.”Hand hygiene should be done before and after direct patient care, before and after each procedure, after using the bathroom, after blowing or wiping the nose, before and after eating, before and after collecting specimen, when hands are soiled, after any contact with contaminated materials, before re-entering nursing bag or patient’s clean supplies.”III. ObservationsOn 4/21/26 at 10:48 a.m. an unidentified certified nursing assistant (CNA) was leaving room #215, after caring for a resident who was identified as being on EBP, by a sign on the door. The CNA did not wear a gown while providing care. On 4/21/26 at 12:53 a.m. CNA #1 exiting a resident’s room not wearing gloves. CNA #1 carried a soiled mechanical lift sling and placed it in the soiled laundry hamper. CNA #1 did not perform hand hygiene. CNA #1 walked down the hall to the nurse’s cart. He ran his hands through his hair and over his face. Then CNA #1 used the facility’s touch screen to document the care provided. Without performing hand hygiene, CNA #1 entered resident room #100 to answer a call light and assist a resident with a request without washing his hands before or after assisting that resident. On 4/22/26 at 9:41 a.m. CNA #2 entered resident room #114, who was on EBP per the sign on the door. CNA #2 entered the room and applied gloves, but did not apply a gown. CNA #2 provided the resident with incontinence care. CNA #2 left the resident’s room with the soiled linens and trash disposed of in the proper hampers, removed the gloves but did not perform any hand hygiene prior to caring for another resident. On 4/23/26 at 9:59 a.m. licensed practical nurse (LPN) #1 entered room 113 to set up the feeding tube. The resident was identified as needing EBP due to the resident having a gastric tube feeding. LPN #1 did not perform hand hygiene before setting up the resident's tube and she did not wear a gown while handing the resident gastric tube and connecting the tubing. On 4/23/26 at 11:16 a.m. LPN #1 entered resident room 113. This room was identified as needing EBP. While in the room LPN #1 provided care to Resident #1 and left with no hand hygiene. IV. Resident representative/family interviewOn 4/21/26 at 2:09 p.m. Resident #1’s representative was interviewed. She said when she visited her sister she saw them working with Resident #1’s feeding tube with no gloves or gown on .V. Staff interviewsCNA #1 was interviewed on 4/21/26 at 12:59 p.m. He said he washed hands for 20 seconds before and after going into a resident room to provide care. CNA #2 was interviewed on 4/22/26 at 9:53 a.m. was interviewed. She said she washed her hands for about 20 seconds before providing resident care. CNA #2 said when a resident was on EBP, she would put on gloves and booties when providing care. CNA #3 was interviewed on 4/22/26 at 10:04 a.m. CNA #3 said he performed hand hygiene before entering a resident's room and put on gloves to provide care assistance. CNA #3 said when he left the resident’s room, he would remove the gloves and perform hand hygiene. CNA #3 said when providing care to a resident who was on EBP, he would also wear a gown. The director of nursing (DON) was interviewed on 4/23/26 at approximately 1:45 p.m. She said she wanted staff to perform hand hygiene as frequently as possible including when they enter and exit rooms. The DON said if a resident was on EBP she said she wanted her staff to follow EBP procedures. She said EBP required wearing a gown and gloves. LPN #2 was interviewed on 4/23/26 at 1:50 p.m. She said staff needed to wash their hands after performing any type of care, as well as when leaving the resident’s room.

A survey with #CO2694997 was completed on 4/21/26 to 4/23/26. Three deficiencies were cited.

Based on record review and interviews, the facility failed to investigate an allegation of verbal abuse involving one (#6) of seven residents of 17 sample residents. Specifically, the facility failed to investigate an allegation of verbal threats overhead by a family member between Resident #6 and Resident #15. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised April 2021, was provided by the nursing home administrator (NHA) on 4/22/26 at approximately 9:20 a.m. It read in pertinent part, “Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents’ symptoms.“Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: other residents.“The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements and protect residents from any further harm during investigations.“Investigate and report any allegations within timeframes required by federal requirements.”The Identifying Types of Abuse policy and procedure, revised September 2022, was provided by the NHA on 4/22/26 at 9:20 a.m. It read in pertinent part:“As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents.“Examples of mental and verbal abuse include but are not limited to: yelling or hovering over a resident, with the intent to intimidate.”II. Resident #6 (alleged victim)A. Resident statusResident #6, aged less than 65, was admitted on 12/11/25. According to the April 2026 computerized physician’s orders (CPO), diagnoses included dysphagia, hemiplegia of the left side (paralysis of the left due to a stroke), attention and concentration deficit, delusional disorder, and major depressive disorder. According to the 3/20/26 comprehensive assessment, Resident #6 had moderate cognitive impairment. The assessment indicated Resident #6 used a wheelchair for mobility and was dependent on staff for most of his activities of daily living (ADL). B. Resident #6 interviewResident #6 was interviewed on 4/21/26 at 2:23 p.m. Resident #6 said he did not think the arguing back and forth between Resident #15 and himself was a big deal. He said his roommate (Resident #15) said to shut the (explicative), and then they were both yelling back-and-forth at each other. He said he could not remember what they each yelled towards each other. He said there was no pushing, shoving or anything like that. C. Resident #6’s representatives interviewsResident #6’s guardian was interviewed over the phone on 4/22/26 at 11:55 a.m. She said that Resident #6 called her after the incident and she went to the facility to see what was going on. She said the staff had