ROCK CREEK REHABILITATION AND HEALTHCARE 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 483.90(a) This survey was conducted on June 17, 2026, for compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012); and all referenced standards. The facility will meet these requirements when the following deficiencies are corrected. This structure is a single (1) story, Type V (000) construction. The building does not have a basement; it’s slab on grade construction. The facility is licensed for 60 beds and the census on the date of the survey was 38.

Through observation and staff interview during the survey, it was determined the facility failed to maintain the means of egress doors in accordance with NFPA 101, 19.2.2 and 7.2.1. Findings include:All exit access doors leading to the public way are equipped with delayed egress components. Upon an audible alarm the delayed egress components failed to begin the irreversible process of unlocking the door. Remove the pre-alarm function (nuisance alarm). You can apply pressure on the door release for up to 3 seconds until an audible alarm sounds in accordance with 7.2.1.6.1.1(3)(a-c) Life Safety Code Section 19.2.2.2.4, in part, does not allow doors within the required means of egress to be equipped with latch or lock that requires the use of a tool or key from the egress side unless permitted. Section 19.2.2.2.4(2), in part, requires delayed-egress locks to comply with 7.2.1.6.1. Section 7.2.1.6.1.1, in part, requires delayed egress to comply with all the criteria identified in (1) thru (5). Section 7.2.1.6.1.1(3)(a) force not to exceed 15 lbf.(b) force not required to be continuously applied for more than 3 seconds(c) initiation of the release process to activate an audible signal(d) once lock is released, relocking by manual means only. The means of egress deficiency has the potential to affect all occupants, who might include staff, residents and visitors within the building; items were discussed during the survey and again during the exit conference.

Based on observation, record review and staff interview during the survey, it was determined the facility failed to maintain the fire alarm system in accordance with NFPA 101, section 19.3.4. Findings include: Annual fire alarm report dated 02/20/2026, indicated that smoke detector #12, zone 3 protecting the corridor in Juniper Hall failed to function when tested. No supporting documentation was provided to indicate whether the detector was replaced or scheduled to be replaced. The fire alarm deficiency has the potential to affect occupants, who might include staff, residents and visitors within 1 of 4 smoke compartments; items were discussed during the survey and again during the exit conference.

Through observation and interview during the survey, it was determined that the facility failed to meet the extinguishment protection requirements in accordance with NFPA 101, section 19.3.5 Findings include: Both bathing rooms have corroded sprinkler heads. One of the sprinkler heads in the Juniper room is also painted or textured. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be replaced if these conditions are identified, NFPA 25, section 5.2.1 This deficiency has the potential to affect occupants within the room who might include residents and staff. Deficient items were discussed during the survey and exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain doors that protect corridor openings in accordance with NFPA 101, section 19.3.6.3. Findings include:Juniper Hall, resident room #6, the door to the corridor failed to latch. Section 19.3.6.3.1, in part, requires doors protecting openings in a corridor to be constructed to resist the passage of smoke. Section 19.3.6.3.5, in part, doors shall be provided with means for keeping the doors closed, the device shall be capable of keeping the door closed when 5 lbf is applied to the latch side of the door. The corridor door deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within 1 of 4 smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the course of the survey conducted on Whenever, it was determined the facility failed to maintain power strips and extension cords in accordance with NFPA 99, 10.2.3.6, 10.2.4 including NFPA 70, National Electric Code. Findings include: Administrator’s office has a heavy-duty appliance consisting of a refrigerator plugged directly into a power strip designed and listed for light duty electronics. Item was fixed while onsite. The electrical deficiency has the potential to affect all room occupants, who might include staff residents, and visitors; items were discussed during the survey and again during the exit conference.

A recertification survey with Incident #2648995, Incident #3004635, Incident #3004724, Incident #3004788, Incident #3004803, Incident #3004815, Incident #3004831, Incident #3004841, Incident #3004852 and Incident #3004857 was completed on 5/17/26 to 5/20/26. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/17/26 to 5/20/26. No deficiencies were cited.

Based on observations, record review, and interviews the facility failed to ensure two (#25 and #35) of eight out of 24 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #25 from verbal abuse from Resident #3 on 12/15/25 and 12/21/25, which caused psychosocial distress for Resident #25; and,-Protect Resident #35 from verbal abuse from Resident #3 on 12/23/25 and 12/31/25, which caused Resident #35 to become tearful after both incidents. Resident #3, who was admitted to the facility on 2/25/22 and readmitted on 12/7/25, was known to have verbally aggressive behaviors toward others and had been involved in verbal altercations with other residents. On 12/15/25 Resident #3 verbally abused Resident #25 in the dining room by yelling foul language, making threatening comments and moving aggressively toward Resident #25. The facility placed both residents on 15-minute checks and educated staff regarding de-escalation techniques. However, six days later, on 12/21/25, Resident #3 again approached Resident #25 in the dining room, calling him names and threatening to kick his (expletive word). Record review and interviews during the survey revealed Resident #25 became fearful, nervous and emotionally distressed following the repeated verbal abuse incidents from Resident #3. Due to the facility’s failure to protect Resident #25 from verbal abuse from Resident #3, Resident #25 sustained psychosocial distress, which included sleep disturbances, fear of Resident #3, avoidance of the dining room and decreased social and activity participation. Additionally, following the second incident with Resident #25, the facility implemented an intervention for staff to escort Resident #3 to and from the dining room. However, on 12/23/25 and again on 12/31/25, Resident #3 was verbally abusive toward Resident #35 in the dining room when he passed by her, causing Resident #35 to become tearful after each incident. Observations during the survey revealed Resident #3 was not consistently escorted to and from the dining room (see observations below). III. Incidents of verbal abuse towards Resident #35 by Resident #3 on 12/23/25 and 12/31/25A. Facility investigation on 12/23/25Review of the 12/23/25 facility investigation documented a verbal altercation between Resident #3 and Resident #35. The incident occurred on 12/23/25 in the dining room when Resident #3 passed Resident #35 and called the resident an inappropriate name. An unknown staff member witness said they saw Resident #35 talking to dietary staff and the resident crying when Resident #3 called Resident #35 a big (expletive) baby and said “All you do is cry.” When interviewed by the facility, Resident #35 began to cry and said Resident #3 was calling her names. She was escorted out of the dining room away from Resident #3. When the facility spoke to Resident #3, he became disruptive, disrespectful and was cursing at staff. He stated he was aware he made nasty comments and stated to staff that he did not feel it was wrong and he did not regret it. He stated he could do whatever he wanted. Staff stayed with Resident #3 until he agreed to leave the dining room. Five residents were interviewed and denied having had issues with Resident #3 being verbally aggressive towards them. Staff interviews were not conducted. Both residents were placed on frequent 15-minute checks. The residents’ responsible parties, the police, and the physicians were notified. The facility substantiated the verbal abuse.-However, Resident #3 was already on 15-minute checks following the verbal abuse incident with Resident #25 on 12/21/25 (see above).-Additionally, after the 12/21/25 incident with Resident #25, Resident #3 was supposed to be escorted to and from the dining room as an intervention to prevent further verbal abuse incidents (see above). Cross-reference F610 for failure to correct an alleged violation. B. Facility investigation on 12/31/25Review of the 12/31/25 facility investigation documented a verbal altercation between Resident #3 and Resident #35. The incident occurred on 12/31/25 in the dining room when Resident #3 began mocking and making fun of Resident #35. The investigation did not reveal what was said between Resident #3 and Resident #35. When interviewed by facility staff Resident #35 again began to cry and said Resident #3 was making fun of her. She was escorted out of the dining room. When staff spoke to Resident #3 he began yelling at the nurse and refused to leave the dining room. Five residents were interviewed and denied having had verbal altercations with Resident #3 or that they were fearful of him. The investigation did not include staff interviews. Both residents were placed on frequent 15-minute checks. The residents’ responsible parties, the police, and the physicians were notified. The facility substantiated the verbal abuse. C. Resident #3 (assailant) 1. Resident observationOn 5/17/26 at 5:00 p.m. Resident #3 was observed entering the dining room unescorted by a staff member.-However, following the verbal abuse incidents in December 2025, interventions included Resident #3 was to be escorted in and out of the dining room and was to sit in an area that would not trigger negative behaviors (see investigations above). 2. Resident interviewResident #3 was interviewed on 5/19/26 at 4:00 p.m. Resident #3 he did not recall having any negative interactions with Resident #35 on 12/23/25 and 12/31/25.3. Record review-Review of Resident #3’s dementia and behavioral care plan, initiated 5/17/22 and revised 2/3/26, did not include the interventions implemented to prevent further verbal abuse incidents (see investigations above). D. Resident #35 (victim) 1. Resident statusResident #35, age greater than 65, was admitted on 9/26/14 and readmitted on 9/22/23. According to the May 2026 CPO, diagnoses included morbid obesity due to excess calories, unspecified intellectual disabilities, depression and seizures. The 4/7/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. The MDS assessment indicated the resident did not have behaviors that impacted others. The MDS assessment indicated the resident felt down, depressed, or hopeless, and had little interest or pleasure in doing things for two to six days during the assessment look-back period. 2. Resident interviewResident #35 was interviewed on 5/17/26 at 3:00 p.m. Resident #35 said Resident #3 would call her names that made her cry several times. She said she was not afraid of him but she stayed away from him, especially in the dining room. She said where she now sat in the dining room, her back was toward him so she did not have to look at him. She said he was not a nice man and yelled quite a bit. 3. Record reviewReview of the communication care plan, initiated 10/3/14 and revised 5/16/24, revealed Resident #35 had limited verbal ability but used smiling, hugging, and holding hands with staff as a form of communication and validation. Interventions included for staff to be aware that this was her form of communication, but due to low cognitive function she would also swing from happiness to sadness as a way of communication and getting her needs met. Review of the vulnerability care plan, initiated 3/13/24 and revised 10/23/25, revealed Resident #35 was at risk of being easily influenced by other residents to the detriment of her own care and wellbeing. Interventions included that the resident needed to be monitored when visiting with residents in their rooms or at daily activities. The resident was vulnerable and should be protected from others who used her to express their own wants or needs. Review of the behavior/trauma care plan, initiated 1/11/16 and revised 4/22/25, revealed Resident #35 had a history of sexual abuse from childhood. She would at times exhibit verbal aggression, self isolation, crying and sadness. Interventions included allowing the resident time to vent and express herself and cry, offering reassurance and attempting to find out what triggered the episode and having the resident removed from the present situation and taken to a private quiet area. Review of the at-risk for abuse care plan, initiated 8/7/25 and revised on 9/30/25, revealed Resident #35 was at risk for abuse related to a diagnosis of intellectual disabilities. The resident could become upset if other residents made derogatory remarks at her. Interventions included assessing the resident regularly and as needed for signs of abuse, investigating any concern or change in functional or mental status as those could be a sign of abuse and observing for and reporting any changes in mental status caused by situational stressors.-The care plan failed to identify the episodes of verbal aggression by Resident #3 towards Resident #35 on 12/23/25 and 12/31/25 (see facility investigations above) and the interventions implemented to prevent further verbal abuse incidents. A review of Resident #35's EMR, from 12/23/25 to 12/31/25, revealed the following;Review of the December 2025 behavior monitoring documentation revealed Resident #35 had three episodes of crying and sadness on 12/23/25, the date of the first verbal abuse incident with Resident #3. The 12/23/25 nurse progress note revealed Resident #35 was sitting in the dining room when Resident #3 entered the dining room and passed Resident #35’s table. Resident #3 told Resident #35”You are a big (expletive) baby, all you do is cry.” When staff intervened, Resident #3 became disrespectful and unable to be redirected and began cursing at staff and refusing to leave the dining room. Staff stayed with him until he agreed to leave the dining room. Resident #3 said he knew he made the comment because he could do what he wanted. After the incident, Resident #35 was tearful. -Review of Resident #35’s EMR failed to reveal documentation of the incident with Resident #3 on 12/31/25.-Further review of Resident #35’s EMR revealed no social services involvement or documentation entries related to the two verbal abuse incidents in December 2025 between Resident #3 and Resident #35. E. Staff interviewsLPN #1 was interviewed on 5/19/26 at 10:15 a.m. LPN #1 said she witnessed the verbal incidents between Resident #35 and Resident #3 (on 12/23/25 and 12/31/25. She said Resident #3 had mocked Resident #35 and when Resident #35 told Resident #3 to be quiet, he called her a fat (expletive). She said Resident #35 came to nursing staff and complained about Resident #3 because he was calling her names. She said there had not been any recent incidents between the two residents that she knew of and Resident #35 was not afraid of Resident #3 and would try to stand up for herself. LPN #1 said since the incidents in December 2025, Resident #35 had moved to a different table in the dining room to not be in close proximity to Resident #3. She said any form of abuse, whether it was resident-to-resident or staff-to-resident, was to be reported immediately to the NHA.Certified nurse aide (CNA) #1 was interviewed on 5/19/26 at 2:30 p.m. CNA #1 said staff were required to complete monthly in-service training that included abuse and dementia training. She said if she witnessed abuse of any kind, whether it was resident-t- resident or staff-to-resident, she would report it immediately to her charge nurse and the NHA. She said if she witnessed two residents involved in a verbal or physical altercation, she would separate them to keep them safe. She said if new interventions were implemented after a resident-to-resident altercation, those interventions were relayed to the staff in writing as education and were passed on verbally during shift-to-shift report. She said the nurses alerted staff of any new changes with residents. She said even though there had been verbal altercations between Resident #3 and Resident #35, Resident #35 had tried to keep to her normal routine and would avoid Resident #3 if at all possible. The nurse practitioner was interviewed on 5/19/26 at 4:00 p.m. The nurse practitioner said it had been a while since she had been notified of any altercations between Residents #3 and Resident #35. She said since the facility moved Resident #3 to a room at the end of the Juniper hall, his behavior had diminished greatly. She said residents did not walk past the doorway of his room and he was not mocking other residents when he would see them in the hall. She said Resident #35 now sat in the dining room with her back to Resident #3 so there was no eye contact between them and less chance for a negative interaction with him. The NHA was interviewed on 5/20/26 at 2:50 p.m. The NHA said she thought the reason for the two occurrences in December 2025 between Resident #3 and Resident #35 was because staff tried to have Resident #3 move to another table in the dining room, away from the entrance. She said he agreed at first, but then would go back to the first table near the entrance where Resident #35 would walk by and he would say demeaning things to her. The NHA said Resident #3 finally agreed to sit at a table at the back of the dining room and since then, there had been no further negative interactions between them. She said Resident #35 now sat at a table on the other side of the dining room, away from Resident #3, with her back to him. She said care plans should be updated with interventions after incidents occurred so that staff were aware of changes. The NHA said Resident #35’s care plan had not been updated after the two incidents in December 2025.

Based on observations, record review and interviews, the facility failed to ensure residents were free from chemical restraints for one (#7) of five residents out of 24 sample residents. Specifically, the facility failed to ensure Resident #7, who was receiving an antipsychotic medication, received appropriate monitoring to ensure signs and symptoms of tardive dyskinesia (involuntary movements that can be caused by taking antipsychotic medications) did not worsen. Findings include: I. Professional reference According to the National Institute of Health (NIH) National Library of Medicine's Impact of A Pharmacist-Driven Tardive Dyskinesia Screening Process (7/16/21), retrieved on 5/26/26 from https://pmc.ncbi.nlm.nih.gov/articles/PMC8287863/#s1,“According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), tardive dyskinesia (TD) is defined as involuntary movements generally of the tongue, lower face, jaw, torso, and extremities that are developed from the use of antipsychotics. These movements can either be choreiform (rapid and jerky) or athetoid (slow, snakelike, and writhing). Tardive dyskinesia (TD) is defined as involuntary movements that can develop with prolonged antipsychotic use. Several studies have investigated risk factors that may be associated with tardive dyskinesia, including age, sex, and long-term antipsychotic use. ”II. Facility policy and procedure The Psychotropic Medication Use policy and procedure, revised February 2025, was provided by the nursing home administrator (NHA) on ) on 5/21/26 at 11:32 a.m. It read in pertinent part, “Residents are monitored for adverse consequences associated with psychotropic medications, including neurologic effects such as agitation, distress, extrapyramidal symptoms, neuroleptic malignant syndrome, Parkinsonism, tardive dyskinesia and cerebrovascular events. If a psychotropic medication is identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication should be discontinued. If the medication is not discontinued, the rationale for this decision must be documented.”III. Resident #7A. Resident status Resident #7, age 68, was admitted on 4/28/25. According to the May 2026 computerized physician orders, diagnosis included type 1 diabetes mellitus with ketoacidosis, mild cognitive impairment, bipolar disorder and hypertension. The 3/11/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He used a cane. He required supervision with eating, oral hygiene, toileting, showering and personal hygiene. The MDS assessment revealed the resident had received antipsychotic medications during the seven-day assessment look-back period. B. Resident interview and observation Resident #7 was interviewed on 5/18/26 at 10:08 a.m. During the interview, Resident #7 was smacking his lips. At the end of the interview, Resident #7 said he had noticed his lips smacking over the last couple of months. He said it was annoying when his lips smacked and the facility did not tell him what they were doing to help him not smack his lips. C. Record review The psychotropic and anticonvulsant care plan, initiated on 5/21/25 and revised on 6/28/25, revealed Resident #7 took psychotropic medications related to his bipolar disorder. Interventions included monitoring for behaviors, administering medications per physician orders, and observing closely for side effects of quetiapine, including extrapyramidal symptoms (EPS), such as tremors, restlessness, and involuntary movement of mouth or tongue and periodically complete the AIMS (abnormal involuntary movement scale) evaluation for EPS. Review of Resident #7’s 4/28/26 AIMS assessment revealed a score of 13, indicating the resident’s movements were clear, prominent and widespread. The assessment revealed the resident had moderate facial and oral movements around his lips and perioral area, such as smacking, around his jaw, such as biting and mouth opening and around his tongue. His lower legs were moderate movements, such as foot tapping. The assessment revealed the resident was aware of mild distress. -However, according to record review and interviews, Resident #7 had been exhibiting signs of tardive dyskinesia prior to 4/28/26 (see interviews and record review below). Review of Resident #7’s May 2026 CPO revealed the following physician’s orders related to antipsychotic medications: Depakote extended release (ER) 500 milligrams (mg) tablet. Take two tablets by mouth at bedtime for bipolar disorder, ordered 12/6/25. Seroquel 25 mg tablet. Take three tablets by mouth at bedtime, ordered 12/9/25. Haldol 1mg. Take one tablet by mouth every eight hours as needed for agitation related to bipolar mania for 14 days, ordered 5/18/26. Monitor the following agitation behaviors. Takes Haldol as needed every shift for 14 days, ordered 5/18/26. Monitor the following behaviors related to Seroquel: agitation, increase in complaints, elopement, delusions, aggressions, ordered 9/25/25. Observe closely for side effects of Seroquel, including dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling, EPS symptoms, every shift, ordered 4/28/25. Review of Resident #7’s electronic medical record (EMR) revealed nursing staff observed the resident’s lip smacking on 3/11/26, 3/17/26, 3/26/26, 4/15/26, 5/4/26 and 5/18/26. -However, according to staff interviews and record review, Resident #7’s physician was not notified that the resident was exhibiting symptoms of tardive dyskinesia. -A review of Resident #7’s EMR did not reveal any documentation to indicate the resident had not been seen by a psychiatrist or behavioral health consultant related to his diagnosis or his tardive dyskinesia since 3/18/26. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 5/19/26 at 2:17 p.m. LPN #2 said she was familiar with Resident #7. She said when Resident #7 had a side effect from a psychotropic medication, she documented the side effect on the resident’s treatment administration record (TAR) and as a progress note. LPN #2 said she had not seen Resident #7 smack his lips for a while. LPN #2 said she thought he smacked his lips when he took Haldol. LPN #2 said an AIMS assessment was completed quarterly when a resident was on antipsychotic medications. She said the assessment determined if the resident exhibited signs of tardive dyskinesia. LPN #2 said the assessment was done on the computer and if the resident's score indicated signs of tardive dyskinesis, she was not sure what the next step was. LPN #2 said she thought the director of nursing (DON) reviewed all AIMS assessments. LPN #2 said if she noticed tardive dyskinesia, she would document it on the TAR and notify the physician. She said the physician was notified because the physician could look at the resident’s medications to see if there were any recommendations to change the resident’s medications. The interim DON was interviewed on 5/20/26 at 3:15pm. She said an AIMS assessment was completed at admission, when a resident started a new antipsychotic medication and every six months. The interim DON said an AIMS assessment was completed to monitor for adverse reactions from antipsychotic medications. She said if a resident scored high, the physician was notified to see if a medication should be slowly titrated before starting a new medication. The interim DON said if a nurse noticed a side effect from a psychotropic medication, the nurse should notify the physician so the physician could assess and determine the best recommendation to reduce the adverse effects. She said nurses should document side effects observed and the physician notification as a progress note. The interim DON said she started working at the facility on 5/17/26 and she was not familiar with Resident #7. She said she would look into the resident's medical record. V. Facility follow upOn 5/20/26 at 4:28 p.m. the interim DON completed a new AIMS assessment for Resident #7 which revealed the resident scored a two. The interim DON said despite the resident’s AIMS score being lower, the nurses who observed the lip smacking on 3/11/26, 3/17/26, 3/26/26, 4/15/26, 5/4/26 and 5/18/26 should have notified the physician about the symptoms.

