LARCHWOOD INNS

A licensure survey with #CO3004228 was completed on 5/18/26 to 5/21/26. Three deficiencies were cited.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent and treat pressure injuries for one (#9) of six residents reviewed for pressure injuries out of 41 sample residents. Specifically, the facility failed to ensure staff consistently implemented care planned interventions for Resident #9, who had an unstageable pressure injury to her right heel. Findings include:I. Professional referenceAccording to Basic Nursing third edition; Leslie S. Treas, Karen Barnett, Mable H. Smith (2022), page 1214-1215, “Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin breakdown, muscle discomfort. People who are immobile are more prone to pressure injury as a result of reduced circulation, impaired oxygen exchange to the tissues and edema.”According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, Emily Haesler (Ed.), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 5/28/26,"Pressure ulcer classification is as follows:“Category/Stage 1: Nonblanchable Erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate ‘at risk’ individuals (a heralding sign of risk). “Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury. “Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.“Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. “Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. “Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility policy and procedureThe Pressure Ulcer Skin Breakdown policy, revised April 2018, was provided by the director of nursing (DON) on 5/20/26 at 2:00 p.m. It read in pertinent part,“The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure ulcers. “The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions, identify the type of an ulcer and define any complications related to pressure ulcers.“Healing or prevention likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic.“Healing or prevention possible: Healing may be delayed or may occur only partially; wounds may occur despite appropriate preventive efforts. “Monitoring during resident visits: The physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker.” III. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 10/8/25. According to the May 2026 computerized physician orders (CPO), diagnoses included osteoporosis, chronic obstructive pulmonary disease, peripheral vascular disease and anxiety. The 4/14/26 comprehensive assessment revealed Resident #9 had severe cognitive impairment. She needed partial to moderate assistance for activities of daily living (ADL). The comprehensive assessment indicated the resident had a pressure injury and she had a pressure reducing mattress. B. ObservationsOn 5/19/26 at 8:59 a.m. Resident #9 was lying in bed on her back and her protective podus boot was laying on the floor next to the bed. During a continuous observation on 5/20/26, beginning at 9:21 a.m. and ending at 11:38 a.m., Resident #9 was lying in bed on her back. The resident’s protective podus boot was laying on the floor next to the bed. -No staff members entered the room during the two hour and 17 minute observation. On 5/21/26 at 8:38 a.m. Resident #9 was lying in bed on her back and her protective podus boot was laying on the floor next to the bed. C. Record review The pressure ulcer care plan, initiated 10/28/25 and revised 3/11/26, revealed Resident #9 had a pressure ulcer to the right heel related to immobility. The pressure ulcer would show signs of healing and remain free from infection. The resident would have intact skin, free of redness, blisters or discoloration through the next review date. Interventions included administering treatments as ordered and monitoring for effectiveness, providing an alternating air mattress with fitness setting three continuously, assessing, recording and monitoring wound healing weekly and as needed, measuring length, width and depth of the wound where possible, assessing and documenting the status of the wound perimeter, wound bed and healing progress, reporting improvements and declines to the medical director (MD), educating the resident, family and caregivers as to causes of skin breakdown, including transfer and positioning requirements; importance of good nutrition and frequent repositioning, following facility policies and protocols for the prevention and treatment of skin breakdown, heel protectors on the resident’s bilateral feet and reminding the resident and assisting the resident to turn and reposition at least frequently. A nurse skin assessment note, dated 10/25/26, revealed Resident #9’s right heel had an approximately four centimeter (cm) diameter dark red and purple discoloration that was tender to the touch. No broken skin was noted to the area. The surrounding skin area was pink and blanching (turning pale or white). Recommendations