separated residents because they were yelling at each other. The guardian said apparently threats were made by Resident #15 towards Resident #6. She said Resident #6 told her that he was fearful of Resident #15. Resident #6’s representative was interviewed on 4/22/26 at 1:27 p.m. The representative said while she was talking to Resident #6 on the phone on 3/15/26, she heard Resident #15 yelling loudly and making threats towards Resident #6. She then heard the nurse enter the room to calm down the situation. The representative said that she tried to call the facility to report the yelling and threatening behavior, but was sent to voicemail and no one called her back. She said she was worried about the situation, so she called the police and reported the threatening behavior. The representative provided a police report number during the call (see emergency services interview below). III. Resident #15 (alleged assailant) A. Resident statusResident #15, age greater than 65, was admitted on 8/28/25. According to the April 2026 CPO, diagnoses included dementia, cognitive communication deficit, depression, and insomnia. According to the 3/2/26 comprehensive assessment, Resident #15 had moderate cognitive impairment. The assessment revealed Resident #15 used a walker for mobility dependent on staff for most of his ADL. The assessment indicated the resident did not have any behaviors. B. Resident interviewResident #15 was interviewed on 4/21/26 at 2:55 p.m. He said that he did not remember the incident between him and Resident #6. C. Resident #15’s representative interviewResident #15’s representative was interviewed on 4/23/26 at 10:45 a.m. The representative said Resident #15 did not remember the incident. Resident #15’s representative said she was made aware of the incident the day after it happened. She said she was told Resident #6 was talking too loud on the phone and Resident #15 started yelling at Resident #6 to be quiet. She said she was told that because of the yelling the facility initiated a room move that night (3/16/26) to separate the two from being roommates. Resident #15’s representative said she agreed to the room change. She said she had asked for the room change prior to 3/15/26 due the behaviors of Resident #6 when she visited Resident #15. She said that Resident #6 would masturbate on the other side of his privacy curtain and would yell racial slurs. She said that she told the director of nursing (DON). IV. Record reviewA request was made for an investigation regarding the allegations of verbal threats by Resident #6 towards Resident #15 (see staff interviews below). Review of both resident’s electronic medical record revealed no documentation of the resident to resident verbal altercation or related concerns. A room change form in Resident # dated 3/16/26 revealed the reason for the resident's room change was Resident #15 and his roommate did not get along. Family requested he be moved. IV. Emergency services interviewA non-emergency dispatcher was interviewed on 4/22/26 at 5:26 p.m. The non-emergency dispatcher said there was an incident reported from Resident #6’s representative. The non-emergency dispatcher said emergency medical services (EMS) responded to the call and not the police. V. Staff interviewsRegistered nurse (RN) #1 was interviewed on 4/23/26 at 10:00 a.m. RN #1 said she did not remember the verbal altercation between Resident #6 and Resident #15 all that well, since it occurred a while ago. She said that she did remember that there was loud yelling and arguing between Resident #6 and Resident #15. She said she did not hear the exact words exchanged and did not know if any threats were made by either resident. RN #1 said she could not remember exactly, but it was either the police or EMS who responded to the facility related to the resident’s yelling. RN #1 said she reported the yelling to the DON that evening, but did not tell the DON about EMS responding to the facility for the residents yelling at each other. RN #1 said she talked to a family member or friend of Resident #6’s regarding the verbal altercation. She said she could not remember who she talked to or the relationship to Resident #6. RN #1 said she had helped Resident #15 to change rooms, due to the resident-to-resident incident on 3/15/26. The social service director (SSD) and the corporate nurse consultant were interviewed together on 4/23/26 at 9:40 a.m. The SSD said she did not know much about the incident that took place between Resident #6 and Resident #15 on 3/16/26. The SSD said it was just an argument between two individuals and there were no threats, or anything else that would rise to the occasion of an allegation. She said it was a back and forth between two residents and nothing else.-However the incident was not investigated and the SSD was not present during the incident. Additionally, both residents had cognitive deficits and there was no documented interview with either resident at the time of the incident. The NHA, the DON and the corporate nurse consultant were interviewed on 4/23/26 at 12:30 p.m. The NHA and the DON said RN #1 had called the DON after the incident to initiate a room change for Resident #15 due to worsening dementia. The DON said that Resident #15’s representative had asked for a room change prior to the incident that took place due to Resident #6 behaviors. The DON said that she was not made aware that the police or EMS were called about the incident and was not told that EMS had arrived in response to the resident-to-resident verbal alteration. The NHA said she did not report the resident’s verbal exchange to the State Agency as abuse of a resident, because there were no threats made by either resident. She said the two residents were just having a disagreement and yelling at each other. The NHA said neither resident called the police or EMS. -However, no facility staff inquired how EMS showed up in response to the resident-to-resident verbal altercation where RN #1 believed it was necessary to initiate an immediate room move to separate the resident permanently. The DON and the NHA said that they followed up to prevent anything from happening in the future, by moving Resident #15 to another room and having compatible roommates.