Based on record review and interviews, the facility failed to take appropriate corrective actions, as a result of abuse investigations, for four of nine abuse allegations. Specifically, the facility failed to take appropriate corrective action following the investigations of four verbal abuse incidents by Resident #3 towards Resident #25 on 12/15/25 and 12/21/25, and Resident #35 on 12/23/25 and 12/31/25, to ensure that verbal abuse did not recur. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, revised 9/22, was provided by the nursing home administrator (NHA) on 5/21/26 at 11:32 a.m. It read in pertinent part, “All allegations are thoroughly investigated. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The individual conducting the investigation reviews the documentation as evidence, reviews the resident’s medical record to determine the resident’s physical and cognitive status at the time of the incident and since the incident, observes the alleged victim, interviews the person reporting the incident, interviews any witnesses, interview the resident, interview staff members, interview the staff member who had contact with the resident, reviews all events leading up to the alleged incident and documents the investigation completely and thoroughly. II. Incidents of verbal abuse between Resident #25 and Resident #3 on 12/15/25 and 12/21/25 The investigations of the resident-to-resident altercations between Resident #25 and Resident #3 on 12/15/25 and 12/21/25 were provided by the NHA on 5/18/26 at approximately 2:00 p.m. A. 12/15/25 facility investigation The facility’s abuse investigation, dated 12/15/25, documented that at approximately 5:40 p.m. Resident #25 and #3 were in the dining room eating dinner when a verbal altercation occurred. Resident #3 was walking out of the dining room and Resident #25 looked at Resident #3, which triggered Resident #3 and Resident #3 began yelling foul language at Resident #25. The situation escalated and both residents started yelling at each other. During the altercation, both residents held silverware in a threatening manner. There was no physical contact between the residents during the altercation. The facility staff separated both residents prior to notifying law enforcement. They provided Resident #25 with emotional support. Resident #25 was interviewed and said he would avoid Resident #3. Resident #3 was interviewed and said he did not remember the verbal altercation. The investigation revealed facility staff did not observe changes in Resident #25’s behavior following the incident and he remained at baseline. The investigation revealed that five other residents were interviewed and they did not report any ongoing safety concerns. The investigation documented that the facility substantiated that the allegation of resident-to-resident verbal abuse occurred. The interventions implemented after the incident for both residents included continued 15-minute checks, adjusting Resident #3’s medications and educating staff regarding de-escalation techniques.-However, the investigation failed to reveal documentation of the education provided to staff regarding de-escalation techniques as a corrective action in order to prevent a recurrence of verbal abuse. Cross-reference F600 for failure to keep residents free from abuse. B. 12/21/25 facility investigationThe facility’s abuse investigation, dated 12/22/25, revealed that on 12/21/25 at 5:35 p.m. a verbal altercation occurred in the dining room between Resident #25 and #3. Resident #3 walked into the dining room to eat dinner and said to Resident #25 he was a fat (expletive word) and that he was going to kick his (expletive word). Resident #25 yelled back at Resident #3 using foul language. An unknown registered nurse (RN) entered the dining room, separated the residents, ensured the safety of the residents and contacted law enforcement. At that time, both residents denied feeling fearful. The investigation revealed both residents were already on 15-minute checks prior to the altercation. Due to the occurrence, Resident #3 was escorted to and from meals. The following morning, Resident #25 said he could not ignore it anymore because Resident #3 kept coming for him and would not leave him alone. Resident #25 said he would slit Resident #3’s throat if he came for him again. Staff educated Resident #25 that the statement was inappropriate and he said he understood. The facility staff provided emotional support to Resident #25. The investigation revealed that Resident #3 was interviewed and said Resident #25 started the altercation and he was not going to let him talk to him that way. The investigation documented that the facility substantiated that the allegation of resident-to-resident verbal abuse occurred. The interventions put into place after the incident included continued 15-minute checks, keeping the residents separated, escorting Resident #3 to and from meals and educating staff regarding de-escalation techniques specific to Resident #3.-However, Resident #3 was already on 15-minute checks and educating staff on de-escalation techniques had already been documented as an intervention following the 12/15/25 verbal abuse incident with Resident #25 (see above). The 12/15/25 interventions proved to be ineffective in preventing the second verbal abuse incident between Resident #3 and Resident #25 on 12/21/25.-Additionally, the facility failed to determine an appropriate corrective action following the 12/15/25 and 12/21/25 verbal abuse incidents with Resident #25 in order to prevent a third occurrence of verbal abuse involving Resident #3 (towards Resident #35 -see below). III. Incidents of verbal abuse between Resident #35 and Resident #3 on 12/23/25 and 12/31/25The investigations of the resident-to-resident altercations between Resident #35 and Resident #3 on 12/23/25 and 12/31/25 were provided by the NHA on 5/18/26 at approximately 2:00 p.m. A. 12/23/25 facility investigationThe facility’s investigation report revealed that on 12/23/25 at 12:18 p.m. Resident #3 was escorted with a nurse to the back of the dining room to a single table. Resident #3 sat for a short time by himself with the kitchen staff. Resident #3 called Resident #35 “a big (expletive) baby” and told Resident #35 ”All you do is cry.” Resident #3 mumbled to himself and staff asked Resident #3 to stop. When Resident #3 did not stop, the charge nurse and the director of nursing (DON) went to the dining room to talk to the resident. Resident #3 was not respectful or redirectable. Resident #3 continued to be disruptive in the dining room, swearing at staff and making comments and refusing to leave the dining room, eat in his room, keep his comments to himself and be kind to others. Staff stayed with Resident #3 until he agreed to leave and go to his room. Resident #35 cried when Resident #3 cursed at her. The facility substantiated the verbal abuse. Cross-reference F600 for failure to keep residents free from abuse. Interventions implemented after the incident included placing both residents on 15-minute checks, moving them to a separate hallway, and offering behavioral health services. Additional interventions included assisting Resident #3 to and from the dining room, additional observation while in the dining room, offering meals in the private dining room, offering extra behavioral health visits during the holidays as his behaviors may be due to depression due to missing his spouse, medications adjusted and recent gradual dose reduction (GDR). -However, 15-minute checks, assisting Resident #3 to and from the dining room and medication adjustments were implemented following the 12/21/25 incident with Resident #25 (see above), before the 12/23/25 incident with Resident #35. -There was no documentation behavioral health services were offered to Resident #3 until 1/28/26, more than 30 days after the incident. -The investigation failed to reveal documentation of education provided to staff regarding the interventions implemented, including additional observations while in the dining room and offering meals in the private dining room. -A review of Resident #3’s electronic medical record (EMR) revealed there was no documentation to offer meals to the resident in the private dining room.-The facility failed to determine an appropriate corrective action following the 12/15/25 and 12/21/25 verbal abuse incidents with Resident #25, and the 12/23/25 verbal abuse incident with Resident #35, which resulted in a fourth verbal abuse incident involving Resident #3 (again towards Resident #35) seven days later (see below). B. 12/31/25 facility investigationReview of the 12/31/25 facility investigation documented a verbal altercation between Resident #3 and Resident #35. The incident occurred on 12/31/25 in the dining room when Resident #3 began mocking and making fun of Resident #35. The investigation did not reveal what was said between Resident #3 and Resident #35. When interviewed by facility staff Resident #35 again began to cry and said Resident #3 was making fun of her. She was escorted out of the dining room. When staff spoke to Resident #3 he began yelling at the nurse and refused to leave the dining room. Five residents were interviewed and denied having had verbal altercations with Resident #3 or that they were fearful of him. The investigation did not include staff interviews. Both residents were placed on frequent 15-minute checks. The residents’ responsible parties, the police, and the physicians were notified. The facility substantiated the verbal abuse.-The facility identified and substantiated four incidents of verbal abuse involving Resident #3. However, the facility failed to identify appropriate corrective actions to prevent further incidents of verbal abuse involving Resident #3. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 5/19/26 at 2:17 p.m. LPN #2 said she reported abuse to the NHA. LPN #2 said she should report abuse as soon as the residents were determined to be safe. She said once abuse was reported, an investigation was started by the nurse and then the NHA and the DON completed the investigation. LPN #2 said she started the investigation by writing what happened, notifying the physician, the police and the resident’s representative. LPN #2 said she knew what interventions were put into place by verbal communication. LPN #2 said there was a communication section in the facility’s electronic records system for nurses to read at the start of their shift. LPN #2 said she was not sure if certified nurse aides (CNA) or other departments had access to the communication section. LPN #2 said she was not educated on resident-specific interventions to prevent resident-to-resident altercations, but there was online training that reviewed different interventions for the staff to try. The interim DON was interviewed on 5/20/26 at 3:15pm. The interim DON said abuse should be reported to the NHA as soon as possible. She said once abuse was reported, the nurse should start an incident file including what was done to keep the residents safe, notifying the physician, the resident’s representative, the NHA and the DON. The interim DON said there should be a statement obtained from the assailant, the victim and any witnesses. The interim DON said there should be documentation of the statements obtained. The interim DON said the interventions to keep the resident safe should be documented in the resident’s care plan and Kardex (an abbreviated care plan). The interim DON said the interviews should have a date, time and signature of who completed the interviews and the statements. She said the statements should be by the assailant, the victim or the witness if possible and it should have the date and the time when the statements were obtained. The interim DON said when she was a DON, she would complete the staff interviews and she interviewed whoever was working including nursing, dietary staff and housekeeping. She said she used the incident report to document initial interventions to keep all pertinent information in one place. The interim DON said there should be an interdisciplinary team (IDT) discussion the following day after the alleged abuse to determine what additional interventions should be in place. She said she did that so the residents' care plans were updated at the same time. The interim DON said she started working at the facility on 5/17/26, and she was not very familiar with the incidents involving Resident #3. The interim DON said she reviewed the incident reports for the verbal abuse incidents between Resident #25 and Resident #3 on 12/15/25 and 12/21/25 and the verbal abuse incidents between Resident #35 and Resident #3 on 12/23/25 and 12/31/25. She said the investigation was not thorough because it was not clear on what interviews were completed, what statements were obtained or how staff were educated on the interventions to keep the residents safe and to prevent a recurrence. The NHA was interviewed on 5/19/26 at 5:05 p.m. The NHA said staff reported abuse to the NHA. The NHA said staff should report abuse as soon as the residents were determined to be safe. She said once abuse was reported, an investigation was started by the nurse and then the NHA and the DON completed the investigation. The NHA said the nurse was responsible for documenting what happened, notifying the physician, the police and the resident’s representative. The NHA said staff knew what interventions were put into place by verbal communication and. The NHA said nurses had access to a communication section in their electronic records system for nurses to read at the start of their shift. The NHA said CNAs or other departments did not have access to the communication section and a paper communication binder was used for educating CNAs. The NHA said investigating an alleged abuse was divided between the DON and herself. She said sometimes the SSD helped as well. The NHA said the questions asked were standard depending on the type of abuse. The NHA said if the type of abuse was verbal, there was a standard set of questions to ask staff and residents. The NHA said staff were interviewed who worked in the unit, were familiar with the resident and included housekeeping and dietary staff. The NHA said the unit nurses determined the initial intervention. The NHA said she did not know if she had access to the electronic records for the communication page to show how nurses were educated. The NHA said she would look to see how CNAs were educated. The NHA was interviewed a second time on 5/20/26 at 9:30 a.m. The NHA said she was unable to locate the electronic records for the communication page to show how the nurses were educated. The NHA said the interventions should be care planned and said the care plans for Resident #25, Resident #35 and Resident #3 could use improvement to reflect the interventions that were put into place after the resident-to-resident altercations in December 2025.

Based on record review and interviews, the facility failed to provide and document sufficient discharge preparation for one (#22) of one resident reviewed for a safe and orderly discharge out of 24 sample residents. Specifically, the facility failed to ensure a written bed hold notice was provided to Resident #22 and/or her representative at the time of the resident’s transfer to the hospital. Findings include:I. Facility policy and procedureThe Bed-Holds and Returns policy, revised October 2022, was provided by the nursing home administrator (NHA) on 5/21/26 at 11:57 a.m. It read in pertinent part,“All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident’s bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice at the time of transfer (or, if the transfer was an emergency, within 24 hours). The written bed-hold notices provided to the residents/representatives explain in detail: the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (forMedicaid residents); the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and the facility return policy.“The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source. Residents who seek to return to the facility within the bed-hold period defined in the state plan are allowed to return to their previous room, if available. “Residents who seek to return to the facility after the state bed-hold period has expired are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident still requires the services provided by the facility and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services.”II. Resident #22A. Resident statusResident #22, age greater than 65, was admitted on 1/15/19, readmitted on 4/29/26 and transferred to the hospital on 5/17/26. According to the May 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), mild intermittent asthma, acute upper respiratory infection and respiratory syncytial virus (RSV). The 4/26/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had no impairment of her upper or lower extremities and used a wheelchair for mobility. She required partial to moderate staff assistance with activities of daily living (ADL). B. Record reviewReview of Resident #22’s May 2026 CPO revealed a physician’s order, dated 5/17/26, to transfer the resident to the emergency room for evaluation and treatment of low oxygen saturation, cough, and shortness of breath. The 5/17/26 at 11:00 a.m. nursing progress note revealed Resident #22 was experiencing increased cough, shortness of breath and she was in respiratory distress. She was transported to the hospital for evaluation. Review of Resident #22’s electronic medical record (EMR) profile revealed she was her own responsible party. -Review of Resident #22’s EMR revealed no documentation to indicate Resident #22 and/or her representative were provided with a written bed hold notice at the time of the resident’s transfer to the hospital on 5/17/26. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 5/17/26 at 2:00 p.m. RN #1 said Resident #22 was transferred to the hospital around lunch time on 5/17/26 for respiratory distress. She said the resident had several instances in the past where she had to be transported to the hospital for respiratory issues and the most recent occurrence was in April 2026. She said she did not know that a bed hold form had to be completed with the resident prior to her being transported to the hospital. She said she had not been made aware of the form and did not know what was required on the form. The social services director (SSD) was interviewed on 5/19/26 8:25 a.m. The SSD said it was her responsibility to complete a bed hold form when a resident required a transfer to the hospital. She said the resident or their responsible party were to sign the form that indicated they understood the bed hold policy. She said Resident #22 was her own responsible party and she did not complete a bed hold form with the resident when she was transferred to the hospital (on 5/17/26). She said at the time of Resident #22’s transfer, getting the bed hold form signed did not cross her mind, and she did not notify the facility’s frequent visitor of the transfer. She said she had not implemented a good process for completion of the bed hold form for the long-term care residents when they required a hospital transfer. The frequent visitor was interviewed on 5/19/26 at 8:47 a.m. The frequent visitor said he was not notified that Resident #22 had been transferred to the hospital on 5/17/26. He said he received notices when a resident was discharged home, but he was not normally notified of hospital transfers unless there was a reportable incident associated with the transfer.