Based on interviews and record review, the facility failed to ensure the resident's representative was informed of changes in condition for one (#1) of three residents out of 17 sample residents. Specifically, the facility failed to:-Inform Resident #1’s physician-appointed healthcare proxy when the resident had a change in condition, including when the resident started on an antibiotic medication; and,-Return phone calls to Resident #1’s healthcare proxy’s voice messages requesting information about the resident’s condition in a timely manner. Findings include:I. Facility policy and procedureThe Notification of Changes policy, revised 2025, was provided by the nursing home administrator (NHA) on 4/23/26 at 1:21 p.m. It read in pertinent part, "The facility must inform the resident, consult with the resident’s physician and/or notify the resident’s family member or legal representative when there is a change requiring such notification. When residents are incapable of making their own decisions the representative will make any decisions that have to be made.”II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 12/12/25. According to the April 2026 computerized physician orders (CPO), diagnoses included paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit and encephalopathy. According to the 3/23/26 comprehensive assessment, the resident was severely cognitively impaired. B. Resident #1’s representatives interviewsResident #1’s designated health care proxy was interviewed on 4/21/26 at 2:55 p.m. The health care proxy said the facility made it very difficult to contact Resident #1. She said facility staff did not return calls for days, making her worry about Resident #1 because she lived so far away and could not just drive over to check on the resident. The health care proxy said the resident was started on antibiotic treatment and she was not informed that Resident #1 had an infection and needed antibiotics until after the resident started on the medication. She said she had several questions about the medication and was not consulted on the medical decision prior to the start of the medication. Another one of Resident #1’s representatives was interviewed on 4/21/26 at 2:55 p.m. The representative said she had called the facility several times; however, the facility never answered the phone. She said phone calls went to a general voice mailbox. The representative said her voicemail message requests for a return call were either not answered or took several days for someone from the facility to respond to the messages. C. Record review Grievances filed on behalf of Resident #1 were requested and provided by the NHA on 4/21/26 at 2:17?p.m. The grievances revealed there were several concerns regarding delays in the facility’s response to the Resident #1’s representatives requests for information about the resident and the delays in reporting changes in the resident’s condition. The grievances revealed the following:A grievance, dated 12/30/25, revealed Resident #1’s representative had concerns related to the representative’s inability to get to speak to Resident #1 over the phone in a timely manner. The resident’s representative called the facility to speak to Resident #1 on 12/28/25 but the call was not returned until three days later (on 12/31/25). The documented facility’s response to the concerns was that a return call was placed to the resident’s representative on 12/31/25 and the call went to the representative’s voicemail. -There was no other documentation to indicate that the facility took further actions to resolve the communication delays. A grievance, dated 1/8/26 and filed by Resident #1’s health care proxy revealed the resident's health care proxy wanted weekly calls since she said it was too hard to contact the nurses in the facility. The facility’s response to the grievance documented that weekly follow-up calls would be completed in response to theconcern, and that the resident’s health care proxy was satisfied with the follow-up. A grievance, dated 2/1/26 and filed by Resident #1’s health care proxy revealed the resident's health care proxy called to express concern over lack of notification for new medication the resident was started on but she was not informed of. The facility followed up by conducting in-services with their staff on 2/1/26, 2/3/26 and 2/5/26, regarding notifying residents’ responsible parties about medication changes, as well as which staff members were responsible for the notifications. Additionally, the facility ensured Resident #1’s health care proxy was listed correctly in their resident information. -The grievance failed to reveal information on whether or not the resident’s health care proxy was satisfied with the facility’s response to the concern. A grievance, dated 3/28/26 and filed by Resident #1’s health care proxy revealed the resident's health care proxy expressed concern over a scheduled video call where she was unable to connect with staff. The health care proxy said she was upset about the lack of communication from the facility. The resident’s health care proxy was called back on 3/31/26 by the activities director, who apologized for the miscommunication regarding the video call. The activities director said the health care proxy could call her if she needed anything from them. -The grievance failed to reveal information on whether or not the resident’s health care proxy was satisfied with the facility’s response to the concern. III. Other residents’ representatives interviewsResident #10’s representative was interviewed on 4/21/26 at 3:19 p.m. Resident 10’s representative said Resident 10 was newly admitted to the facility. He said he called to check on the resident's status and the call was sent to the facility’s voicemail. Resident #10’s representative said it took the facility two days to return his call. Resident #6’s representative and a secondary witness were interviewed together on 4/22/26 at 1:27 p.m. They said they attempted to contact the facility to report a suspected instance of verbal abuse that they over heard while on the phone with Resident #6 but the call was sent to the facility’s voicemail. They said they tried to call the social services director (SSD) and were again sent to voicemail. They said they never received a return call. IV. Staff interviewsThe SSD was interviewed on 4/22/26 at 3:15 p.m. The SSD said she was not entirely sure where the concerns about the communication with Resident #1’s representatives were coming from. She said all calls to the facility first went to the front desk receptionist and were then transferred to the nurses’ stations for direct contact with nursing staff. The SSD said Resident #1’s representatives had her cell phone number as well as the cell phone number for the director of nursing (DON), whom they could call if she was unable to get through to the nurses’ station. Licensed practical nurse (LPN) #1 was interviewed on 4/23/26 at 11:09 a.m. LPN #1 said one of Resident #1’s representatives often called his personal cell phone multiple times a day. The DON, the NHA, and the corporate nurse consultant were interviewed together on 4/28/26 at 12:34 p.m. The NHA said the Resident #1’s healthcare proxy wanted a call from the facility staff every single day. The NHA said the facility was aware several of the resident’s representatives’ phone calls went to voicemail when the nurses were unable to pick up the phone calls. The corporate nurse consultant said that voicemail messages left in the facility's voicemail message system should be returned within 24 hours. The NHA said she did not think it was accurate that Resident #1’s healthcare proxy was not getting called back and that the assistant director of nursing (ADON) was texting the health care proxy on a weekly basis to provide information. -However, there was no documentation for the weekly calls provided by the facility. The NHA said Resident #1’s representative and health care proxy had her cell phone number as well as the cell phone number for the SSD and the DON. The representatives could have called any of them directly if they were unable to get through to the nurses’ station. The NHA said Resident #1’s representatives often called during shift change when it was harder to get through to the nurse on duty. The NHA said if the nurse was unable to answer the phone call, the call went directly to voicemail where it was later picked up and returned.

Based on observations, interviews and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases in four of four units. Specifically, the facility failed to:-Ensure staff performed hand hygiene before and after providing resident care; and,-Ensure staff followed enhanced barrier precautions (EBP) while providing direct resident care for residents who were identified as being on EBP. Findings include:I. Professional referenceAccording to the Center for Disease Control and Prevention (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, (2/27/24), retrieved on 5/4/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html,“Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with, handwashing with water and soap, antiseptic hand rub, or surgical hand antisepsis.”According to the CDC’s Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO), (4/2/24), retrieved on 5/4/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html,"Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities."EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO."Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing)."II. Facility policy and procedureThe Enhanced Barrier Precautions policy, revised December 2024, was provided by the nursing home administrator (NHA) on 4/23/26 1:21 p.m. It read in pertinent part, “EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.”The Hand Hygiene policy, undated, was provided by the NHA on 4/23/26 1:21 p.m. It read in pertinent part, “hand hygiene will be done by all employees, volunteers and contract staff to reduce transfer of microbes to patients.”Hand hygiene should be done before and after direct patient care, before and after each procedure, after using the bathroom, after blowing or wiping the nose, before and after eating, before and after collecting specimen, when hands are soiled, after any contact with contaminated materials, before re-entering nursing bag or patient’s clean supplies.”III. ObservationsOn 4/21/26 at 10:48 a.m. an unidentified certified nurse aide (CNA) was leaving room #215, after caring for a resident who was identified as being on EBP, by a sign on the door. The CNA did not wear a gown while providing care. On 4/21/26 at 12:53 a.m. CNA #1 exiting a resident’s room not wearing gloves. CNA #1 carried a soiled mechanical lift sling and placed it in the soiled laundry hamper. CNA #1 did not perform hand hygiene. CNA #1 walked down the hall to the nurse’s cart. He ran his hands through his hair and over his face. Then CNA #1 used the facility’s touch screen to document the care provided. Without performing hand hygiene, CNA #1 entered resident room #100 to answer a call light and assist a resident with a request without washing his hands before or after assisting that resident. On 4/22/26 at 9:41 a.m. CNA #2 entered resident room #114, who was on EBP per the sign on the door. CNA #2 entered the room and applied gloves, but did not apply a gown. CNA #2 provided the resident with incontinence care. CNA #2 left the resident’s room with the soiled linens and trash disposed of in the proper hampers, removed the gloves but did not perform any hand hygiene prior to caring for another resident. On 4/23/26 at 9:59 a.m. licensed practical nurse (LPN) #1 entered room 113 to set up the feeding tube. The resident was identified as needing EBP due to the resident having a gastric tube feeding. LPN #1 did not perform hand hygiene before setting up the resident's tube and she did not wear a gown while handing the resident gastric tube and connecting the tubing. On 4/23/26 at 11:16 a.m. LPN #1 entered resident room 113. This room was identified as needing EBP. While in the room LPN #1 provided care to Resident #1 and left with no hand hygiene. IV. Resident representative/family interviewOn 4/21/26 at 2:09 p.m. Resident #1’s representative was interviewed. She said when she visited her sister she saw them working with Resident #1’s feeding tube with no gloves or gown on .V. Staff interviewsCNA #1 was interviewed on 4/21/26 at 12:59 p.m. He said he washed hands for 20 seconds before and after going into a resident room to provide care. CNA #2 was interviewed on 4/22/26 at 9:53 a.m. was interviewed. She said she washed her hands for about 20 seconds before providing resident care. CNA #2 said when a resident was on EBP, she would put on gloves and booties when providing care. CNA #3 was interviewed on 4/22/26 at 10:04 a.m. CNA #3 said he performed hand hygiene before entering a resident's room and put on gloves to provide care assistance. CNA #3 said when he left the resident’s room, he would remove the gloves and perform hand hygiene. CNA #3 said when providing care to a resident who was on EBP, he would also wear a gown. The director of nursing (DON) was interviewed on 4/23/26 at approximately 1:45 p.m. She said she wanted staff to perform hand hygiene as frequently as possible including when they enter and exit rooms. The DON said if a resident was on EBP she said she wanted her staff to follow EBP procedures. She said EBP required wearing a gown and gloves. LPN #2 was interviewed on 4/23/26 at 1:50 p.m. She said staff needed to wash their hands after performing any type of care, as well as when leaving the resident’s room.