Based on observations, record review and interviews, the facility failed to ensure residents who required respiratory care received care consistent with professional standards of practice for one (#10) of two residents out of 24 sample residents. Specifically, the facility failed to maintain, clean, sanitize and properly store Resident #10's nebulizer machine (breathing treatment device) and mask. Findings include:I. Resident #10A. Resident statusResident #10, age 85, was admitted on 3/7/26. According to the May 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (chronic lung disease), dependence on supplemental oxygen, and hypertension (high blood pressure). The 3/3/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment documented the resident used continuous oxygen therapy. B. Resident interview and observationsResident #10 was interviewed on 5/17/26 at 3:20 p.m. Resident #10 said he did not know how often staff cleaned his nebulizer mask. Resident #10's nebulizer machine was observed on the television stand in the resident’s room. The nebulizer mask had visible brown residue buildup inside it. On 5/18/26 at 2:35 p.m. Resident #10's nebulizer machine remained on the television stand in the resident’s room. The nebulizer mask had not been cleaned. The mask had visible brown residue buildup inside it and was greasy. Resident #10 said he did not know whether staff cleaned the nebulizer equipment after use. C. Record reviewA review of Resident #10's May 2026 CPO revealed the following physician’s order:-Albuterol Sulfate nebulization solution (2.5 milligrams/3 milliliters) 0.083%, one vial inhale orally via nebulizer, ordered on 5/6/26.-However, there were no physician’s orders for cleaning, sanitizing or storing the nebulizer equipment. Resident #10's respiratory care plan, initiated 2/27/26, revealed Resident #10 had an impaired respiratory status. Pertinent interventions included administering medications as ordered, monitoring for signs and symptoms of respiratory distress and reporting to the physician, monitoring lung sounds for wheezing or crackles as needed, providing oxygen as needed when the resident exhibited signs and symptoms of difficulty breathing and treatments as ordered by the physician.-The care plan failed to include interventions related to cleaning, sanitizing or storing the resident’s nebulizer equipment. II. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 5/19/26 at 9:43 a.m. CNA #3 said nurses were responsible for sanitizing nebulizer equipment. CNA #3 said nebulizer equipment was usually taken apart and cleaned between treatments. CNA #3 said brown residue buildup inside a nebulizer mask was not sanitary. CNA #3 said if a resident’s respiratory equipment was dirty, she would notify the nurse and obtain new equipment. Licensed practical nurse (LPN) #1 was interviewed on 5/19/26 at 9:54 a.m. LPN #1 said nurses were responsible for rinsing nebulizer equipment. LPN #1 said nebulizer equipment should be rinsed, taken apart and allowed to air dry after breathing treatments. LPN #1 said the night shift changed the nebulizer tubing and masks and provided a new one. LPN #1 said visible residue buildup inside nebulizer masks created a risk that the resident could inhale contaminants. LPN #1 said Resident #10's nebulizer treatment was ordered every six hours as needed and the resident’s last breathing treatment was administered on 5/5/26, during the night shift. LPN #1 said staff should discard nebulizer equipment with visible buildup or contamination and obtain new equipment. The nursing home administrator (NHA) was interviewed on 5/19/26 at 10:55 a.m. The NHA said oxygen tubing changes were documented, however nebulizer equipment cleaning was not documented. The NHA said nursing staff received infection control training through SNF(skilled nursing facility) Clinic as needed. The NHA said respiratory equipment with visible buildup should be replaced because it was important for infection control. The NHA said nurses were responsible for ensuring nebulizer equipment remained clean and sanitary after each use. The NHA said Resident #10’s nebulizer mask should have been discarded and replaced with a new mask.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#37) of one resident reviewed for pain out of 24 sample residents. Specifically, the facility failed to:-Ensure a thorough pain assessment was completed that identified Resident #37’s history of pain and its treatment, history of addiction, characteristics of pain and the impact of pain on the resident’s quality of life; -Identify Resident #37’s goals for pain management and the resident’s acceptable level of pain; -Ensure Resident #37’s location of pain was consistently identified when administering pain medication to the resident; and, -Ensure Resident #37’s pain medication was administered as ordered and needed, based on the resident’s observed status. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy and procedure, revised April 2025, was provided by the nursing home administrator (NHA) on 5/21/26 at 11:32 a.m. It read in pertinent part, “Pain assessments should include the resident’s pain history and prior treatments, including pharmacological and non-pharmacological interventions. The assessment should identify whether the pain is acute, subacute, or chronic and evaluate pain characteristics such as location, intensity, description, pattern, frequency, timing, and duration. The assessment should also address the impact of pain on function, mobility, mood, sleep, and quality of life; factors that worsen or relieve pain; associated symptoms; history of opioid use disorder; current medical conditions and medications; and the resident’s pain management goals and satisfaction with pain control.“When establishing a pain medication regimen, considerations include starting with lower doses and increasing as needed, administering medications routinely rather than only as needed, combining long-acting medications with as needed medications for breakthrough pain, using non-narcotic and narcotic analgesics together when appropriate, and implementing measures to reduce or prevent adverse medication effects, such as bowel regimens for opioid-related constipation.”II. Resident #37A. Resident status Resident #37, age 80, was admitted on 2/6/23. According to the May 2026 computerized physician orders (CPO), diagnoses included Parkinson’s disease, Lewy body neurocognitive disorder with dementia and behavioral disturbances (progressive brain disease caused by abnormal protein clumps that damage nerve cells), anxiety, depression, type 2 diabetes, hypertension, lumbar radiculopathy and sciatica (irritation or compression of nerve root in the lower spine and radiating leg pain caused by sciatic nerve), tremors, encephalopathy (damage to the brain) and history of lumbar compression fracture (vertebrae in lower spin collapses often due to osteoporosis or trauma). The 4/23/26 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long-term memory problems and her cognitive skills for daily decision making were severely impaired. The assessment revealed Resident #37 had a pain medication regimen and did not receive as needed pain medications. The assessment revealed non-medication interventions were provided to the resident. The assessment section indicating the pain frequency, the effect on daily activities, the numeric scale and pain intensity was not completed. B. Observations During a continuous observation on 5/17/26, beginning at 4:30 p.m. and ending at 5:52 p.m., the following observations were made in the facility’s dining room: Resident #37 was observed at a dining room table close to the door to the outside. An unknown staff member was assisting the resident with eating her meal. Prior to the meal, the resident was observed biting her clothing protector. No staff members tried to redirect the resident from biting her clothing protector. During a continuous observation on 5/18/26, beginning at 2:22 p.m. and ending at 4:25 p.m., the following observations were made: From 2:22 p.m. to 4:10 p.m. Resident #37 was observed lying on her back in her bed. Resident #37 was observed leaning to the left side of the bed and her back was not touching the bed. At 3:21 p.m. certified nurse aide (CNA) #2 told licensed practical nurse (LPN) #2 that Resident #37 kept trying to crawl out of her bed and was trying to hold on to the left side of her mattress. From 4:10 p.m. to 4:25 p.m. Resident #37 was observed in her high back wheelchair in her room and the hallway in front of her room. At 4:12 p.m. Resident #37 was observed with her left leg shaking more than her right leg. At 4:23 p.m. Resident #37 was observed with her right hand trying to hold the toes on her right foot. On 5/19/26 at approximately 1:52 p.m. Resident #37 was observed in her high back wheelchair in the hallway in front of her room. Resident #37 was observed biting her shirt and lifting her shirt up. CNA #2 told Resident #37 to stop biting her shirt and assisted the resident to lower her shirt. At 1:53 p.m. Resident #37 stopped biting her shirt and started to bite her lips. CNA #2 went to LPN #2 and said Resident #37 was in pain. LPN #2 came over and assessed the resident for pain. CNA #2 said she thought Resident #37 bit her clothes because she was in pain. As CNA #2 talked about Resident #37’s pain, Resident #37 leaned forward to touch and hold the toes on her left foot. CNA #2 said Resident #37’s legs did not always shake but today, 5/19/26, the resident’s legs were more shaky than usual. C. Record Review Resident #37’s pain care plan, initiated 7/28/25 and revised 7/29/25, revealed the resident had the potential for acute and chronic pain. She was able to verbalize she was in pain. If she had pain, she became restless and was at risk for falls. She had a stable fracture to her thoracic (T) 3 and T4 vertebrae (middle back), chronic fracture to her T8 vertebra and a stable fracture to her lumbar (L)1 vertebra (lower back) and a sternal fracture (thoracic and lumbar spine fractures on the mid-back and lower back region, breastbone). Interventions included administering medications per physician orders and monitoring for effectiveness, determining what the resident’s optimal pain level was for day-to-day function, ensuring the resident’s fentanyl patch (pain patch) was in a location, monitoring for any changes in usual activities, monitoring for changes in behavior that may be indicators of pain, monitoring for changes in mood that may be indicators of pain, monitoring for changes in sleep patterns, monitoring for verbal and non-verbal signs and symptoms relating to pain, offering non-pharmacological interventions to relieve pain and providing rest periods to prompt relief, sleep and relaxation. -The care plan did not identify the resident’s goal for pain management and acceptable level of pain. Resident #37’s behavior care plan, initiated 4/20/23 and revised 8/12/25, revealed the resident had a behavior of constantly chewing on the neck of her shirt and blanket. Staff tried to redirect her, but she continued. Interventions included assessing and anticipating the resident’s needs, assessing the resident’s understanding of the situation, encouraging as much participation and interaction by the resident during care activities and offering non-pharmacological behavior interventions prior to behavior medication administration. The 1/8/26 pain assessment revealed Resident #37 did not have evidence of pain and the FACES pain rating scale (a self-reported assessment tool that uses a series of six facial expressions to measure pain intensity) was used. Pharmacological interventions included administering acetaminophen, Sombra and fentanyl patches for pain management. -However, the prior non-pharmacological interventions section of the assessment was not completed, the pharmacological interventions section failed to indicate the use of tramadol, the resident's acceptable pain level was not completed and the pain location section failed to indicate the resident’s leg pain. The 4/8/26 pain assessment revealed Resident #37 expressed complaints of back and leg pain at times. The resident was unable to communicate the intensity of her pain. The pharmacological interventions section indicated the resident used gabapentin and Tylenol. The pain location section, including the pain duration and frequency of pain revealed the resident had pain in her upper to mid-vertebrae. Relieving factors included position changes and medication. -However, the prior non-pharmacological interventions section was not completed, the pharmacological interventions section failed to indicate the use of a fentanyl patch, tramadol, Sombra gel and acetaminophen suppositories, the pain location section failed to indicate the resident’s leg pain and the resident’s acceptable pain level section was not completed. Review of Resident #37’s May 2026 CPO revealed the following physician’s orders: Fentanyl transdermal patch 72-hour 12 microgram (mcg)/hour. Apply one patch transdermally in the morning every three days for pain, ordered 10/3/25. Gabapentin 300 milligrams (mg) capsule. Take one capsule by mouth in the afternoon for painful legs, ordered 11/15/24. Acetaminophen 500 mg tablet. Take two tablets three times a day by mouth for back pain, ordered 7/1/24 and discontinued 2/24/26. Acetaminophen 500 mg tablet. Take two tablets by mouth every eight hours as needed for pain control, ordered 2/24/26. Acetaminophen 650 mg suppository. Insert one suppository rectally every six hours as needed for pain. Do not exceed three grams of acetaminophen in 24 hours, ordered 7/28/25. Sombra natural pain relieving external gel 3%. Apply to legs, feet and back topically every four hours as needed for pain, ordered 11/15/24. Tramadol 50 mg tablet. Take one tablet by mouth every six hours as needed for pain, ordered 1/27/26. Check fentanyl patch placement every shift, ordered 8/26/25. Document pain every shift two times a day for pain, ordered 2/6/23. Observe closely for side effects of opioid medication use, ordered 10/3/25. Offer non-pharmacological pain interventions prior to pain medication administration. Non-pharmacological interventions include repositioning, pillows for support, cold compress and massage. Complete two times a day, ordered 3/19/24. -Review of Resident #37’s EMR did not reveal documentation indicating if the non-pharmacological interventions were effective or what interventions were attempted for the resident’s pain relief. Review of Resident #37’s medication administration records (MAR) from February 2026 to May 2026 revealed the following as needed pain medications were administered: Tramadol 50 mg was administered on 2/1/26, 2/2/26, 2/3/26, 2/8/26, twice on 2/13/26, 2/20/26, 2/24/26, 2/26/26, 2/27/26, 3/4/26, twice on 3/15/26, 3/24/26, 4/13/26, 5/4/26, 5/11/26 and 5/12/26. Acetaminophen 500 mg was administered on 4/17/26, 5/4/26 and 5/10/26 -However, there was no documentation indicating where the resident’s pain was located when the tramadol 50 mg or the acetaminophen 500 mg was administered to the resident. III. Staff interviews CNA #2 was interviewed on 5/19/26 at 1:52 p.m. CNA #2 said she was familiar with Resident #37. She said she thought Resident #37 bit her clothes because she was in pain. She said it was hard for Resident #37 to communicate when she was in pain. CNA #2 said she was not sure why Resident #37 bent forward to touch and hold her feet when she was in her wheelchair. CNA #2 said she must be uncomfortable but she was not sure why. CNA #2 said she told the nurse when she noticed the resident was uncomfortable. LPN #2 was interviewed on 5/20/26 at 5:52 p.m. LPN #2 said a pain assessment included if the resident had pain, using the Pain Assessment in Advanced Dementia (PAINAD )scale (an observational tool used by healthcare providers and caregivers to assess pain in patients with advanced dementia or severe cognitive impairments who cannot verbally communicate), what the resident’s acceptable level of pain was, where the pain was located, what non-pharmacological and pharmacological interventions were used and if the interventions were effective. LPN #2 said when pain medications were used as needed, the nurse found out where the resident had pain, tried non-pharmacological interventions first and if that was not effective, to offer an as needed pain medication to the resident. LPN #2 said she followed up with the resident to see if the pain medication was effective. LPN #2 said the location of pain should be documented on the MAR and she entered a progress note with a thorough explanation of the pain. LPN #2 said when a resident had multiple as needed pain medications and the resident was unable to communicate, she used the PAINAD and used her judgment on what medication to use based on the resident’s level of pain. LPN #2 said she was familiar with Resident #37. She said she thought the resident’s pain management goal was to have a pain level of zero and be comfortable. LPN #2 said Resident #37 had pain in her lower legs in the afternoon and had pain in her back. She said she knew Resident #37 had pain because she would vocalize pain, and demonstrate facial grimacing, biting, and grabbing or reaching out for things. LPN #2 said she used the stronger as needed pain medications, such as tramadol when Resident #37’s pain level was high based on the PAINAD scale. The interim director of nursing (DON) was interviewed on 5/20/26 at 3:15pm. The interim DON said a pain assessment covered the resident’s pain history, the pain impact on the resident’s life, the resident’s pain management goal, the acceptable level of pain and the location of pain. The interim DON said the assessment helped determine what interventions to use to help manage the resident’s pain. She said the assessment helped to determine if the pain medications were controlled in order to ensure a better quality of life for the resident. The interim DON said when administering as needed pain medications, a nurse should assess the resident to see if there was facial grimacing, guarding and what the nurse was actually seeing from the resident. The interim DON said the location of pain should be documented in a progress note and on the MAR. She said the nurse should attempt a non-pharmacological pain intervention and if the non-pharmacological intervention was ineffective, the pain medication could be attempted. The interim DON said it was hard for nurses to determine which pain medication to administer when residents had multiple pain medications ordered as needed. The interim DON said the physician should direct which pain medication should be administered. The interim DON said she started working in the facility on 5/17/26 and she was not familiar with Resident #37. She said she would review the residents' pain medication regimen and pain assessment.

Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial well being for one (#3) of seven residents out of 24 sample residents. Specifically, the facility failed to identify Resident #3’s history of depression to monitor and provide ongoing assessment to determine whether the care approaches met the emotional and psychosocial needs of the resident. Findings include: I. Resident #3 A. Resident status Resident #3, age 74, was admitted on 2/25/22 and readmitted on 12/7/25. According to the May 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and depressive disorder. The 3/10/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. He required partial assistance with bathing, dressing, and personal hygiene, and required supervision assistance with eating and toileting. The MDS assessment revealed the resident displayed verbal behaviors directed towards others during the assessment look-back period. The MDS assessment revealed the resident had depression based on the patient health questionnaire-9 (PHQ-9), a standardized, 9-question self-report tool used by healthcare providers to screen, diagnose, and measure the severity of depression.) Resident #3 reported he felt little interest or pleasure in doing things every day (12 to 14 days), felt down, depressed and hopeless every days, had trouble fall asleep or sleeping too much on seven to 11 days, felt tired or having little energy on two to six days, had a poor appetite or overeating on 12 to 14 days and felt bad about himself on two to six days during the assessment look-back period. The assessment revealed the resident took an antipsychotic medication and an antidepressant medication. The assessment revealed a gradual dose reduction was not attempted and was not documented as clinically contraindicated. B. Resident observations and interview On 5/17/26 at 3:00 p.m. Resident #3 was in his room. The room was dark with no lights on and the blinds closed. Certified nurse aide (CNA) #2 went into his room and spoke Spanish to the resident. On 5/17/26 at 5:01 p.m. Resident #3 was in the dining room. Resident #3 sat by himself in the corner of the dining room and did not engage with other residents. On 5/18/26 at 9:55 a.m. Resident #3 was lying in his bed and had his television turned on. The room was dark with no lights on and the blinds closed. Resident #3 said he stayed in his room most of the day and he did not like to participate in any facility activities. He said he liked to stay in his room because the other residents did not have the same interests as him. On 5/18/26 at 2:35 p.m. Resident #3 was in his room. The room was dark with no lights on and the blinds closed. CNA #2 went into his room and asked him if he wanted to attend the resident council meeting. Resident #3 said no. C. Record reviewThe dementia and behavioral care plan, initiated 5/17/22 and revised 2/3/26, revealed Resident #3 had verbally aggressive behaviors towards others and used threatening gestures. Pertinent interventions included approaching the resident in a calm manner, redirecting the resident when exhibiting behaviors and re-approaching after de-escalation, monitoring and documenting episodes of inappropriate behaviors, and providing non-pharmacological behavior interventions such as calm approach, positive reassurance, one-on-one interactions and a quiet environment. The psychotropic medication care plan, initiated 3/7/22 and revised 6/16/25, revealed Resident #3 was medicated daily with a psychotropic medication due to depression and self isolation. Interventions included monitoring for behaviors for Seroquel treatment, including calling out, offering non-pharmacological interventions for noted behaviors, such as calm approach, positive reassurance, one-on-one and quiet environment, encouraging resident to verbalize his feelings, establishing a consistent daily routine, and monitoring for side effects of antipsychotics and antidepressants. Monitoring for target behavior and documenting; monitoring for isolation throughout shift for Lexapro, providing psychiatry consult as needed, providing distraction and diversional activities and responding to concerns and feelingsThe depression care plan, initiated 5/17/22 and revised 10/6/25, revealed Resident #3 was at risk for alteration in psychosocial well-being related to depression and at times would self-isolate in his room. Interventions included allowing the resident to express his feelings, encouraging alternative communication opportunities with visitors, encouraging and providing activities of interest, monitoring for changes in psychosocial changes, notifying the physician of changes in mental status, offering behavioral services and talking with a therapist, PHQ-9 assessment quarterly and as needed. The 5/25/25 psychiatry behavioral health note revealed the facility was to encourage Resident #3 to attend activities by using a slightly more proactive approach, such as going into his room and saying “It is time to go to dinner” or “It is time to attend whatever activity is about to occur” rather than asking if he would like to go to dinner or to an activity. The facility was to respect the resident if he declined or refused.-However a review of Resident #3’s EMR did not reflect the recommended intervention. The 12/9/25 social services director (SSD) note revealed an assessment was completed for Resident #3 on 12/9/25. Resident #3’s advance directives were do not resuscitate with comfort focused treatment and no artificial nutrition. Resident #3 had an acute hospitalization for chronic obstructive pulmonary disease, depression, dementia, psychotic disturbance, mood disturbance, anxiety and other specified depressive episodes. Resident #3 was on Lexapro (an antidepressant medication) 20 milligrams (mg) daily in the morning for depressive episodes and Seroquel (an antipsychotic medication) 25 mg twice a day for verbal aggression. The facility would continue to monitor the resident for changes in mood and behaviors. Resident #3 could make his needs known and did leave his room more frequently and was eating in the dining room. He sat in the lobby and talked with others occasionally. The resident's family was involved with his care and attended care conferences by phone. The SSD continued to monitor the resident’s mood status. The SSD would encourage positive behaviors, continue the current plan of care and provide social emotional support as tolerated. Review of Resident #3’s PHQ-9 assessments revealed the following:The 9/18/25 PHQ-9 assessment revealed Resident #3 scored a nine out of 27, indicating the resident had mild depression. The 12/10/25 PHQ-9 assessment revealed Resident #3 scored a 14 out of 27, indicating the resident had moderate depression, which had increased since his previous PHQ-9 assessment. The 3/10/26 PHQ 9 assessment revealed the resident scored a 13 out of 27, indicating the resident continued to have moderate depression. -A review of Resident #3’s EMR did not reveal any documentation that addressed the resident’s PHQ-9 score and what follow up, interventions or services were offered to the resident. Review of Resident #3’s May 2026 CPO revealed the following physician’s orders: Escitalopram 20 mg (Lexapro, an antidepressant medication). Take one tablet in the morning, ordered 12/24/25. Seroquel 25 mg (an antipsychotic medication). Take one tablet three times a day for verbal aggression, ordered 1/14/26. Behavior monitoring for verbal outbursts throughout shift twice a day for behavior monitoring, ordered 6/14/22. Monitor for behaviors for Seroquel, including negative statements every shift, ordered 6/4/25. Monitor for adverse side effects of antipsychotic medications, ordered 5/10/24. Monitor for side effects of Lexapro, ordered 10/9/25. Monitor for isolation throughout shift for Lexapro every shift for behavior monitoring, ordered 8/29/24. Offer non-pharmacological interventions for noted behaviors. Interventions included calm approach, positive reassurance, one-on-one and quiet environment. Complete twice a day. Document “Y” for yes interventions attempted prior to medication administration and “N” for no interventions not attempted prior to medication administration, ordered 7/1/24. Escort in and out of the dining room for meals attending three times a day for behavior, ordered 12/22/25.-However, this intervention was not being implemented consistently by staff, which resulted in four verbal abuse incidents with other residents. Cross-reference F600 for failure to keep residents free from abuse. -A review of Resident #3’s medication administration records (MAR) and treatment administration records (TAR), from 12/1/25 to 5/20/26, revealed the resident exhibited behaviors and interventions that were not consistently offered and documented if interventions were effective. II. Staff interviews CNA #2 was interviewed on 5/19/26 at 1:52 p.m. CNA #2 said interventions for residents who had behaviors were documented on shift report. CNA #2 said if she saw a resident had a behavior that required an intervention, she told the nurse and the nurse charted the behavior. She said some residents had an option for her to chart if she saw a behavior and when she could chart the behavior, she documented what behavior she saw, what intervention was used and if the intervention was effective. CNA #2 said she was familiar with Resident #3. She said one effective intervention to de-escalate Resident #3 was to speak Spanish to him. CNA #2 said Resident #3 spoke Spanish and he was in a good mood when they spoke Spanish together. CNA #2 said she tried to make jokes in Spanish to keep his mood positive. CNA #2 said the facility could identify better interventions for Resident #3’s behavior. She said he was in a lot of resident-to-resident altercations and he was blamed for most of the altercations. CNA #2 said if the facility staff approached him differently, instead of blaming him for the altercations, but seeking to understand what happened from his standpoint, Resident #3 would be in a different spot. Licensed practical nurse (LPN) #2 was interviewed on 5/19/26 at 2:17 p.m. LPN #2 said interventions for residents who had behaviors were documented in a couple of different ways. She said if nursing needed to monitor post resident-to-resident altercation, there was alert charting where the nurse was responsible for documenting what they saw during their shift. LPN #2 said the alert charting was free form and the nurse could chart whatever they saw. LPN #2 said when a resident was first admitted, she tried to learn the resident’s behaviors and what escalated the resident and what de-escalated the resident. LPN #2 said she knew what interventions worked to de-escalate a resident by trying one approach and if it upset the resident, then she did not try that approach again. LPN #2 said if she saw a behavior, she documented it as a progress note and wrote what intervention was used and if the intervention was effective. LPN #2 said she was familiar with Resident #3. LPN #2 said interventions to de-escalate Resident #3 included encouraging him to stay away from residents he did not like, calling his family to come in and talk to him to calm him down and removing him from the situation. LPN #2 said she learned first hand to not approach Resident #3 in a way that suggested he was to blame for resident-to-resident altercations. She said Resident #3 escalated when she and other staff members approached him in a way that suggested he was to blame. The nursing home administrator (NHA) was interviewed on 5/19/26 at 5:05 p.m. The NHA said staff knew what interventions were put in place by verbal communication. The NHA said nurses had access to a communication section in their electronic records system for nurses to read at the start of their shift. The NHA said CNAs or other departments did not have access to the communication section and a paper communication binder was used for educating CNAs. The NHA was interviewed a second time on 5/20/26 at 9:30 a.m. The NHA said she was unable to locate the electronic records for the communication page to show how the nurses were educated on interventions for Resident #3’s behaviors. The NHA said the interventions should be care planned and said the care plans for Resident #3 could use improvement to reflect the interventions put into place after the resident-to-resident altercations. The SSD and the NHA were interviewed together on 5/20/26 at 12:07 p.m. The SSD said she and the corporate social services director were responsible for completing PHQ-9 assessments with residents. The SSD said the PHQ-9 assessment measured the resident’s level of depression. She said the PHQ-9 assessment was completed at admission, quarterly and as needed. The NHA said anyone who triggered for depression was reviewed by the interdisciplinary team (IDT) in a monthly meeting. The NHA and the SSD said the SSD documented what occurred while the PHQ 9 was completed with the resident as a progress note. The NHA said the IDT reviewed the PHQ 9 to see if there were interventions, review medications and add activities as needed. The SSD said if a resident's PHQ 9 score increased from one quarter to another, she documented the conversation as a progress note and she offered behavioral health services to the resident. The NHA said the facility looked to see why the resident’s PHQ-9 assessment score increased. The NHA said maybe the resident’s score increased because of a recent death, an anniversary of a death or the resident was sad because of the season. The SSD said she was responsible for coordinating behavioral health services for residents. The SSD said she was responsible for implementing interventions recommended by behavioral health services. The SSD said when residents came back from an outpatient behavioral health services appointment, nursing was responsible for reviewing the consult form. The SSD said she knew what interventions were recommended by behavioral health services through the IDT.The NHA said the director of nursing (DON) reviewed the consult form and collaborated with the IDT to implement any recommendations. The NHA said interventions were documented in the resident’s chart in their care plans, verbal report and a paper communication sheet. The SSD and the NHA said they were familiar with Resident #3. The SSD said Resident #3 had depression. During the interview, the SSD looked in Resident #3’s chart to see who completed Resident #3’s PHQ 9 and she was unable to find documentation of a progress note indicating why Resident #3’s PHQ 9 increased from the September PHQ 9 assessment to the December 2025 PHQ assessment. The NHA said Resident #3’s PHQ 9 may have increased because December was the month of the anniversary of the resident’s spouse’s death.-However, there was no documentation to indicate why Resident #3’s PHQ-9 assessment score increased and what additional interventions were offered. The SSD and the NHA said they were not aware behavioral health services recommended for staff to not ask Resident #3 to attend activities but to tell him it was time to go to an activity. The SSD and the NHA said if behavioral health services recommended the intervention, it should be in the resident’s care plan and staff should follow the intervention.

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition;-Maintain the ice machine in a sanitary condition; and,-Ensure food items were properly covered, labeled, dated and discarded within appropriate use-by timeframes. Findings include:I. Failure to maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 5/27/26, read in pertinent part, “The physical facilities shall be cleaned as often as necessary to keep them clean.” (6-501.12)“Equipment food-contact surfaces and utensils shall be clean to sight and touch.” (4-601.11)“Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.” (4-601.11)“The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment.” (6-501.114)B. ObservationsThe initial tour of the kitchen was completed on 5/17/26 at 1:05 p.m., and revealed the following: -There was food debris and grease buildup on the floor beneath the steam table and oven area in the kitchen.-There were three unopened butter cups underneath the steam table.-There was dark brown residue, unidentified debris buildup and dirt accumulation underneath the steam table and near the wheels. C. Staff interviewsThe food service supervisor (FSS) was interviewed on 5/19/26 at 1:33 p.m. The FSS said the dietary completed sweeping daily at the end of each meal. The FSS said dietary aides took turns cleaning and staff knew their responsibilities based on the kitchen duty schedule. The FSS said the staff performed spot sweeping and the staff swept and mopped the kitchen after each meal and each night and he reminded them again during the survey. The FSS said failure to keep the kitchen clean could lead to rodents, mold and odors. Dietary aide #2 was interviewed on 5/19/26 at 1:40 p.m. Dietary aide #2 said staff swept the kitchen floors after every meal, including the dish room and the dining room. Dietary aide #2 said the cook was responsible for cleaning the kitchen floors. Dietary aide #3 was interviewed on 5/19/26 at 3:30 p.m. Dietary aide #3 said she followed daily cleaning tasks, swept the floors after each meal and mopped daily. II. Failure to maintain the ice machine in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 5/27/26, read in pertinent part, “Equipment food-contact surfaces and utensils shall be clean to sight and touch.” (4-601.11)“Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.” (4-601.11)B. ObservationsThe initial tour of the kitchen was completed on 5/17/26 at 1:05 p.m., and revealed the following: The ice machine had dirt and debris buildup that was gray in color on the upper interior portion of the ice dispensing opening and on the interior surface near the top of the door. A second observation of the kitchen was conducted on 5/19/26 at 1:20 p.m. Observations identified the same concerns as identified on 5/17/26 during the initial tour. C. Staff interviewsThe dietary manager (DM) was interviewed on 5/19/26 at 1:26 p.m. The DM said the dietary staff cleaned the ice machine weekly and reported any dirt, debris or maintenance concerns to the FSS. The DM said the dietary staff notified maintenance if there were major issues. The DM said dirt and debris could come into contact with the ice, contaminate the ice and cause residents to become sick. The FSS was interviewed on 5/19/26 at 1:33 p.m. The FSS said dietary aides were responsible for cleaning the ice machine every Wednesday. The FSS said he did not think they cleaned the ice machine the previous Wednesday because gray lint buildup was present on the interior surfaces of the ice machine. The FSS said the ice machine was sanitized monthly by either him or maintenance staff. The FSS said if maintenance staff could not sanitize the ice machine, he cleaned it. The FSS said he sanitized the ice machine on 4/28/26. Dietary aide #2 was interviewed on 5/19/26 at 1:40 p.m. Dietary aide#2 said she would notify the FSS if she observed dirt or debris buildup in the ice machine. Dietary aide #2 said she would ask the FSS before cleaning the ice machine and would clean it if the FSS approved. Dietary aide #2 said cleaning kitchen equipment was everyone’s responsibility. Dietary aide #3 was interviewed on 5/19/26 at 3:30 p.m. Dietary aide #3 said the ice machine was cleaned weekly and the staff member assigned to duty cleaned it. Dietary aide #3 said she received initial food safety and kitchen sanitation training during orientation and attended monthly in-service training. The maintenance director was interviewed on 5/20/26 at 5:07 p.m. The maintenance director said maintenance staff sanitized the ice machine monthly and dietary staff cleaned it daily. The maintenance director said the filter contained a gauge that alerted staff when replacement was needed. The maintenance director said the ice machine was last sanitized in April 2026 and was due for cleaning again this month. The maintenance director said staff cleaned the entire ice machine during the monthly sanitizing process. III. Failure to properly label, cover and discard expired food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 5/27/26, read in pertinent part, “Food shall be protected from contamination by storing the food in a clean, dry location and, where it is not exposed to splash, dust, or other contamination.” (3-305.11)“Working containers holding food or food ingredients that are removed from their original packages for use in the food establishment shall be identified with the common name of the food.” (3-302.12)“Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded.” (3-501.17)“A food specified in 3-501.17(A) or (B) shall be discarded if it exceeds the temperature and time combination specified, is in a container or package that does not bear a date or day, or is inappropriately marked with a date or day that exceeds the temperature and time combination.” (3-501.18)B. ObservationsThe initial tour of the kitchen was completed on 5/17/26 at 1:05 p.m., and revealed the following: -A tray containing 10 individual portions of banana pudding cake was observed in the walk-in refrigerator without a protective covering, wrapping or label. There were multiple food items and drinks observed in the dining room refrigerator beyond their use-by or discard dates. -One opened container of thickened cranberry cocktail was dated 4/30/26;-One container of cranberry juice had a use-by date of 5/15/26;-One container of orange juice had a use-by date of 5/16/26;-Six containers of cantaloupe were dated 5/11/26;-Ten cups of Jello were dated 5/5/26;-Seven cups of butterscotch pudding were dated 5/14/26; and,-One pitcher containing a beverage was observed stored in the refrigerator without a label or date.-The thickened cranberry, cantaloupe, Jello and butterscotch pudding dates did not indicate if it was a preparation date or use by date. During dinner observation on 5/17/26, the following was observed:At 5:20 p.m. dietary aide #1 filled Resident #30’s pitcher with cranberry beverage and returned the pitcher to the refrigerator after filling it. At 5:23 p.m. dietary aide #1 removed Resident #30’s pitcher from the refrigerator and placed it on the meal tray cart for delivery to Resident #30. C. Staff interviewsThe FSS was interviewed on 5/19/26 at 1:23 p.m. The FSS said dietary aide #1 prepared the banana pudding the night before. The FSS said dietary aide #1 forgot to wrap and date the dessert because he started working at the facility approximately two weeks ago. The FSS said dietary aide #2 provided training to dietary aide #1. The FSS said he expected staff to label and date food items to prevent contamination. The FSS and the DM were interviewed together on 5/19/26 at 1:33 p.m. The FSS said he used a reference sheet to determine how long food items remained safe and how they should be labeled. The FSS said cantaloupe cups were good for five days and the containers of cantaloupe should have been discarded on 5/16/26. The FSS said he did not know how long Jello remained good once prepared and said he would look it up online. The FSS said pudding was good for two days and the containers of pudding in the refrigerator should have been discarded on 5/16/26. The FSS said the 4/30/26 date on the thickened cranberry cocktail container was the received date. The FSS said the thickened cranberry cocktail was good for seven days and should have been discarded after seven days. The FSS said he discarded the expired food items. The DM said unlabeled food items could not be properly monitored for safety because staff would not know how old the items were. The DM services said unwrapped food items could become contaminated and cause illness. Dietary aide #2 was interviewed on 5/19/26 at 1:40 p.m. Dietary aide #2 said she labeled prepared drinks with the date the item was prepared. Dietary aide #2 said, for example, orange juice remained good for three days and she labeled the container with a three-day discard date. Dietary aide #3 was interviewed on 5/19/26 at 3:30 p.m. Dietary aide #3 said she covered and dated food and dessert items immediately after preparation. Dietary aide #3 said the staff member who prepared the item was responsible for labeling and dating it. Dietary aide #3 said if she observed an unlabeled item, she would ask staff when the item was prepared and if she could not determine when it was made, she would discard the item for safety reasons. Dietary aide #3 said she checked dates on food items to identify expired FSS and discarded items after three days. Dietary aide #3 said she would discard Jello if it became watery, even if the item had not expired.

A survey prompted by #CO3029226 was completed on 5/17/26 to 5/20/26. One deficiency was cited.