A survey for Incident #2615094 was conducted 10/15/25 to 12/8/25. One deficiency was cited. The actual survey exit date was 10/15/25. Per AHFSA guidance from CMS on 11/17/25, the end date was adjusted to the date the CMS-2567 was issued to the provider, on 12/8/25.

Based on record review and interviews, the facility failed to protect residents from physical abuse for two (#2 and #3) of five residents reviewed for abuse out of five sample residents. Specifically, the facility failed to protect Resident #2 and Resident #3 from physical abuse by Resident #1. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation policy, revised April 2021, was provided by the director of nursing (DON) on 10/15/25 at 10:45 a.m. The policy read in pertinent part,“Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident’s symptoms.“The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors and/or any other individual.“The facility will develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents, neglect of residents and/or theft, exploitation or misappropriation of resident property.“The facility will establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. The facility will provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.“The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements and protect residents from any further harm during investigations.”II. Facility investigation of physical abuse towards Resident #2 and Resident #3 by Resident #1 on 7/30/25The facility investigation, dated 7/30/25, revealed that on 7/30/25, an incident occurred between Resident #1, Resident #2 and Resident #3. Resident #1 entered the room shared by Resident #2 and Resident #3. Resident #2 was upset Resident #1 entered their room and began throwing pieces of pineapple at Resident #1. Resident #1 became upset with Resident #2 and left the room, knocking a glass jar of pickles off Resident #2’s dresser as he left the room to go outside and smoke. Upon returning to his room, Resident #1 discovered that his laptop had been shattered. Resident #1 returned to Resident #2 and Resident #3’s room and asked Resident #2 if she broke his laptop. Resident #2 refused to respond to Resident #1’s question, which angered Resident #1. Resident #1 then proceeded to remove the armrest from his wheelchair and threw it at Resident #2. The wheelchair armrest struck Resident #2 in the chest and then hit Resident #3 in the leg. The incident was not witnessed by staff, but staff responded when they heard the altercation. The residents were separated and assessed for injuries and no injuries were noted to any of the residents. The nursing home administrator (NHA), the DON and social services were notified and the police were called. The investigation documented that all three residents were interviewed by the facility following the incident. The interviews were as follows:Resident #3 said Resident #1 came into her and Resident #2’s room and Resident #2 began throwing pineapple at Resident #1. Resident #3 said Resident #1 left the room and knocked over a jar of pickles on his way out. She said Resident #1 later came back to their room to ask Resident #2 if she broke his laptop and when Resident #2 did not answer him, he took the armrest off his wheelchair and threw it at Resident #2. Resident #3 said the armrest hit Resident #2 in the chest and then bounced off and hit her (Resident #3) in the leg. Resident #3 said she was not a part of the argument between Resident #1 and Resident #2, but she got caught in the middle of it. She said she did not want to be involved in the drama between Resident #1 and Resident #2. Resident #2 said she was upset because she found out Resident #1 took her vaporizer device. She said when Resident #1 came into her and Resident #3’s room, she (Resident #2) threw pineapple at him which made Resident #1 mad so he left the room and knocked a jar of pickles off her dresser when he left. Resident #2 said Resident #1 later came back to the room and asked her if she broke his laptop. She said when she did not answer Resident #1, he got mad and threw his wheelchair armrest at her. Resident #2 said the armrest hit her and then hit Resident #3. She said the incident got out of hand and if she got mad at Resident #1 again, she would talk to staff about it instead of getting in another incident. Resident #1 said he took Resident #2’s vaporizer device and she got mad at him and threw pineapple at him when he walked into Resident #2 and Resident #3’s room. He said that made him mad and he knocked over a pickle jar as he left the room and then he walked off to cool down. Resident #1 said when he went back to his room, his laptop was broken. He said he went back to Resident #2’s room to ask her if she broke his laptop, but she refused to answer him. Resident #1 said he got mad and threw the armrest from his wheelchair at Resident #2. He said the armrest hit Resident #2 and also hit Resident #3. He said he did not mean to hit anyone but he was frustrated. Resident #1 said if something like that happened again, he would go to a staff member before things escalated. The investigation documented other residents and staff members were interviewed about abuse and nobody had any concerns. Resident #1 and Resident #2’s care plans were updated regarding the incident and both residents were counseled individually and agreed to utilize staff support and anger management strategies moving forward. III. Resident #1 (assailant)A. Resident statusResident #1, age less than 65, was admitted on 6/12/25. According to the October 2025 computerized physician orders (CPO), diagnoses included paraplegia (paralysis of the lower half of the body caused by damage to the spinal cord), generalized anxiety disorder and depression. The 9/19/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. He was independent with most activities of daily living (ADL). The assessment indicated the resident had verbal behavioral symptoms directed toward others, such as threatening others, screaming at others or cursing at others on one to three days during the assessment look-back period. B. Resident interviewResident #1 was interviewed on 10/15/25 at 11:00 a.m. Resident #1 said Resident #2 accused him of taking her vaporizer device, which he said he did. He said he and Resident #2 liked to mess around and give each other a hard time. He said he got mad when Resident #2 started throwing fruit at him, so he knocked a jar of pickles off Resident #2’s dresser when he left the room to go outside and smoke. Resident #1 said when he came back to his room, his laptop was broken so he went back to Resident #2 and Resident #3’s room to ask Resident #2 if she broke his laptop. He said Resident #2 refused to answer him, so he got mad again and threw his wheelchair armrest at Resident #2. He said the armrest hit Resident #2 and Resident #3. He said he did not mean to hit anyone with the armrest and he should not have thrown it. He said now if he got mad, he tried to let the staff know instead of just reacting. Resident #1 said he liked hanging out with Resident #2 so he was working on controlling his temper better. C. Record reviewReview of Resident #1’s physical aggression care plan, initiated 7/31/25, revealed the resident had the potential to be physically aggressive related to anger and poor impulse control. The resident smashed glass in another resident’s room and then threw his wheelchair armrest at two other residents. Interventions included administering medications as ordered and monitoring/documenting for side effects and effectiveness, analyzing times of day, places, circumstances, triggers and what de-escalated the resident’s behavior and documenting, assessing the resident and addressing for contributing sensory deficits, providing the resident with physical and verbal cues to alleviate anxiety, giving positive feedback, assisting the resident with verbalization of his source of agitation, assisting the resident to set goals for more pleasant behavior and encouraging the resident to seek out staff members when he was agitated. The 7/30/25 at 5:49 p.m. nurse progress note documented Resident #1 was found in another resident's (Resident #2) room where he had broken a pickle jar and was reportedly breaking other items belonging to the resident. The resident appeared agitated and was heard stating “If somebody messes with me, I will mess with them.” A registered nurse (RN) responded to the incident, assessed the situation, and redirected Resident #1 back to his own room. The RN educated the resident on the importance of respecting others’ property and privacy. The resident responded with anger and stated he did not want anyone to talk to him and then entered his own room. A licensed practical nurse (LPN) followed up by checking on the resident in his room to ensure his safety and emotional status. The resident was observed to be upset and staff would continue to monitor him for safety and behavior. The 7/30/25 at 8:08 p.m. nurse progress noted documented Resident #3 reported another resident (Resident #1) entered her and her roommate's (Resident #2) room and smashed a glass jar along with other things belonging to Resident #2. As a result, there was broken glass on Resident #2’s bed and on the floor. Resident #1 accused Resident #2 of smashing his laptop and the two residents began yelling profanities at each other. Resident #1 then detached the arm of his wheelchair and threw it in the direction of Resident #2, striking Resident #2 and Resident #3. Resident #1 then left the area. No injuries were reported by either Resident #2 or Resident #3 and neither resident reported any pain. The nurse spoke to Resident #1 and Resident #2 and instructed them to stay away from each other. Physician’s orders were added to the residents’ electronic medical records (EMR) for each resident to stay away from each other. The DON, the NHA, the physician and the residents’ representatives were notified. The 7/31/25 physician’s visit note documented Resident #1 and another resident (Resident #2) had an altercation last night (7/30/25) that became physical. Resident #1 threw part of a wheelchair at the other resident and she smashed his laptop. The police were called and the situation was controlled. Both residents were uninjured and remained in the facility. This was the first such event since Resident #1’s admission. Resident #1 reported to the physician that the other resident was the instigator. The incident was an isolated episode and there were no changes made to Resident #1’s plan of care. Resident #1 was aware of his behavior and that it would not be tolerated. If the incident recurred, the physician would reevaluate the resident’s plan of care. The 8/1/25 at 12:41 p.m. social services note documented Resident #1 met with social services and openly discussed the events that occurred on 7/30/25. The resident admitted to taking Resident #2’s vaporizer device and expressed genuine remorse for his actions. Resident #1 verbalized that he became overwhelmed and reacted impulsively when his property was broken, and he was especially regretful that anyone was hurt as a result. The resident said he felt safe and would like to repair the relationships that were impacted. Resident #1 agreed to practice anger management techniques and to seek staff support when he began to feel upset in the future. He was counseled on positive coping strategies and accepted responsibility for his role in the incident. IV. Resident #2 (victim)A. Resident statusResident #2, age less than 65, was admitted on 4/24/25 and readmitted on 10/9/25. According to the October 2025 CPO, diagnoses included anxiety disorder, restlessness and agitation and depression. The 9/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with most ADLs. The MDS assessment indicated the resident did not have any behaviors. B. Resident interviewResident #2 was interviewed on 10/15/25 at 10:30 a.m. Resident #2 said Resident #1 took her vaporizer pen and when he came into her and Resident #3’s room, she (Resident #2) was upset with him and told him to get out and she started throwing pineapple pieces at him. She said Resident #1 got mad and left the room, but pushed a pickle jar off her dresser as he left and it broke on the floor. Resident #2 said when Resident #1 was outside smoking, she went to his room and messed around with his stuff. She said when he came back from smoking, he came back to her room and asked her if she broke his laptop. Resident #2 said she did not answer him, which made him mad and he threw the armrest from his wheelchair at her. She said the armrest hit her in the chest and then bounced off and hit Resident #3’s leg. She said it did not hurt and she did not have any injury from it. Resident #2 said the staff made Resident #1 get out of her room and she later told the DON that she did break his laptop because he stole her vaporizer device. Resident #2 said she liked hanging out with Resident #1. She said they were friends and they liked to pick on each other, but she said sometimes Resident #1 could get really mad and she could too. She said she was working on her anger and her reactions to things. She said she saw a counselor regularly. C. Record reviewReview of Resident #2’s physical aggression care