Based on observations, record review, and interviews the facility failed to ensure two (#25 and #35) of eight out of 24 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #25 from verbal abuse from Resident #3 on 12/15/25 and 12/21/25, which caused psychosocial distress for Resident #25; and,-Protect Resident #35 from verbal abuse from Resident #3 on 12/23/25 and 12/31/25, which caused Resident #35 to become tearful after both incidents. Resident #3, who was admitted to the facility on 2/25/22 and readmitted on 12/7/25, was known to have verbally aggressive behaviors toward others and had been involved in verbal altercations with other residents. On 12/15/25 Resident #3 verbally abused Resident #25 in the dining room by yelling foul language, making threatening comments and moving aggressively toward Resident #25. The facility placed both residents on 15-minute checks and educated staff regarding de-escalation techniques. However, six days later, on 12/21/25, Resident #3 again approached Resident #25 in the dining room, calling him names and threatening to kick his (expletive word). Record review and interviews during the survey revealed Resident #25 became fearful, nervous and emotionally distressed following the repeated verbal abuse incidents from Resident #3. Due to the facility’s failure to protect Resident #25 from verbal abuse from Resident #3, Resident #25 sustained psychosocial distress, which included sleep disturbances, fear of Resident #3, avoidance of the dining room and decreased social and activity participation. Additionally, following the second incident with Resident #25, the facility implemented an intervention for staff to escort Resident #3 to and from the dining room. However, on 12/23/25 and again on 12/31/25, Resident #3 was verbally abusive toward Resident #35 in the dining room when he passed by her, causing Resident #35 to become tearful after each incident. Observations during the survey revealed Resident #3 was not consistently escorted to and from the dining room (see observations below). III. Incidents of verbal abuse towards Resident #35 by Resident #3 on 12/23/25 and 12/31/25A. Facility investigation on 12/23/25Review of the 12/23/25 facility investigation documented a verbal altercation between Resident #3 and Resident #35. The incident occurred on 12/23/25 in the dining room when Resident #3 passed Resident #35 and called the resident an inappropriate name. An unknown staff member witness said they saw Resident #35 talking to dietary staff and the resident crying when Resident #3 called Resident #35 a big (expletive) baby and said “All you do is cry.” When interviewed by the facility, Resident #35 began to cry and said Resident #3 was calling her names. She was escorted out of the dining room away from Resident #3. When the facility spoke to Resident #3, he became disruptive, disrespectful and was cursing at staff. He stated he was aware he made nasty comments and stated to staff that he did not feel it was wrong and he did not regret it. He stated he could do whatever he wanted. Staff stayed with Resident #3 until he agreed to leave the dining room. Five residents were interviewed and denied having had issues with Resident #3 being verbally aggressive towards them. Staff interviews were not conducted. Both residents were placed on frequent 15-minute checks. The residents’ responsible parties, the police, and the physicians were notified. The facility substantiated the verbal abuse.-However, Resident #3 was already on 15-minute checks following the verbal abuse incident with Resident #25 on 12/21/25 (see above).-Additionally, after the 12/21/25 incident with Resident #25, Resident #3 was supposed to be escorted to and from the dining room as an intervention to prevent further verbal abuse incidents (see above). B. Facility investigation on 12/31/25Review of the 12/31/25 facility investigation documented a verbal altercation between Resident #3 and Resident #35. The incident occurred on 12/31/25 in the dining room when Resident #3 began mocking and making fun of Resident #35. The investigation did not reveal what was said between Resident #3 and Resident #35. When interviewed by facility staff Resident #35 again began to cry and said Resident #3 was making fun of her. She was escorted out of the dining room. When staff spoke to Resident #3 he began yelling at the nurse and refused to leave the dining room. Five residents were interviewed and denied having had verbal altercations with Resident #3 or that they were fearful of him. The investigation did not include staff interviews. Both residents were placed on frequent 15-minute checks. The residents’ responsible parties, the police, and the physicians were notified. The facility substantiated the verbal abuse. C. Resident #3 (assailant) 1. Resident observationOn 5/17/26 at 5:00 p.m. Resident #3 was observed entering the dining room unescorted by a staff member.-However, following the verbal abuse incidents in December 2025, interventions included Resident #3 was to be escorted in and out of the dining room and was to sit in an area that would not trigger negative behaviors (see investigations above). 2. Resident interviewResident #3 was interviewed on 5/19/26 at 4:00 p.m. Resident #3 he did not recall having any negative interactions with Resident #35 on 12/23/25 and 12/31/25.3. Record review-Review of Resident #3’s dementia and behavioral care plan, initiated 5/17/22 and revised 2/3/26, did not include the interventions implemented to prevent further verbal abuse incidents (see investigations above). D. Resident #35 (victim) 1. Resident statusResident #35, age greater than 65, was admitted on 9/26/14 and readmitted on 9/22/23. According to the May 2026 CPO, diagnoses included morbid obesity due to excess calories, unspecified intellectual disabilities, depression and seizures. The 4/7/26 comprehensive assessment revealed the resident had severe cognitive impairment. The comprehensive assessment indicated the resident did not have behaviors that impacted others. The comprehensive assessment indicated the resident felt down, depressed, or hopeless, and had little interest or pleasure in doing things for two to six days during the assessment look-back period. 2. Resident interviewResident #35 was interviewed on 5/17/26 at 3:00 p.m. Resident #35 said Resident #3 would call her names that made her cry several times. She said she was not afraid of him but she stayed away from him, especially in the dining room. She said where she now sat in the dining room, her back was toward him so she did not have to look at him. She said he was not a nice man and yelled quite a bit. 3. Record reviewReview of the communication care plan, initiated 10/3/14 and revised 5/16/24, revealed Resident #35 had limited verbal ability but used smiling, hugging, and holding hands with staff as a form of communication and validation. Interventions included for staff to be aware that this was her form of communication, but due to low cognitive function she would also swing from happiness to sadness as a way of communication and getting her needs met. Review of the vulnerability care plan, initiated 3/13/24 and revised 10/23/25, revealed Resident #35 was at risk of being easily influenced by other residents to the detriment of her own care and wellbeing. Interventions included that the resident needed to be monitored when visiting with residents in their rooms or at daily activities. The resident was vulnerable and should be protected from others who used her to express their own wants or needs. Review of the behavior/trauma care plan, initiated 1/11/16 and revised 4/22/25, revealed Resident #35 had a history of sexual abuse from childhood. She would at times exhibit verbal aggression, self isolation, crying and sadness. Interventions included allowing the resident time to vent and express herself and cry, offering reassurance and attempting to find out what triggered the episode and having the resident removed from the present situation and taken to a private quiet area. Review of the at-risk for abuse care plan, initiated 8/7/25 and revised on 9/30/25, revealed Resident #35 was at risk for abuse related to a diagnosis of intellectual disabilities. The resident could become upset if other residents made derogatory remarks at her. Interventions included assessing the resident regularly and as needed for signs of abuse, investigating any concern or change in functional or mental status as those could be a sign of abuse and observing for and reporting any changes in mental status caused by situational stressors.-The care plan failed to identify the episodes of verbal aggression by Resident #3 towards Resident #35 on 12/23/25 and 12/31/25 (see facility investigations above) and the interventions implemented to prevent further verbal abuse incidents. A review of Resident #35's EMR, from 12/23/25 to 12/31/25, revealed the following;Review of the December 2025 behavior monitoring documentation revealed Resident #35 had three episodes of crying and sadness on 12/23/25, the date of the first verbal abuse incident with Resident #3. The 12/23/25 nurse progress note revealed Resident #35 was sitting in the dining room when Resident #3 entered the dining room and passed Resident #35’s table. Resident #3 told Resident #35”You are a big (expletive) baby, all you do is cry.” When staff intervened, Resident #3 became disrespectful and unable to be redirected and began cursing at staff and refusing to leave the dining room. Staff stayed with him until he agreed to leave the dining room. Resident #3 said he knew he made the comment because he could do what he wanted. After the incident, Resident #35 was tearful. -Review of Resident #35’s EMR failed to reveal documentation of the incident with Resident #3 on 12/31/25.-Further review of Resident #35’s EMR revealed no social services involvement or documentation entries related to the two verbal abuse incidents in December 2025 between Resident #3 and Resident #35. E. Staff interviewsLPN #1 was interviewed on 5/19/26 at 10:15 a.m. LPN #1 said she witnessed the verbal incidents between Resident #35 and Resident #3 (on 12/23/25 and 12/31/25. She said Resident #3 had mocked Resident #35 and when Resident #35 told Resident #3 to be quiet, he called her a fat (expletive). She said Resident #35 came to nursing staff and complained about Resident #3 because he was calling her names. She said there had not been any recent incidents between the two residents that she knew of and Resident #35 was not afraid of Resident #3 and would try to stand up for herself. LPN #1 said since the incidents in December 2025, Resident #35 had moved to a different table in the dining room to not be in close proximity to Resident #3. She said any form of abuse, whether it was resident-to-resident or staff-to-resident, was to be reported immediately to the NHA.Certified nurse aide (CNA) #1 was interviewed on 5/19/26 at 2:30 p.m. CNA #1 said staff were required to complete monthly in-service training that included abuse and dementia training. She said if she witnessed abuse of any kind, whether it was resident-t- resident or staff-to-resident, she would report it immediately to her charge nurse and the NHA. She said if she witnessed two residents involved in a verbal or physical altercation, she would separate them to keep them safe. She said if new interventions were implemented after a resident-to-resident altercation, those interventions were relayed to the staff in writing as education and were passed on verbally during shift-to-shift report. She said the nurses alerted staff of any new changes with residents. She said even though there had been verbal altercations between Resident #3 and Resident #35, Resident #35 had tried to keep to her normal routine and would avoid Resident #3 if at all possible. The nurse practitioner was interviewed on 5/19/26 at 4:00 p.m. The nurse practitioner said it had been a while since she had been notified of any altercations between Residents #3 and Resident #35. She said since the facility moved Resident #3 to a room at the end of the Juniper hall, his behavior had diminished greatly. She said residents did not walk past the doorway of his room and he was not mocking other residents when he would see them in the hall. She said Resident #35 now sat in the dining room with her back to Resident #3 so there was no eye contact between them and less chance for a negative interaction with him. The NHA was interviewed on 5/20/26 at 2:50 p.m. The NHA said she thought the reason for the two occurrences in December 2025 between Resident #3 and Resident #35 was because staff tried to have Resident #3 move to another table in the dining room, away from the entrance. She said he agreed at first, but then would go back to the first table near the entrance where Resident #35 would walk by and he would say demeaning things to her. The NHA said Resident #3 finally agreed to sit at a table at the back of the dining room and since then, there had been no further negative interactions between them. She said Resident #35 now sat at a table on the other side of the dining room, away from Resident #3, with her back to him. She said care plans should be updated with interventions after incidents occurred so that staff were aware of changes. The NHA said Resident #35’s care plan had not been updated after the two incidents in December 2025.

A survey for Incident #1933087 was conducted on 10/14/25 to 12/11/25. Three deficiencies were cited. The actual survey exit date was 10/14/25. 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 12/11/25.

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of three residents reviewed for acute changes in condition out of four sample residents. Specifically, the facility failed to timely notify the physician and intervene to treat high blood pressure for Resident #1. Findings include:I. Professional reference The article Hypertensive crisis: What are the symptoms? (2024) was retrieved on 11/24/25 from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/expert-answers/hypertensive-crisis/faq-20058491?cjdata=MXxOfDB8WXww&cjevent=765460d1cfad11f082c907180a1cb829&cm_mmc=CJ-_-100357191-_-5250933-_-Evergreen+Link+for+Mayo+Clinic+Diet&utm_source=cj&utm_content=100357191&utm_capaign=3-months read in pertinent part;“A hypertensive crisis is a sudden, severe increase in blood pressure. The blood pressure reading is 180/120 millimeters of mercury (mmHg) or greater. A hypertensive crisis is a medical emergency. It can lead to a heart attack, stroke, or other life-threatening health problems. See emergency medical help for anyone with these blood pressure numbers.”“Call 911 or emergency medical services if your blood pressure is 180/120 mmHg or greater and you have chest pain, shortness of breath, or symptoms of stroke. Stroke symptoms include:-numbness or tingling;-loss of feeling in the face, arm, or leg;-trouble walking;-trouble speaking; and,-changes in vision.”II. Facility policy and procedureThe Change in a Resident’s Condition or Status policy, undated, was received from the director of nursing (DON) on 11/14/25 at 12:10 p.m. It read in pertinent part,“Our facility promptly notifies the resident, the physician, and the resident representative of changes in the resident's medical status.“The nurse will notify the physician when there has been a(n): -accident or incident involving the resident;-significant change in the resident’s physical condition; and/or,-need to transfer the resident to a hospital.“A significant change of condition is a major decline in the resident status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.“Prior to notifying the physician, the nurse will gather relevant information for the physician, including information prompted by the interactive communication form.“The nurse will record in the resident’s medical record information relative to changes in the resident's medical status.”II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 9/4/21 and discharged to the hospital on 6/8/25. Resident #1 did not return to the facility and expired on 6/12/25 while in hospice care. According to the June 2025 computerized physician orders (CPO), diagnoses included hypertension, diabetes mellitus and Alzheimer’s disease. The 5/8/25 minimum data set (MDS) assessment revealed Resident #1 was unable to complete the brief interview for mental status (BIMS) assessment. Resident #1 was assessed by staff to be severely impaired in cognition and daily decision-making. The assessment revealed Resident #1 was dependent on staff for all activities of daily living (ADL). Resident #1 did not walk and was dependent on staff for mobility with a manual wheelchair. B. Record reviewResident #1's fall prevention care plan, revised 5/7/25, revealed Resident #1 was at risk for falls. The pertinent fall prevention interventions included placing a sign for Resident #1 to call for assistance, and placing anti-tipper devices on Resident #1’s wheelchair to prevent tipping backwards (5/8/24). A fall occurrence progress note, dated 6/8/25 at 9:00 a.m., revealed Resident #1 was being pushed in a manual wheelchair to her room. The resident’s foot caught on the carpet and she fell out of the wheelchair onto the floor. Resident #1 hit her head and sustained a laceration surrounded by a hematoma (bruising and swelling) to the middle of the upper forehead at her hairline. Resident #1 was unable to follow commands, and the nurse completed passive range of motion for all major joints while Resident #1 was on the floor. Vital signs were normal except for the resident’s blood pressure measurement of 190/108 millimeters of mercury (mmHg). Resident #1’s statement on what was being attempted when the fall occurred was that her wheelchair did not have a footrest or foot pedals and her feet were dragging on the floor. The evaluation revealed Resident #1’s representative, the physician, the DON, and the nursing home administrator (NHA) were notified regarding the fall. The record review revealed there were no new physician’s orders given at the time of the initial fall notification. Review of Resident #1’s post-fall neurological assessments revealed the following:On 6/8/25 at 9:00 a.m. the resident had a normal level of consciousness, abnormal speech/aphasia(impaired speech) and no hand grasps. Vital signs: blood pressure 139/106 mmHg, heart rate 90 beats per minute (bpm) and respiration rate was 18 per minute. On 6/8/25 at 9:15 a.m. the resident had a normal level of consciousness, abnormal speech/aphasia and no hand grasps. Vital signs: blood pressure 190/108 mmHg, heart rate 77 bpm, respirations 18 per minute. On 6/8/25 at 9:30 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 191/90 mmHg, heart rate 89 bpm, respirations 15 per minute. On 6/8/25 at 9:45 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 187/94, heart rate 82 bpm, respirations 16 per minute. On 6/8/25 at 10:15 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 190/98, heart rate 80 bpm, respirations 15 per minute. On 6/8/25 at 10:45 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 184/86 mmHg, heart rate 78 bpm, respirations 15 per minute. On 6/8/25 at 11:15 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 187/91 mmHg, heart rate 82, respirations 16 per minute. On 6/8/25 at 11:45 a.m. the resident had a normal level of consciousness, rambling speech and equal hand grasps. Vital signs: blood pressure 194/96 mmHg, heart rate 77 bpm, respirations 15 per minute. On 6/8/25 at 12:45 p.m. the resident had a normal level of consciousness, normal speech and equal hand grasps. Vital signs: blood pressure 186/82, heart rate 73, respirations 15 per minute. On 6/8/25 at 1:45 p.m. the resident had a normal level of consciousness, normal speech and equal hand grasps. Vital signs: blood pressure 184/81 mmHg, heart rate 81 bpm, respirations 15 per minute. A CPO, dated 6/8/25 at 1:32 p.m., was initiated for hydralazine 25 mg by mouth every eight hours as needed for high blood pressure with a systolic reading of greater than 180. The medication was not administered.-However, Resident #1’s blood pressure had remained high for over four hours after the fall before the facility notified the physician. A nurse progress note, dated 6/8/25 at 1:56 p.m., revealed Resident #1’s blood pressure did not recover in four hours following her fall. Resident #1’s blood pressure remained in the 180s range. The nurse contacted the physician regarding the fall and high blood pressure readings and the physician gave a new order for hydralazine 25 mg every eight hours as needed for a systolic blood pressure reading greater than 180. A nurse progress note, dated 6/8/25 at 3:00 pm., revealed Resident #1’s representative and power of attorney (POA) were informed regarding Resident #1’s fall and insisted Resident #1 be transferred to the hospital emergency department for evaluation. The registered nurse (RN) documentation revealed the RN did due diligence and educated the family members there were no signs of serious injury or neurological damage after the fall. The POA was informed Resident #1 had high blood pressure and had a new order for medication to control the high blood pressure. The manager on duty returned to the facility to transport Resident #1 to the emergency department. Resident #1 was changed and prepped for transfer to the emergency department. The RN documented the blood pressure had normalized by the afternoon without using the hydralazine. The hospital progress notes, dated 6/8/25, revealed Resident #1’s representative was notified at 3:00 p.m. that Resident #1 had fallen in the morning. The representative went to visit the resident at the facility and found Resident #1 was not at her baseline. The representative said Resident #1 was holding her left arm and was uncomfortable. Resident #1 arrived at the hospital by facility transport van. Resident #1’s blood pressure at 5:50 p.m. at the emergency department was 208/115. IV. Staff interviewsRN #1 was interviewed on 10/14/25 at 2:52 p.m. RN #1 said after a resident had a fall, it was the facility’s policy to have the resident assessed by a registered nurse. RN #1 said the assessment included a measurement of vital signs, including blood pressure. RN #1 said the post-fall assessments were documented in the resident's electronic medical record (EMR) and also on the facility’s neurological assessment form, if the fall was unwitnessed, or if the resident struck their head while falling. RN #1 said when a resident had high blood pressure, it was the nursing standard to recheck the blood pressure to verify the result. RN #1 said if the reading were high, it would indicate the resident had a heart issue or maybe elevated pain. RN #1 said if a resident had continuous high blood pressure after about three minutes, she would contact the physician and report the resident's condition. RN #1 said it was not a good idea to monitor high blood pressure for hours without a physician's awareness and orders. RN #1 said the facility had medication to lower blood pressure in the facility's emergency medication supply, and a nurse could access the medication without delay after a physician's order was initiated. The DON and the nursing home administrator in training were interviewed together on 10/14/25 at 3:15 p.m. The DON said after Resident #1 fell, nursing staff followed policy and completed neurological assessments and notified the physician. The DON said post-fall assessments included a complete body assessment and measuring vital signs. The DON said the purpose of frequent assessments was to closely monitor residents so that nursing staff could identify concerning changes in assessment and implement interventions and notify the physician if necessary. The DON said the neurological assessments were completed after an unwitnessed fall or anytime a resident hit their head. The DON said the neurological assessments included looking at skin for trauma or new deformities, pain, acting abnormally and changes in vital signs. The DON said Resident #1 had a history of high blood pressure and had fluctuations in blood pressure before the 6/8/25 fall, but had not previously required new medications to lower blood pressure. The DON said the neurological assessments completed on 6/8/25 did not reveal a change in Resident #1’s normal status, and Resident #1 was monitored appropriately. The DON said Resident #1 had no signs of serious injury, moved all major joints, and did not grimace or hold her head. The DON said that when the family requested Resident #1 to be evaluated at the hospital, the facility’s manager on duty transported Resident #1 in the facility van because the nurse assessment documented Resident #1 was stable and had no indicators for ambulance transport.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accident hazards received adequate supervision out of four sample residents. Resident #1, who was dependent on facility staff for wheelchair mobility, sustained a fall from her wheelchair on 6/8/25, which resulted in a cervical spine fracture. During the facility’s investigation of the fall, it was discovered that staff failed to attach the foot pedals to Resident #1's wheelchair. As a result, Resident #1 was unable to rest her feet on the foot pedals while being transported. On 6/8/25, while Resident #1 was being transported from the dining room to her room, Resident #1 caught her foot/feet on the rug, fell forward out of the wheelchair, and hit her head on the floor as she fell. Due to the facility’s failure to ensure staff used wheelchair safety equipment/foot pedals, Resident #1 sustained a fall on 6/8/25, which resulted in a cervical (C1) spine fracture. Specifically, the facility failed to ensure staff transported residents in their wheelchairs with the foot pedals in place, which resulted in a fall for Resident #1 where she sustained a C1 spine fracture. Findings include:Record review and interviews confirmed the facility corrected the deficient practice before the onsite investigation on 10/14/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/9/25. I. Incident on 6/8/25Resident #1, who was dependent on facility staff for wheelchair mobility, sustained a fall from her wheelchair on 6/8/25, which resulted in a cervical spine fracture. During the facility’s investigation of the fall, it was discovered that staff failed to attach the foot pedals to Resident #1's wheelchair. As a result, Resident #1 was unable to rest her feet on the foot pedals while being transported. On 6/8/25, while Resident #1 was being transported from the dining room to her room, Resident #1 caught her foot/feet on the rug, fell forward out of the wheelchair, and hit her head on the floor as she fell. Due to the facility’s failure to ensure staff used wheelchair safety equipment/foot pedals, Resident #1 sustained a fall on 6/8/25, which resulted in a cervical (C1) spine fracture. II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #1The correction action plan implemented by the facility in response to Resident #1’s fall on 6/8/25 was provided by the director of nursing (DON) on 10/14/25 at 4:10 p.m. The corrective action plan included documentation that all facility nursing staff were educated on 6/9/25 on the facility's wheelchair safety procedure and the wheelchair policy and procedure. The education included instructions that all residents who required staff assistance for wheelchair mobility must have foot pedals in place. The corrective action plan identified that the facility ensured an adequate supply of foot pedals was available when needed. B. Systemic changesStaff were educated on 6/9/25 to ensure residents that required staff assistance for wheelchair mobility were required to have foot pedals on their wheelchairs. Staff were educated foot pedals must be used during transportation. C. MonitoringThe interdisciplinary team (IDT) was responsible for reviewing all fall occurrences and occurrences that involved facility equipment, including wheelchairs. The maintenance inspection and repair logbook documentation, dated 9/18/25, revealed the facility inspected all manual wheelchairs for damaged or missing components such as, hand grips, brakes, casters, wheels, seats and leg rests. The work history monthly report for 10/31/24 to 9/30/25 documented the wheelchair inspections that were completed. III. Facility policy and procedureThe Wheelchair policy and procedure, undated, was provided by the DON on 11/14/25 at 12:14 p.m. It revealed in pertinent part, "To safely push a wheelchair, you must communicate with the user and take special precautions for obstacles like ramps and curbs. Check the equipment. Ensure the wheelchair is in good working order. Check that all parts are securely attached.“Footrests significantly enhance safety for older adults in wheelchairs by preventing their feet and legs from draping, which could cause them to catch on the ground, get caught under the wheels, or even get pulled out of the wheelchair entirely. “Keeping the feet elevated and supported on the footrests ensures that there is sufficient ground clearance, preventing the footplate from hitting obstacles or catching on the ground, which can cause the wheelchair to tip."IV. Facility Investigation of incident on 6/8/25On 6/8/25, the facility investigated Resident #1’s fall. The facility investigation revealed that on 6/8/25 at 9:00 a.m., while a staff member was transporting Resident #1 in a manual wheelchair, Resident #1 caught her foot on the carpeted floor and fell to the floor. Resident #1 struck her head on the floor and staff observed a laceration and a hematoma (bruising and swelling) on her forehead. Resident #1 had a bruise on her left hand. Resident #1 had a blood pressure reading of 190/108 millimeters of mercury (mmHg). The nurse immediately placed a foot shelf on Resident #1’s wheelchair, completed neurocognitive assessments, and notified appropriate parties, including the physician. Resident # 1 was transferred to the emergency department for an evaluation. The facility interviewed all staff on duty who were involved in care for the resident on the day of the fall. The staff member who witnessed the occurrence provided a written incident statement that revealed Resident #1 was assisted from the dining room to her room and was often assisted without foot pedals and Resident #1 had previously been able to lift her feet when requested while she pushed her in the wheelchair. The statement revealed Resident #1 sat in her chair as usual, but the resident leaned forward and landed on the floor. Inspection of Resident #1’s wheelchair revealed the foot pedals were not attached to her wheelchair and therefore Resident #1 was unable to keep her feet off the floor while being transported by a staff member. The investigation documented the nurse on duty immediately attached foot pedals to Resident #1’s wheelchair. The investigation revealed that a registered nurse (RN) completed a post-fall assessment, and Resident #1 was able to move all her extremities, had no facial grimacing, and had a laceration on her forehead with a bruise forming on the backs of her right and left hands. The assessment documented that Resident #1 had no changes in her cognitive status. The investigation revealed Resident #1 was transferred to a hospital for higher-level care for a C1 spine fracture. The family declined surgical care and placed Resident #1 on hospice care and Resident #1 passed away on 6/12/25. The facility investigation revealed that the facility followed policy, procedure, and manufacturer guidelines for wheelchair use, and the staff member involved had been adequately trained in using the equipment. V. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 9/4/21 and discharged to the hospital on 6/8/25. Resident #1 did not return to the facility and expired on 6/12/25 while in hospice care. According to the June 2025 computerized physician orders (CPO), diagnoses included high blood pressure, diabetes mellitus and Alzheimer’s disease. The 5/8/25 minimum data sets (MDS) assessment revealed Resident #1 was unable to complete the brief interview for mental status (BIMS) assessment. Resident #1 was assessed by staff to be severely impaired in cognition and daily decision-making. The assessment revealed Resident #1 was dependent on staff for all activities of daily living (ADL). Resident #1 did not walk and was dependent on staff for mobility with a manual wheelchair. B. Record reviewResident #1's fall prevention care plan, revised 5/7/25, revealed Resident #1 was at risk for falls. The pertinent fall prevention interventions included placing a sign for Resident #1 to call for assistance and placing anti-tippers on Resident #1’s wheelchair to prevent tipping backwards (5/8/24). A fall occurrence progress note, dated 6/8/25 at 9:00 a.m., revealed Resident #1 was being pushed in a manual wheelchair to her room when her foot caught on the carpet and she fell out of the wheelchair onto the floor. Resident #1 hit her head and sustained a laceration surrounded by a hematoma to the middle of the upper forehead at her hairline. Resident #1 was unable to follow commands, and the nurse completed passive range of motion for all major joints while Resident #1 was on the floor. Vital signs were normal except for the blood pressure measurement of 190/108 millimeters of mercury (mmHg). Resident #1’s statement on what was being attempted when the fall occurred was that her wheelchair did not have a footrest or foot pedals, and her feet were dragging on the floor. The evaluation revealed Resident #1’s representative, the physician, the DON, and the nursing home administrator (NHA) were notified regarding the fall. The progress note did not include the time of notification or response from those notified. The record review revealed there were no new CPOs given at the time of the initial fall notification. -Review of Resident #1’s vital signs following the fall revealed the resident’s blood pressure readings remained high for over four hours after the fall before the facility notified the physician for a physician’s order to address the high blood pressure. Cross reference F684 for failing to notify the physician of high blood pressure readings. A nurse progress note, dated 6/8/25 at 3:00 pm., revealed Resident #1’s representative and power of attorney (POA) were informed regarding Resident #1’s fall and insisted Resident #1 be transferred to the hospital emergency department for evaluation. The RN documentation revealed the RN did due diligence and educated the family member there were no signs of serious injury or neurological damage after the fall. The POA was also informed Resident #1 had high blood pressure and had a new order for medication to control high blood pressure. The manager on duty returned to the facility to transport Resident #1 to the emergency department. Resident #1 was changed and prepped for transfer to the emergency department. -A review of Resident #1’s electronic medical record (EMR) did not reveal a time or assessment status of Resident #1 left for the emergency department. The hospital progress notes, dated 6/8/25, revealed Resident #1’s representative was notified at 3:00 p.m. that Resident #1 had fallen in the morning. The representative went to visit the resident at the facility and found Resident #1 was not at her baseline and said Resident #1 was holding her left arm and was uncomfortable. Resident #1 arrived at the hospital by facility transport van. Resident #1’s blood pressure at 5:50 p.m. at the emergency department was 208/115. The hospital Xray report for left arm pain, dated 6/8/25, revealed Resident #1 had a mild superior subluxation (joint dislocation) of the elbow and an age undetermined of the radial neck (elbow). The hospital computerized tomography (CT) scan of the cervical spine, dated 6/8/25, revealed Resident #1 had a type 2 dens/odontoid fracture with displacement of the dens/odontoid and anterior ring by 5 millimeters (mm). Fracture lines were seen through the posterior ring of C1 in two places. Resident #1 was diagnosed on 6/8/25 at the emergency department with a C1 spine fracture, closed head injury, wedging of the thoracic spine, and left radial head/neck impacted fracture. A rigid cervical collar was placed on Resident #1, and a splint was placed on the left upper extremity. Resident #1’s representative was informed of the diagnoses and the decision was made to transfer Resident #1 to a higher level of care for appropriate specialty management with neurosurgery capability. Resident #1 was transferred in fair condition on 6/8/25 via rotor flight transport. VI. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 10/14/25 at 2:30 p.m. CNA #1 said she frequently used wheelchairs and assisted residents with mobility inside the facility. CNA #1 said she received education and training on safe wheelchairs and equipment in her CNA training, and also a few weeks ago. CNA #1 said wheelchair foot pedals were used to lift the resident’s feet off the floor and were adjustable to help position the leg and foot placement of each resident. CNA #1 said staff were educated not to remove foot pedals from wheelchairs until the residents were checked off and able to maneuver themselves independently. CNA #1 said that when foot pedals were missing from a wheelchair and were needed, staff would look around the facility, in closets or storage rooms, to locate the required appropriate wheelchair equipment. CNA #1 said she was unsure how to determine if the wheelchair equipment in use was as ordered or evaluated. She said she continued mobility equipment use based on what was in each resident's room, and if the equipment was not appropriate or adequate, she would talk to the floor nurse. RN #1 was interviewed on 10/14/25 at 2:52 p.m. RN #1 said that after a resident fell in the facility, the facility policy required the RN on duty to complete a post-fall assessment. The RN said the nurse should try not to move the resident until a head-to-toe assessment was completed and the nurse determined it was safe to move the resident. The RN said after the resident was assisted to their bed, the facility policy required close monitoring for three days. The RN said the monitoring intervals started frequently, every 15 minutes, and then went to every 30 minutes, then every four hours, then every eight hours, and then once per shift. The RN said that after the resident assessment was completed, the RN was responsible for notifying the physician and family, and documenting the fall occurrence, notifying the physician, and documenting if the physician gave new orders. The RN said the physician could be informed by voicemail or directly. The RN said a nurse did not always need a physician's order to call 911 and would base the decision to call 911 on nursing judgment and education. The RN said the decision to move a resident after a fall where the resident hit their head would depend on assessment and judgment. The RN said a high blood pressure reading after a fall could be evidence of pain, but the RN should call the physician if the resident’s blood pressure was rising after a head injury. The director of rehabilitation (DOR) was interviewed on 10/14/25 at 3:06 p.m. The DOR said wheelchair assessments were completed by the occupational therapist (OT). The DOR said residents were assessed for mobility status when they were admitted to the facility. The DOR said if the OT determined the resident required a wheelchair for mobility, the facility provided a wheelchair for the resident's use. The DOR said the maintenance department was responsible for inspecting wheelchair equipment for safety and providing wheelchair maintenance. The DOR said Resident #1 did not have a wheelchair assessment that determined whether or not foot pedals were required for Resident #1. The DOR said nursing staff would know from the residents' EMR or care plan what equipment was needed for each resident and how the nursing staff would be aware of changes in equipment required, such as when a resident had a change in status and required different equipment. The DOR said if a wheelchair assessment was not available, nursing staff were able to screen residents and get a general idea of what equipment was required for resident care. The DON and the nursing home administrator in training were interviewed together on 10/14/25 at 3:15 p.m. The DON said after Resident #1 fell, nursing staff followed policy and completed neurological assessments and notified the physician. The DON said post-fall assessments included a complete body assessment and measuring vital signs. The DON said the purpose of frequent assessments was to closely monitor residents so that nursing staff could identify concerning changes in assessment and implement interventions and notify the physician if necessary. The DON said the neurological assessments were completed after an unwitnessed fall or anytime a resident had a head strike. The DON said the neurological assessments included looking at skin for trauma or new deformities, pain, acting abnormally, and changes in vital signs. The DON said the neurological assessments completed on 6/8/25 did not reveal a change in Resident #1’s normal status, and Resident #1 was monitored appropriately. The DON said Resident #1 had no signs of serious injury, moved all major joints, and did not grimace or hold her head. The DON said that when the family requested Resident #1 to be evaluated at the hospital, the facility manager on duty transported Resident #1 in the facility van because the nurse assessment documented Resident #1 was stable and had no indicators for ambulance transport. The DON said the interdisciplinary team (IDT) reviewed the 6/8/25 fall and discussed that nursing staff would receive education on the use of foot pedals with wheelchairs. The DON said there had not been additional occurrences or injuries that involved wheelchairs since 6/9/25.

Based on record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#1) of three residents reviewed for maintaining resident health records out of four sample residents. Specifically, the facility failed to ensure physicians' progress notes for Resident #1 were available in the electronic medical record (EMR). Findings include:I. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 9/4/21 and discharged to the hospital on 6/8/25. According to the June 2025 computerized physician orders (CPO), diagnoses included high blood pressure, diabetes mellitus and Alzheimer’s disease. The 5/8/25 minimum data set (MDS) assessment revealed Resident #1 was unable to complete the brief interview for mental status (BIMS) assessment. Resident #1 was assessed by staff to be severely impaired in cognition and daily decision-making. The assessment revealed Resident #1 was dependent on staff for all activities of daily living (ADL). Resident #1 did not walk and was dependent on staff for mobility with a manual wheelchair. B. Record reviewRecord review revealed there were no physician’s progress notes in Resident #1's EMR after 1/15/25. As a result, physician’s records were unavailable for review during the survey. II. Staff interviewsThe director of nursing (DON) and the nursing home administrator in training were interviewed together on 10/14/25 at 3:15 p.m. The DON said she was unable to locate the physician's progress notes in Resident #1’s EMR after 1/15/25. The DON said the previous physician documented in a system separate from the facility’s EMR. The DON said that she was able to contact the former physician and request records as needed, and the documents would be available either late evening or on 10/15/25. The DON said the facility obtained physician services from a new provider in July 2025, and the facility had been working with the new provider to ensure documentation was available in residents’ EMRs.

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 waiver. A plan of correction is not required.

A revisit survey was completed on 4/8/24 for all previous deficiencies cited on 2/8/24. The facility is in compliance with all regulations surveyed.

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 4/8/24 for all previous deficiencies cited on 2/8/24. The facility is in compliance with all regulations surveyed.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only, and are a representation of the facility's general characteristics. The facility is a one story Type V (000) structure with a complete National Fire Protection Association (NFPA) 13 automatic fire suppression system. The building is slab-on-grade construction without a basement. The survey was conducted on March 07, 2024 for compliance with the NFPA 101 Life Safety Code, 2012 Edition, Chapter 19 and referenced Publications. The following deficiencies were discussed with the Maintenance Director during the survey, and with the Maintenance Director and the Administrator at the conclusion of the survey.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code Sections 7.8.1.1.and 7.9.2.3. 1. Missing multiple monthly inspection reports (Jul, Aug, Sep)NFPA 101, 7.9.2.3. The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1. No previous Semi-Annual Cleaning or Inspection reports available for review NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at leastevery 6 months. 11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. 11.4 Table Systems serving moderate-volume cooking operations SemiannuallyThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. No semi annual fire alarm report available for reviewNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should a delay occur in locating a fire throughout the facility. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101.1. No 5 year internal report available for inspectionNFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1. Storage door does not latch into frameNFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesNFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Fire Drills | No drills recorded for 1st shift, 4th quarter | 2nd and 3rd shift, 3rd quarter | 1st shift, 2nd quarter NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:1. No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

A recertification survey with complaint #CO33766 was completed from 2/5/24 to 2/8/24. Ten deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/5/24 to 2/8/24. No deficiencies were cited.