plan, initiated 7/31/25, revealed the resident had the potential to be physically aggressive related to anger and poor impulse control. The resident was involved in a fight with another resident and went into the other resident’s room and broke stuff in retaliation to the other resident breaking stuff in her room. The police were called and the resident refused to talk with them. The residents were separated and monitored frequently for safety and to keep them apart. Interventions included administering medications as ordered and monitoring/documenting for side effects and effectiveness, analyzing times of day, places, circumstances, triggers and what de-escalated the resident’s behavior and documenting, assessing the resident and addressing any contributing sensory deficits, assessing and anticipating the resident's needs, such as food, thirst, toileting needs, comfort level, body positioning and pain, providing the resident with physical and verbal cues to alleviate anxiety, giving positive feedback, assisting the resident with verbalization of her source of agitation, assisting the resident to set goals for more pleasant behavior, encouraging the resident to seek out a staff member when she was agitated, giving the resident as many choices as possible about her care and activities, monitoring/documenting/reporting as needed, any signs/symptoms of the resident posing danger to herself and others, when the resident became agitated, intervene before the agitation escalates, guiding the resident away from sources of distress, engaging the resident calmly in conversation and if the resident’s response was aggressive, staff were to walk calmly away and approach the resident later. The 7/30/25 at 6:13 p.m. behavior progress note documented that Resident #1 went to Resident #2’s room and smashed her stuff for no reason. Resident #2 did not tell the nurse or other staff members about the incident, but in return, Resident #2 went to Resident #1’s room and broke his laptop, according to Resident #1. Resident #1 then returned to Resident #2’s room and started throwing things at Resident #2 and the residents both started throwing things at each other. The night shift nurse supervisor came and took Resident #1 out of the room to de-escalate the situation. The DON was notified and the staff would continue to monitor the situation. The 8/1/25 at 12:39 p.m. social services progress note documented Resident #2 was interviewed privately and expressed regret regarding her involvement in the incident on 7/30/25. She acknowledged throwing pineapple pieces toward Resident #1 out of frustration and stated she now understood that was not an appropriate way to respond. Resident #2 verbalized that she felt safe in the facility and wished to move forward peacefully. She denied any further desire for retaliation and agreed to use staff support if she began to feel overwhelmed in the future. The resident also agreed to practice anger management strategies and to communicate with staff rather than escalating situations on her own. She declined any emotional support services but was aware that the support services were available to her if needed. V. Resident #3 (victim)A. Resident statusResident #3, age less than 65, was admitted on 8/20/24. According to the October 2025 CPO, diagnoses included schizoaffective disorder, bipolar type (a mental health condition where one experiences episodes of psychosis along with bouts of mania and depression) and acute stress reaction. The 8/1/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with most ADLs. The MDS assessment indicated the resident did not have any behaviors. B. Resident interviewResident #3 was interviewed on 10/15/25 at 10:45 a.m. Resident #3 said Resident #1 came into the room she shared with Resident #2 and smashed several of Resident #2’s belongings to the floor. She said Resident #2 told Resident #1 to leave their room, which he did, but then he came back. She said when he came back, Resident #1 and Resident #2 started arguing in the hall and then Resident #1 took off the armrest of his wheelchair and threw it at Resident #2. Resident #3 said the wheelchair armrest hit Resident #2 and then bounced off Resident #2 and hit her (Resident #3) in the leg. She said it did not hurt and she did not have a bruise or scratch. Resident #3 said the staff removed Resident #1 from the room and called the police. She said she, Resident #1 and Resident #2 all hung out together and Resident #1 and Resident #2 had not had any more issues since the incident on 7/30/25. Resident #3 said she was not afraid of Resident #1 and he was usually pretty nice. C. Record reviewThe 7/30/25 at 5:35 p.m. nurse progress note documented Resident #3 was hit in the right thigh with a wheelchair armrest as a result of an altercation between two other residents (Resident #1 and Resident #2). A full body skin check was performed. The resident’s skin was intact with no abrasions, bruises or cuts noted. There were no injuries identified and the resident reported no pain. The DON and the physician were notified. The 8/1/25 at 12:40 p.m. social services progress note documented Resident #3 reported feeling startled by the situation on 7/30/25 but stated she felt safe and supported by staff. She expressed disappointment about being physically affected during the altercation, as she was unintentionally struck in the leg by the armrest thrown by Resident #1. Resident #3 stated that she believed the issue stemmed from a misunderstanding and she did not harbor resentment. She accepted Resident #1’s apology and expressed that she too was open to using staff for mediation and support in future conflicts. Resident #3 was calm and cooperative during the follow-up and did not wish to change rooms at the time. She agreed to continue working toward a calm and respectful living environment. VI. Staff interviewsLPN #1 was interviewed on 10/15/25 at 11:40 a.m. LPN #1 said he had only worked at the facility for three months. He said Resident #1 was young and staff had to sometimes redirect his agitated behaviors, but he said he had never seen the resident be physically aggressive with staff or residents. LPN #1 said he received abuse training upon his hire to the facility and he had not seen any resident abuse. He said if he were to witness an abuse situation, he would report it to the DON or the NHA immediately. Certified nurse aide (CNA) #1 was interviewed on 10/15/25 at 11:50 a..m. CNA #1 said she had not witnessed any abuse situations but she had heard of the incident with Resident #1 and Resident #2. She said Resident #1 could get aggressive with staff when he did not