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning staff, laundry and housekeeping. Findings include:I. Facility policy and procedureThe Grievance policy, which was undated, was provided by the nursing home administrator (NHA) on 2/7/24 at 11:05 a.m. It read it pertinent part, "All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response."Upon receipt of a grievance or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance. "The resident, or person filing the grievance on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and any actions that will be taken to correct any identified problems."II. Resident interviewsResident #13 was interviewed on 2/5/24 at 10:46 a.m. She said the facility did not follow up on grievances brought up in the resident council meetings. She said she had brought up grievances regarding call lights and staffing but the facility had not followed up with a resolution. The resident council president, Resident #3, was interviewed on 2/6/24 at 3:13 p.m. She said the resident council had brought up grievances regarding call lights, staffing shortages and rooms not getting cleaned enough. Resident #3 said when a grievance came up in the resident council meeting the department head tried to address it during the meeting. If it was an individual grievance the department head would follow up with the individual resident. If it was a group grievance a resolution was not brought back to the next resident council meeting by the facility. III. Record reviewA review of the resident council meeting minutes dated 11/8/23 revealed group grievances concerning beds not being made, not enough staff in the facility, one CNA's attitude and residents getting other residents' clothes returned from the laundry department. A review of the resident council meeting minutes dated 12/13/23 revealed group grievances concerning resident rooms not getting cleaned. A review of the resident council meeting minutes dated 1/10/24 revealed group grievances regarding the facility needing more certified nurse aides (CNA). -There was no documentation in any of the resident council minutes to indicate resolutions were discussed with the resident council members for the grievances brought up at the 11/8/23, 12/13/3 or 1/10/24 resident council meetings. Resident council generated grievances for November 2023, December 2023 and January2024 were requested from the NHA on 2/7/24 at 2:51 p.m. Individual grievances for Resident #13 and Resident #3 were also requested at that time. -The NHA responded via email on 2/7/24 at 3:35 p.m. that there were no grievances for Resident #13 or Resident #3 or the concerns from the resident council meetings. IV. Staff interviews The social services consultant (SSC) was interviewed on 2/7/24 at 2:00 p.m. The SSC said the facility had hired a social services director (SSD) who started a few days before the survey. The SSC was filling in as the director from September 2023 until January 2024. He said resident council grievances should be handled the same as individual grievances. A grievance form should be completed and a resolution should be brought back to the council by the next meeting. He said he would look for resident council grievances. The NHA was interviewed on 2/8/24 at 9:46 a.m. The NHA said the social services department handled resident council grievances and the SSD was the grievance official. A grievance needed to be filled out on a grievance form and then the form was given to the department responsible for the resolution. A resolution should be brought back to the next resident council meeting for the group grievances. If it was an individual grievance, a follow up should be completed within 24-48 hours. -There were no grievances from the resident council meetings provided by the end of the survey on 2/8/24.

Based on observations and interviews the facility failed to post a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies and advocacy groups. Specifically, the facility failed to post a list of names, addresses, and telephone numbers of all pertinent state agencies, such as the State Survey Agency and the Office of the State Long-Term Care Ombudsman program. Findings include: I. Resident interview The resident council president, Resident #3, was interviewed on 2/6/24 at 3:13 p.m. She said she did not know where the facility posted contact information for State Agencies or the Ombudsman. The contact information and resident rights had been taken down approximately four months ago. II. Observations Observations on 2/5/24, 2/6/24, and 2/7/24 revealed there were no posting of names, addresses (mailing and email) and telephone numbers of pertinent State Agencies. There was no posting of the Ombudsman information. III. Interviews The nursing home administrator (NHA) was interviewed on 2/6/24 at approximately 4:00 p.m. The NHA said there was no posted information in regard to pertinent State Agencies. She said there had been a posting next to the dining room but residents kept tearing down the postings. The NHA said she was aware of the regulation that such information needed to be posted.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for six of 22 resident rooms in two hallways. Specifically, the facility failed to ensure blinds were intact in six resident rooms. Findings include:I. Environmental tour and interviewThe environmental tour was completed with the nursing home administrator (NHA) and the maintenance director (MTCE) on 2/8/24 at 9:03 a.m. The following items were found:Resident rooms #2, #4, #31, #33, #35 and #37 had broken blinds covering the windows. The NHA said prior to the ongoing change of ownership the facility was only ordering a few items at a time. She said the blinds may have been ordered previously and the facility was waiting for the delivery. She said it was important for the residents' privacy to have intact blinds. II. Record reviewThe December 2023 resident council meeting minutes documented the facility had informed the residents they were going to get estimates to replace the blinds. III. Facility follow upThe NHA provided an order receipt for the blinds dated 2/6/24, during the survey.

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for one (#13) out of 17 sample residents. Specifically, the facility failed to ensure the discharge planning process focused on Resident #13's discharge goals. Findings include: I. Resident #13A. Resident statusResident #13, age 78, was admitted on 1/15/19. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and developmental disorder of scholastic skills (learning disability). The 1/11/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She used a wheelchair for mobility and required substantial staff assistance with transfers, toileting, showering, and dressing. The section about discharge planning and goals revealed the resident had not been interviewed but had been interviewable. The legal representative was interviewed and there were no plans for discharge. B. Resident interviewThe resident was interviewed on 2/5/24 at 10:46 a.m. She said the facility would not let her leave and she did not know why. No one had explained to her why she was unable to leave and she did not want to live in the facility anymore. The resident became emotional and could not further articulate where she wanted to be discharged. C. Record reviewThe resident had a medical durable power of attorney for assistance with medical decisions dated 11/16/02. -There were no documents in the resident's medical record showing the resident was unable to make decisions. The comprehensive care plan, revised 1/11/21, revealed the resident required extensive assistance with bathing and toileting. The resident required limited to set up assistance with mobility, dressing and personal hygiene. The resident or family expressed a preference to remain in long term care at the facility. The resident at times made statements of wanting to return to the community. Interventions included to assess the resident on comprehensive assessments for discharge planning. A review of progress notes dated 10/1/23 to 2/6/24 failed to reveal concerns regarding discharge planning. Certified nurse aide (CNA) tasks (abbreviated care plan) revealed a task for discharge planning initiated on 4/24/23. It indicated if the resident made statements regarding wanting to return to the community, staff were to listen and validate the resident's concerns. Staff were to explain to the resident a discharge plan home was unrealistic and it was imperative she remain in 24 hour care. II. Staff interviewsThe social services consultant (SSC) was interviewed on 2/7/24 at 2:00 p.m. The SSC said the facility had hired a social services director who started a few days before the survey. The SSC was filling in as the director from September 2023 until January 2024. The social worker was responsible for assisting residents with discharge planning. If a resident consistently brought up wanting to discharge and there were efforts made to assist the resident with discharge planning, the care plan should be updated to reflect. The SSC said the resident's family wanted her to remain in long term care but Resident #13 was able to make her own decisions. The resident had told the SSC she had a friend who she could live with but did not have contact information. The SSC said if the resident provided him with contact information, he would have followed up with her friends to discuss if a discharge plan was feasible. He could not recall exactly when he had these conversations with the resident. The SSC said he would look for documentation of the discharge planning conversations. The SSC was interviewed on 2/8/24 at 9:45 a.m. He said he just checked in with the resident this morning regarding discharge planning. He said the resident would let him know when she was ready to discharge but currently didnot have a formulated plan. He was not able to find documentation of prior conversations. The NHA was interviewed on 2/8/24 at 9:46 a.m. She said there had not been conversations with the resident regarding discharge planning. The resident would become anxious and conversations regarding discharge would have done the resident more harm than good. The conversations consisted of redirecting the resident to another topic or an activity. The NHA said she would look to see if there were any care conference notes regarding discharge conversations with the resident. -There was no additional documentation provided by the time of exit on 2/8/24.

Based on observations, record review and interviews, the facility failed to ensure residents received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable for one (#23) of two residents reviewed for mobility out of 17 sample residents. Specifically, the facility failed to ensure a carrot contracture prevention device was placed according to physician orders for Resident #23. Findings include:I. Resident #23A. Resident statusResident #23, age over 65, was admitted on 2/6/23 and readmitted on 11/29/23. According to the January 2024 computerized physician orders (CPO), diagnoses included muscle weakness and Parkinson's disease. The 11/15/23 minimum data set (MDS) assessment revealed the resident's mental status was severely impaired. The assessment did not identify functional limitations in the upper extremities. B. ObservationsResident #23 was in her room on 2/5/23 at 9:53 a.m. with no carrot splint in her hand. Resident #23 was in her room on 2/6/23 at 9:30 a.m. with no carrot splint in her hand. C. Record reviewThe care plan, initiated 2/23/23 and revised on 1/15/24, identified the resident was at risk for skin tears and bruises. Interventions included an orange carrot palm protector to the left hand, on in the morning and off at noon. Check skin before and after application.-The resident did not have a care plan focus that addressed the contracture of the resident's left hand. Review of the February 2024 CPO revealed the following physician order:Place orange carrot in left hand in morning upon awakening and remove at midday. Check for red areas or skin breakdown two times a day for contracture. The occupational therapy (OT) note dated 12/10/23 documented Resident #23 was tolerating wearing the left hand carrot splint. The OT discharge summary note dated 12/14/23 documented Resident #23 was wearing the left hand carrot splint in the palm to reduce the risk of skin breakdown.-There was no documentation in the resident's electronic medical record (EMR) to indicate Resident #23 was refusing to wear the carrot splint. D. InterviewsCertified nurse aide (CNA) #2 was interviewed on 2/6/24 at 9:50 a.m. CNA #2 said Resident #23 often pulled the carrot out of her hand. She said she would report it to the nurse who would attempt to replace the carrot three times. After the third time, the carrot would be put away. She said the nurse was the person responsible for placing the carrot. She said the resident only wore the device in the mornings. Licensed practical nurse (LPN) #1 was interviewed on 2/6/24 at 10:00 a.m. LPN #1 said the carrot would be placed in Resident #23's left hand in the morning and taken out at 12:00 p.m. She said the resident did not like the carrot and would pull it out. She said after three attempts she would stop trying to replace the carrot in the resident's hand and put it away. She said if the resident refused to let her put the carrot in her hand she would not force her to wear it. The director of nursing (DON) was interviewed on 2/7/24 at 10:01 a.m. The DON said the nurses were to put the carrot in Resident #23's left hand in the morning and remove it at lunch. She said when the carrot was applied the nurses were to assess her skin for any breakdown. She said the resident did remove the carrot by herself. She said if an aide found the carrot they were to give it to the nurse for her to reapply the carrot. She said if the resident removed it repeatedly or refused to wear it, there should be a nurse note documented so the team would know the resident was refusing to wear the device. She said the resident was not getting the benefits of contracture prevention when the carrot was not put in her left hand consistently.. She said she would talk to the staff about documenting the resident's refusals of the carrot and report the refusals to the provider and the therapist.

Based on observations, interviews and record review, the facility failed to ensure the environment was free of accidents and hazards for two (#16 and #4) of four residents reviewed for falls out of 17 sample residents. Resident #16, who was at high risk for falls, sustained 17 falls from 9/4/23 to 1/31/24. The facility failed to ensure fall interventions were implemented after each fall and implement effective interventions when they were added. The resident, who required maximum assistance with toileting according to her care plan, often fell trying to go to the bathroom. Due to the facility's failures to implement effective interventions, Resident #16 had a major injury on 1/9/24 when she fell trying to go to the bathroom which required hospital treatment for a head laceration where she had two staples. Observations during the survey from 2/5/24 to 2/8/24 revealed the facility had not consistently implemented fall interventions. In addition, the facility failed to ensure fall interventions were utilized consistently for Resident #4. Findings include:I. Resident #16A. Resident statusResident #16, age 89, was admitted on 7/15/22. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and diabetes. The 10/2/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment and was unable to complete a brief interview for mental status (BIMS). The resident had behaviors of delusions and wandering. She used a wheelchair for mobility and required maximum staff assistance with transfers and ambulation. It indicated the resident had two or more falls since the prior assessment. B. ObservationsOn 2/5/24 at 10:46 a.m. Resident #16 was observed in her bed. The bed was not in the lowest position and the resident did not have a fall mat next to her bed. No positioning device was observed in the resident's wheelchair (indicated as an intervention, see below). On 2/6/24 at 1:15 p.m. Resident #16 was observed propelling herself down the hallway towards her room. There were no staff present in the resident's hallway. When the resident approached the door, she locked her brakes and stood up. Her nasal cannula was still in her nose and her oxygen concentrator was still attached to the back of her wheelchair. The resident attempted to walk into her room but she was attached to the wheelchair via her oxygen tubing. The resident eventually removed her cannula and started to walk inside her room and towards her bathroom. At 1:21 p.m., a certified nurse aide (CNA) walking past the hallway noticed the resident's wheelchair in the hallway and came into the resident's room to assist. No positioning device was observed in the resident's wheelchair. C. Record reviewThe fall care plan, initiated on 7/27/22, revealed the resident had a history of falls and used an assistive device. Interventions initiated 7/27/22 included providing a therapy evaluation as indicated, call light within reach, bed in low position, and side rails up while the resident was in bed. Interventions initiated 10/13/22 included call light and personal items within reach, and educating the resident on using the call light. Interventions initiated 3/20/23 included providing a call light with a longer cord to reach the recliner and offer non skid socks. Interventions initiated 7/26/23 included non slip matting added to the resident's recliner and non skid strips by the bed and recliner. Interventions initiated 1/10/24 included fall mat by bed and lipped mattress. -The fall care plan interventions did not include frequent checks or anticipating toileting needs. The resident fell 17 times between 9/4/23 and 1/31/24 and the care plan did not reflect additions to interventions or modifications in response. The activities of daily living (ADL) care plan, revised on 1/10/24 revealed the resident required limited to total assistance with her activities of daily living. The resident did not acknowledge her limitations or use her call light for assistance. The resident required maximum assistance with transfers and toileting.-The CNA tasks (abbreviated care plan) did not reveal fall interventions. The February 2024 CPO revealed the following physician orders:Non skid strips in front of the recliner and bed. Non skid strips on recliner cushion- ordered on 3/23/23; Physical therapy to evaluate for vertigo related to falls and complaints of dizziness- ordered on 9/7/23; Send resident for magnetic resonance imaging (MRI) for confusion with new onset of gait disturbance- ordered on 9/12/23; Buspirone (antianxiety) 10 MG- give two times daily for anxiety- ordered on 2/2/24; and, Fall mat placed when in bed- ordered on 2/7/24 (during survey).-No orders for fall mats, positioning devices, or alarms were located prior to the survey. The fall incident report dated 9/4/23 to 1/31/24 revealed:1. Fall incident 9/4/23 According to the 9/4/23 interdisciplinary (IDT) fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she had taken her oxygen off and she could not recall how she fell. No injuries were observed. The interventions included decreasing a medication the resident complained made her feel dizzy. 2. Fall incident 9/7/23According to the 9/7/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she had become dizzy. No injuries were observed. The interventions included encouraging the resident to utilize the call light to ask for assistance. 3. Fall incident 9/14/23According to the 9/14/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she fell while trying to go to the bathroom. She complained of pain in her hip. No injuries were observed. The interventions included making frequent rounds on the resident. 4. Fall incident 9/19/23According to the 9/19/23 IDT fall incident report, the resident sustained a witnessed fall while taking herself to the bathroom in her room. The staff said the resident was not wearing her oxygen or her shoes. No injuries were observed. -It did not include any new interventions. 5. Fall incident 9/25/23According to the 9/25/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she fell while trying to go to the bathroom. A skin tear to her finger was observed. -It did not include any new interventions. 6. Fall incident 10/1/23According to the 10/1/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident was unable to explain why she fell. No injuries were observed. -It did not include any new interventions. 7. Fall incident 10/2/23According to the 10/2/23 IDT fall incident report, the resident sustained an unwitnessed fall. The resident said she had slipped and fallen. No injuries were observed. -The interventions included encouraging the resident to utilize the call light to ask for assistance. 8. Fall incident 10/3/23According to the 10/3/23 IDT fall incident report, the resident sustained an unwitnessed fall while trying to get up. The resident was confused and disorientated. Bruises to the right elbow and left elbow were observedThe intervention indicated the nursing home administrator had ordered bed and chair alarms.-However, the nurse was unable to find any within the facility. 9. Fall incident 10/17/23According to the 10/17/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she had slipped and fallen. A bruise was observed on the resident's posterior right forearm. -It did not include any new interventions. 10. Fall incident 11/5/23According to the 11/5/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident had been incontinent in her bed and slipped. No injuries were observed. The interventions included encouraging the resident to utilize the call light to ask for assistance and implement a fall mat. 11. Fall incident 11/19/23According to the 11/19/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. No injuries were observed. -It did not include any new interventions. 12. Fall incident 11/20/23According to the 11/20/23 IDT fall incident report, the resident sustained a witnessed fall when her legs buckled. The resident said she was trying to get up to get into her wheelchair. No injuries were observed. -It did not include any new interventions. 13. Fall incident 12/19/23According to the 12/19/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she was trying to go to the bathroom. No injuries were observed. -It did not include any new interventions. 14. Fall incident 12/27/23According to the 12/27/23 IDT fall incident report, the resident sustained a witnessed fall at 8:06 a.m. when she slid out of her bed. The resident said she was trying to put her shoes on. No injuries were observed. The interventions included encouraging the resident to utilize the call light to ask for assistance. 15. Fall incident 12/27/23According to the 12/27/23 IDT fall incident report, the resident sustained an unwitnessed fall at 5:01 p.m. while taking herself to the bathroom in her room. The resident said she was trying to go to the bathroom. No injuries were observed. -It did not include any new interventions. 16. Fall incident 1/9/24According to the 1/9/24 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she was trying to go to the bathroom. The resident was observed with blood on her face, a laceration to the top of her scalp, and a skin tear to her right forearm. The resident was sent out to the hospital. The resident received two staples at the hospital and was returned to the facility. The fall intervention indicated a wheelchair positioning device was requested by the power of attorney (POA). 17. Fall incident 1/31/24According to the 1/31/24 IDT fall incident report, the resident sustained an unwitnessed fall while trying to get into her bed. The resident said she was trying to go to bed. Redness was observed to the resident's right anterior ankle. The intervention included encouraging the resident to utilize the call light to ask for assistance. D. Staff interviewsCNA #3 was interviewed on 2/5/24 at 1:30 p.m. CNA #3 said Resident #16 was a high fall risk and had fall interventions when in bed keeping her bed in the lowest position and using a fall mat. The resident did not have interventions of frequent checks or routine toileting. Licensed practical nurse (LPN) #3 was interviewed on 2/6/24 at 10:35 a.m. LPN #3 said Resident #16 had behaviors of impatience and impulsivity. The resident was at a high fall risk and the interventions were to utilize a fall mat when she was in bed, check on the resident frequently, and toilet the resident before and after meals. The resident frequently fell when attempting to toilet herself and did not remember how to use the call light. The director of nursing (DON) was interviewed on 2/7/24 at 10:22 a.m. She said the facility evaluated a resident's circumstances after a fall and made recommendations for fall interventions based on the circumstances and resident status. Fall interventions were updated in the care plan and the CNA tasks. The DON did not know the resident's fall interventions. She was recently put on anti anxiety medication to decrease anxiety to reduce falls. The DON stated the facility had not identified any recurring theme to the resident's fallsand she was not aware the resident had been trying to toilet herself before the majority of the falls. The nurse practitioner (NP) was interviewed on 2/8/24 at 11:00 a.m. Resident #16 had fall interventions of a low bed and occupational therapy as needed. The NP had put the resident onto comfort care because it appeared she was declining but the resident had recently returned to her baseline. The resident was at risk for falls related to manipulative behaviors. The resident would throw herself on the floor for attention. The NP said there was a staff member who stayed in the hallway to monitor the resident and sometimes the nurses took the resident to the nurses station to be monitored. II. Resident #4A. Resident statusResident #4, age over 65, was admitted on 2/2/22 and readmitted on 11/11/22. According to the January 2024 CPO, diagnoses included muscle weakness, spondylolisthesis lumbar region (occurs when one vertebra in the spinal column becomes fractured and the spine slips out of place, usually in the lumbar area) and osteoarthritis. The 11/9/23 MDS assessment revealed the resident's mental status was not impaired with a (BIMS score of 13 out of 15. She had no behaviors or rejections of care. B. ObservationsResident #4 was in her bed on 2/5/24 at 10:45 a.m. The fall mat was tucked in between the headboard of the bed and the wall and her wheelchair was next to her bed. Resident #4 was in her bed on 2/6/24 at 2:45 p.m. The fall mat was not next to her bed and her wheelchair was placed next to her bed. C. Record reviewThe care plan, initiated 2/28/22 and revised on 11/16/23, identified the potential for falls related to a history of falls, unsteady gait, and the use of an assistive device. Interventions included to have the fall mat by the bed when Resident #4 was in bed. Review of Resident #4's electronic medical record revealed the resident sustained two falls in January 2024. D. InterviewsCNA #1 was interviewed on 2/6/24 at 2:50 p.m. She said Resident #4's fall mat was only used at night. She said the resident preferred the fall mat only at night. LPN #1 was interviewed on 2/6/24 at 2:55 p.m. She said Resident #4's fall mat was only for night. She said during the day the fall mat was a trip hazard. She said the resident preferred to not have the mat by her bed during the day. She said the resident preferred the wheelchair be placed next to the bed during the day. The DON was interviewed on 2/7/24 at 10:01 a.m. She said the fall mat needed to be next to the bed every time the resident was in bed. She said she was not aware the mat was only being used at night. She said with the resident's history of falls, the mat needed to be utilized every time she was laying in bed. She said the wheelchair next to the bed could cause more injury if there was a fall. She said she would provide education to the staff.

Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively a day for seven days a week. Specifically, the facility failed to have a RN on duty for eight consecutive hours on a consistent basis from 11/1/23 to 2/5/24. Findings include:I. Record reviewReview of the nursing schedule from 11/1/23 to 2/5/24 revealed the following:-In November 2023, the facility did not have a RN on duty for eight consecutive hours on seven days during the month;-In December 2023, the facility did not have a RN on duty for eight consecutive hours on seven days during the month;-In January 2024, the facility did not have a RN on duty for eight consecutive hours on four days during the month; and,-In February 2024, from 2/1/24 to 2/5/24, the facility did not have a RN on duty for eight consecutive hours for one day. II. Staff interviewThe director of nursing (DON) was interviewed on 2/7/24 at 10:26 a.m. She said she was not aware of the federal requirement regarding the need for a RN for eight consecutive hours seven days a week. She said going forward she would do her best to meet the federal requirement for the safety of the residents.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #3, CNA #4 and CNA #5. Findings include:I. Record reviewCNA #3 (hired on 10/20/15), CNA #4 (hired on 6/16/93) and CNA #5 (hired on 10/1/21) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. InterviewThe director of nursing (DON) was interviewed on 2/7/24 at 10:30 a.m. She said she could not locate the performance reviews for CNA #3, CNA #4 and CNA #5. She said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews were completed annually to ensure best care was being delivered to the residents.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of one medication rooms. Specifically, the facility failed to date a multi use vial of tuberculin when opened. Findings include:I. Professional referenceAccording to the Tubersol package insert, retrieved 2/12/24 from: https://www.fda.gov/media/74866/download, "A vial of Tubersol which has been entered and in use for 30 days should be discarded."II. Observation and interviewThe medication room was reviewed on 2/6/24 at 1:15 p.m. An opened multi use vial of Tubersol was in the refrigerator. -There was no date on the vial to indicate when the medication was opened. Licensed practical nurse (LPN) #1 said she did not know when the vial was opened. She said it should have been dated when opened for the safety of the residents. III. Additional interviewThe director of nursing (DON) was interviewed on 2/6/24 at 3:30 p.m. She said Tubersol was good for 30 days after opening. She said the vial should have been dated when opened to make sure the medication was safe for residents.

Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for four (#13, #3, #16 and #20) of five residents reviewed for vaccinations of 17 sample residents. Specifically, the facility failed to ensure Residents #13, #3, #16 and #20 were offered and/or received pneumococcal immunization. Findings include:Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), Pneumococcal Vaccine Recommendations website, revised 9/21/23, retrieved on 2/13/24 from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html read in pertinent part,"CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown:"If PCV15 is used, this should be followed by a dose of PPSV23 one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak."According to the CDC Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 3/27/23 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. It read, in pertinent part,"The pneumococcal vaccine was to be administered to immunocompetent adults aged 65 years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV 23."For special situations (see-www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4. htm): individuals aged 19-64 years with chronic medical conditions (chronic heart excluding hypertension, lung, or liver disease, diabetes), alcoholism, or cigarette smoking: give 1 dose PPSV23."II. Resident #13 Resident #13, age 78, was admitted on 1/15/19. The medical record revealed the resident declined the influenza vaccination on 12/6/23 and her pneumococcal vaccination was not up-to-date. The minimum data set (MDS) assessment dated 1/11/24 indicated the resident had refused the influenza vaccine and the pneumococcal vaccine.-The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. III. Resident #3 Resident #3, age 79, was admitted on 11/7/19. The medical record revealed the resident received the influenza vaccination on 11/30/23 and her pneumococcal vaccination was not up-to-date. The MDS assessment dated 11/19/23 indicated the resident had received the influenza vaccine and had not been offered the pneumococcal vaccine.-The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. IV. Resident #16 Resident #16, age 89, was admitted on 7/15/22. The medical record revealed the resident declined the influenza vaccination on 11/30/23 and her pneumococcal vaccination was not up-to-date. The MDS assessment dated 11/2/23 revealed the section pertaining to vaccines had not been completed. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. V. Resident #20 Resident #20, age 77, was admitted on 7/7/22. The medical record revealed the resident received the influenza vaccination on 10/30/23 and her pneumococcal vaccination was not up-to-date. The MDS assessment dated 1/14/24 indicated the resident had received the influenza vaccine and had declined the pneumococcal vaccine.-The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. V. Staff interviewsThe nursing home administrator (NHA) was interviewed on 2/8/24 at 9:46 a.m. She said she did not know if the facility had documentation of pneumococcal vaccines being offered to the residents. The NHAwould have to look for the records. The infection preventionist (IP) was responsible for the tracking but was not available for interview during the survey. The nurse practitioner (NP) was interviewed on 2/8/24 at 11:00 a.m. She said the residents should be offered the pneumococcal vaccine when they enter the facility if there was no record of the vaccine being given. Proof of the vaccine being offered or refused with education should be in the resident's medical record at the facility.-There was no pneumococcal vaccine documentation provided by the exit on 2/8/24.

A survey prompted by complaint #CO35066 was completed 2/5/28 to 2/8/24. One deficiency was cited.

Based on observations, interviews and record review, the facility failed to ensure the environment was free of accidents and hazards for two (#16 and #4) of four residents reviewed for falls out of 17 sample residents. Resident #16, who was at high risk for falls, sustained 17 falls from 9/4/23 to 1/31/24. The facility failed to ensure fall interventions were implemented after each fall and implement effective interventions when they were added. The resident, who required maximum assistance with toileting according to her care plan, often fell trying to go to the bathroom. Due to the facility's failures to implement effective interventions, Resident #16 had a major injury on 1/9/24 when she fell trying to go to the bathroom which required hospital treatment for a head laceration where she had two staples. Observations during the survey from 2/5/24 to 2/8/24 revealed the facility had not consistently implemented fall interventions. In addition, the facility failed to ensure fall interventions were utilized consistently for Resident #4. Findings include:I. Resident #16A. Resident statusResident #16, age 89, was admitted on 7/15/22. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and diabetes. The 10/2/23 facility assessment revealed the resident had a severe cognitive impairment and was unable to complete a brief interview for mental status (BIMS). The resident had behaviors of delusions and wandering. She used a wheelchair for mobility and required maximum staff assistance with transfers and ambulation. It indicated the resident had two or more falls since the prior assessment. B. ObservationsOn 2/5/24 at 10:46 a.m. Resident #16 was observed in her bed. The bed was not in the lowest position and the resident did not have a fall mat next to her bed. No positioning device was observed in the resident's wheelchair (indicated as an intervention, see below). On 2/6/24 at 1:15 p.m. Resident #16 was observed propelling herself down the hallway towards her room. There were no staff present in the resident's hallway. When the resident approached the door, she locked her brakes and stood up. Her nasal cannula was still in her nose and her oxygen concentrator was still attached to the back of her wheelchair. The resident attempted to walk into her room but she was attached to the wheelchair via her oxygen tubing. The resident eventually removed her cannula and started to walk inside her room and towards her bathroom. At 1:21 p.m., a certified nurse aide (CNA) walking past the hallway noticed the resident's wheelchair in the hallway and came into the resident's room to assist. No positioning device was observed in the resident's wheelchair. C. Record reviewThe fall care plan, initiated on 7/27/22, revealed the resident had a history of falls and used an assistive device. Interventions initiated 7/27/22 included providing a therapy evaluation as indicated, call light within reach, bed in low position, and side rails up while the resident was in bed. Interventions initiated 10/13/22 included call light and personal items within reach, and educating the resident on using the call light. Interventions initiated 3/20/23 included providing a call light with a longer cord to reach the recliner and offer non skid socks. Interventions initiated 7/26/23 included non slip matting added to the resident's recliner and non skid strips by the bed and recliner. Interventions initiated 1/10/24 included fall mat by bed and lipped mattress. -The fall care plan interventions did not include frequent checks or anticipating toileting needs. The resident fell 17 times between 9/4/23 and 1/31/24 and the care plan did not reflect additions to interventions or modifications in response. The activities of daily living (ADL) care plan, revised on 1/10/24 revealed the resident required limited to total assistance with her activities of daily living. The resident did not acknowledge her limitations or use her call light for assistance. The resident required maximum assistance with transfers and toileting.-The CNA tasks (abbreviated care plan) did not reveal fall interventions. The February 2024 CPO revealed the following physician orders:Non skid strips in front of the recliner and bed. Non skid strips on recliner cushion- ordered on 3/23/23; Physical therapy to evaluate for vertigo related to falls and complaints of dizziness- ordered on 9/7/23; Send resident for magnetic resonance imaging (MRI) for confusion with new onset of gait disturbance- ordered on 9/12/23; Buspirone (antianxiety) 10 MG- give two times daily for anxiety- ordered on 2/2/24; and, Fall mat placed when in bed- ordered on 2/7/24 (during survey).-No orders for fall mats, positioning devices, or alarms were located prior to the survey. The fall incident report dated 9/4/23 to 1/31/24 revealed:1. Fall incident 9/4/23 According to the 9/4/23 interdisciplinary (IDT) fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she had taken her oxygen off and she could not recall how she fell. No injuries were observed. The interventions included decreasing a medication the resident complained made her feel dizzy. 2. Fall incident 9/7/23According to the 9/7/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she had become dizzy. No injuries were observed. The interventions included encouraging the resident to utilize the call light to ask for assistance. 3. Fall incident 9/14/23According to the 9/14/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she fell while trying to go to the bathroom. She complained of pain in her hip. No injuries were observed. The interventions included making frequent rounds on the resident. 4. Fall incident 9/19/23According to the 9/19/23 IDT fall incident report, the resident sustained a witnessed fall while taking herself to the bathroom in her room. The staff said the resident was not wearing her oxygen or her shoes. No injuries were observed. -It did not include any new interventions. 5. Fall incident 9/25/23According to the 9/25/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she fell while trying to go to the bathroom. A skin tear to her finger was observed. -It did not include any new interventions. 6. Fall incident 10/1/23According to the 10/1/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident was unable to explain why she fell. No injuries were observed. -It did not include any new interventions. 7. Fall incident 10/2/23According to the 10/2/23 IDT fall incident report, the resident sustained an unwitnessed fall. The resident said she had slipped and fallen. No injuries were observed. -The interventions included encouraging the resident to utilize the call light to ask for assistance. 8. Fall incident 10/3/23According to the 10/3/23 IDT fall incident report, the resident sustained an unwitnessed fall while trying to get up. The resident was confused and disorientated. Bruises to the right elbow and left elbow were observedThe intervention indicated the nursing home administrator had ordered bed and chair alarms.-However, the nurse was unable to find any within the facility. 9. Fall incident 10/17/23According to the 10/17/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she had slipped and fallen. A bruise was observed on the resident's posterior right forearm. -It did not include any new interventions. 10. Fall incident 11/5/23According to the 11/5/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident had been incontinent in her bed and slipped. No injuries were observed. The interventions included encouraging the resident to utilize the call light to ask for assistance and implement a fall mat. 11. Fall incident 11/19/23According to the 11/19/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. No injuries were observed. -It did not include any new interventions. 12. Fall incident 11/20/23According to the 11/20/23 IDT fall incident report, the resident sustained a witnessed fall when her legs buckled. The resident said she was trying to get up to get into her wheelchair. No injuries were observed. -It did not include any new interventions. 13. Fall incident 12/19/23According to the 12/19/23 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she was trying to go to the bathroom. No injuries were observed. -It did not include any new interventions. 14. Fall incident 12/27/23According to the 12/27/23 IDT fall incident report, the resident sustained a witnessed fall at 8:06 a.m. when she slid out of her bed. The resident said she was trying to put her shoes on. No injuries were observed. The interventions included encouraging the resident to utilize the call light to ask for assistance. 15. Fall incident 12/27/23According to the 12/27/23 IDT fall incident report, the resident sustained an unwitnessed fall at 5:01 p.m. while taking herself to the bathroom in her room. The resident said she was trying to go to the bathroom. No injuries were observed. -It did not include any new interventions. 16. Fall incident 1/9/24According to the 1/9/24 IDT fall incident report, the resident sustained an unwitnessed fall while taking herself to the bathroom in her room. The resident said she was trying to go to the bathroom. The resident was observed with blood on her face, a laceration to the top of her scalp, and a skin tear to her right forearm. The resident was sent out to the hospital. The resident received two staples at the hospital and was returned to the facility. The fall intervention indicated a wheelchair positioning device was requested by the power of attorney (POA). 17. Fall incident 1/31/24According to the 1/31/24 IDT fall incident report, the resident sustained an unwitnessed fall while trying to get into her bed. The resident said she was trying to go to bed. Redness was observed to the resident's right anterior ankle. The intervention included encouraging the resident to utilize the call light to ask for assistance. D. Staff interviewsCNA #3 was interviewed on 2/5/24 at 1:30 p.m. CNA #3 said Resident #16 was a high fall risk and had fall interventions when in bed keeping her bed in the lowest position and using a fall mat. The resident did not have interventions of frequent checks or routine toileting. Licensed practical nurse (LPN) #3 was interviewed on 2/6/24 at 10:35 a.m. LPN #3 said Resident #16 had behaviors of impatience and impulsivity. The resident was at a high fall risk and the interventions were to utilize a fall mat when she was in bed, check on the resident frequently, and toilet the resident before and after meals. The resident frequently fell when attempting to toilet herself and did not remember how to use the call light. The director of nursing (DON) was interviewed on 2/7/24 at 10:22 a.m. She said the facility evaluated a resident's circumstances after a fall and made recommendations for fall interventions based on the circumstances and resident status. Fall interventions were updated in the care plan and the CNA tasks. The DON did not know the resident's fall interventions. She was recently put on anti anxiety medication to decrease anxiety to reduce falls. The DON stated the facility had not identified any recurring theme to the resident's falls and she was not aware the resident had been trying to toilet herself before the majority of the falls. The nurse practitioner (NP) was interviewed on 2/8/24 at 11:00 a.m. Resident #16 had fall interventions of a low bed and occupational therapy as needed. The NP had put the resident onto comfort care because it appeared she was declining but the resident had recently returned to her baseline. The resident was at risk for falls related to manipulative behaviors. The resident would throw herself on the floor for attention. The NP said there was a staff member who stayed in the hallway to monitor the resident and sometimes the nurses took the resident to the nurses station to be monitored. II. Resident #4A. Resident statusResident #4, age over 65, was admitted on 2/2/22 and readmitted on 11/11/22. According to the January 2024 CPO, diagnoses included muscle weakness, spondylolisthesis lumbar region (occurs when one vertebra in the spinal column becomes fractured and the spine slips out of place, usually in the lumbar area) and osteoarthritis. The 11/9/23 facility assessment revealed the resident's mental status was not impaired with a (BIMS score of 13 out of 15. She had no behaviors or rejections of care. B. ObservationsResident #4 was in her bed on 2/5/24 at 10:45 a.m. The fall mat was tucked in between the headboard of the bed and the wall and her wheelchair was next to her bed. Resident #4 was in her bed on 2/6/24 at 2:45 p.m. The fall mat was not next to her bed and her wheelchair was placed next to her bed. C. Record reviewThe care plan, initiated 2/28/22 and revised on 11/16/23, identified the potential for falls related to a history of falls, unsteady gait, and the use of an assistive device. Interventions included to have the fall mat by the bed when Resident #4 was in bed. Review of Resident #4's electronic medical record revealed the resident sustained two falls in January 2024. D. InterviewsCNA #1 was interviewed on 2/6/24 at 2:50 p.m. She said Resident #4's fall mat was only used at night. She said the resident preferred the fall mat only at night. LPN #1 was interviewed on 2/6/24 at 2:55 p.m. She said Resident #4's fall mat was only for night. She said during the day the fall mat was a trip hazard. She said the resident preferred to not have the mat by her bed during the day. She said the resident preferred the wheelchair be placed next to the bed during the day. The DON was interviewed on 2/7/24 at 10:01 a.m. She said the fall mat needed to be next to the bed every time the resident was in bed. She said she was not aware the mat was only being used at night. She said with the resident's history of falls, the mat needed to be utilized every time she was laying in bed. She said the wheelchair next to the bed could cause more injury if there was a fall. She said she would provide education to the staff.