get his way immediately. She said he could be unpredictable with staff because he did not like feeling controlled. She said he was usually easy to calm down and redirect if staff talked to him calmly. She said Resident #1, Resident #2 and Resident #3 all hung out together and the three of them sometimes got into arguments, but she said all three residents were easily redirectable and staff would just separate them for a time and then they were fine with each other. She said she had not witnessed any further abuse situations with any of the residents when they were together. She said if she were to witness an abuse situation, she would report it immediately to the NHA.CNA #2 was interviewed on 10/15/25 at 12:00 p.m. CNA #2 said she was working on 7/30/25 when the abuse incident occurred between Resident #1, Resident #2 and Resident #3. She said Resident #1 was antagonizing Resident #2, going into her room and knocking stuff off of her dresser and “talking smack” to her. CNA #2 said Resident #1 removed one of the armrests from his wheelchair because he got frustrated with Resident #2 and threw it at her. CNA #2 said she did not know if the armrest hit Resident #2, but she said it did hit Resident #3 in the leg. She said Resident #3 did not have any injuries and the residents were separated and the police were called. CNA #2 said Resident #1 and Resident #2 had an “up and down” relationship, almost like a sibling rivalry. She said they would get frustrated and annoyed with each other and then would be fine together. She said the residents were kept separated for awhile but had since been allowed to hang out together because they were friends. She said staff kept a close eye on them and if Resident #1 or Resident #2 started to get upset with each other, staff told them to stay away from each other for awhile until they calmed down. She said the residents were compliant with following that intervention. CNA #2 said Resident #1 did not seem to be getting upset as much as he used to and there had been no further incidents with the residents. CNA #3 was interviewed on 10/15/25 at 12:07 p.m. CNA #3 said she had not witnessed any resident abuse situations personally, but she said if she did, she would immediately report it to the NHA. She said she heard about the incident on 7/30/25 with Resident #1, Resident #2 and Resident #3, but she was not working when the incident occurred. She said she heard Resident #1 and Resident #2 were arguing and Resident #1 threw his wheelchair armrest at Resident #2 and it hit Resident #2 and Resident #3 but they were not hurt. CNA #3 said after the incident, staff were instructed to keep Resident #1 and Resident #2 separated from each other and Resident #1 was moved to another room on a different hallway. She said Resident #1, Resident #2 and Resident #3 were friends. She said the residents were allowed to hang out together now andthere had been no further incidents between them, but she said staff kept a close eye on the residents when they were together so no other situations occurred. The DON and the regional director of clinical services were interviewed together on 10/15/25 at 1:30 p.m. The DON said the incident on 7/30/25 involving Resident #1, Resident #2 and Resident #3 occurred after Resident #2 accused Resident #1 of taking her vaporizer device. She said Resident #1 went to Resident #2 and Resident #3’s room and Resident #2 started throwing food at Resident #1 because she was upset about her vaporizer device. She said Resident #1 became upset and left the room, smashing Resident #2’s jar of pickles as he left the room. The DON said Resident #1 went outside to smoke and when he returned to his room, he found his laptop smashed and went back to Resident #2’s room to ask her if she broke his laptop. She said when Resident #2 did not answer Resident #1’s question about the laptop, Resident #1 got angry, took the armrest off his wheelchair and threw it at Resident #2. The DON said the armrest hit Resident #2 in the chest and then bounced off and hit Resident #3 in the leg. She said neither resident sustained an injury. The DON said staff overheard the commotion and immediately intervened and separated the residents and Resident #1 was immediately moved to a room on another hallway. She said the police were called and by the time the police arrived, everything had calmed down and there were no further concerns. The DON said the residents were all placed on 15-minute checks and kept separated from each other for 72 hours to make sure there were no further issues. She said both Resident #1 and Resident #2 were spoken to about the incident and both agreed to mental health services visits. She said Resident #2 had been seeing a mental health services provider prior to the incident. She said Resident #1 had previously declined mental health services, but agreed to utilize the services following the incident with Resident #2. The DON said both Resident #1 and Resident #2 could be very short tempered with staff and they would occasionally yell and cuss, but they had never exhibited anything physically aggressive prior to the incident on 7/30/25. She said the residents, including Resident #3 were very good friends and it was hard to keep them apart after the incident, but she said they were now allowed to be together and both residents had agreed to come to staff if they were getting agitated or to walk away from each other. The DON said she checked in frequently with both residents to ensure they were doing okay and managing their frustrations successfully. She said the residents had her cell phone number and would call her sometimes if they were frustrated. She said staff knew to keep a close eye on them when they were together to ensure another incident did not occur between the residents. The regional director of clinical services said Resident #1 and Resident #2 had a sibling type relationship and the facility did not want to dissuade their interaction with each other. She said the staff was very aware of the history between the two residents and were all very diligent in monitoring the residents when they were together to ensure the situation did not escalate into another incident.

A complaint survey, prompted by #CO2671111 was conducted on 12/3/25. No deficiencies were cited.

A health survey with complaint #CO2683138 was completed 12/3/25. No response necessary.

A complaint survey, prompted by #CO39603 was conducted on 4/28/25 to 4/29/25. No deficiencies were cited.

A complaint survey, prompted by #CO38956 was completed on 2/10/25. No deficiencies were cited.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.