were to apply skin prep to the area, float the resident’s heels while in bed and place protective booties on her heels. The resident’s heels were to be floated at all times to mitigate potential pressure. A nurse skin assessment note, dated 11/6/25, revealed Resient #9’s right heel wound was unstageable and measured at 2.6 cm long by 3.2 cm wide and 3.2 cm deep. The resident had an air mattress placed and had heels floating. A nurse skin note, dated 1/14/26, revealed the skin to Resident #9’s heel wound was dry and no drainage was noted. The wound nurse covered the area with a bordered foam dressing after measuring the wound to be 1.54 cm long by 2.11 cm wide by 0.4 cm deep. The resident removed her protective podus boots and had to be reminded to wear them. -However the care plan did not reflect the resident’s refusals or removal of the podus boots (see care plan above). A nurse skin note, dated 2/17/26, revealed Resident #9’s wound bed had minimal slough (soft tissue), no eschar (dead tissue) and epithelial (damage) tissue to the wound. The wound had improved. A new dressing was in place and boots were on the resident’s heels. Skin issue education was provided to staff to turn the resident every two hours.-However, observations revealed staff did not consistently reposition the resident (see observations above). A nurse note, dated 5/14/26, revealed the nurse was called to Resident #9’s room because the resident had removed the blue foam boot and the heel protector pad. The nurse made a foam heel cup instead of a slip-on protector covered the entire foot with a stockinette secured at the ankle to attempt to keep the dressing in place longer and reapplied foam boot. The resident stated she would leave the dressing alone.-However the care plan did not address the resident’s noncompliance to leave the dressing and the podus boot on. Review of Resident #9’s May 2026 CPO revealed the following physician’s orders: Wound care right heel: make sure podus boots are applied and heels are floated, every day and night shift, ordered 12/19/25 and discontinued 5/8/26. Wound care right heel: make sure socks and heel protectors are on and heels are floated every day and night shift, ordered 5/8/26. IV. Staff interviewsThe infection preventionist was interviewed on 5/19/26 at 7:50 a.m. The infection preventionist said she was responsible for the wound care for the residents. She said she was alerted when a resident had a skin issue and she completed the risk assessments and the Braden scale.. She said she educated the staff on new interventions when needed, such as air mattresses, heel or elbow protectors, when to float heels and repositioning residents. She said Resident #9 often peeled her dressings off her heel and took her protective boots off. She said was repositioned every two hours and she was encouraged to keep her podus boots on her feet. -However, observations revealed staff were not consistently ensuring the resident’s podus boot was on (see observations above). Certified nurse aide (CNA) #1 was interviewed on 5/20/26 at 11:25 a.m. CNA #1 said residents were repositioned every two hours on average. She said the nurse would let her know when a new skin injury occurred for a resident and what to do to help with the care. She said the staff kept a close eye on Resident #9 because she removed her podus boots and threw them on the floor.-However, observations revealed staff were not consistently ensuring the resident’s podus boot was on (see observations above). Licensed practical nurse (LPN) #1 was interviewed on 5/20/26 at 2:02 p.m. LPN #1 said verbal education was given to the CNAs for positioning and offloading areas with pressure for residents. LPN #1 said Resident #9 was problematic because she would take her boots off. She said the resident refused to keep her heel protectors on and staff reminded her to keep them on but the resident forgot.-However, observations revealed staff were not consistently ensuring the resident’s podus boot was on (see observations above). LPN #2 was interviewed on 5/21/26 at 11:50 a.m. LPN #2 said the first line of any skin redness was to use skin barriers to avoid further breakdown. She said residents were monitored every shift and staff made sure the resident was repositioned at least every two hours. CNA #2 was interviewed on 5/21/26 at 11:45 a.m. CNA #2 said the nurses would verbally tell her when a resident had a pressure wound and staff would turn the resident every two hours and use pillows for positioning. Registered nurse (RN) #1 was interviewed on 5/21/26 at 2:32 p.m. RN #1 said residents who had pressure injuries were followed by the wound nurse and sometimes the wound doctor. She said the residents required frequent turning and had pressure relieving devices to keep pressure off the site. She said Resident #9 wore protective boots but she liked to rip them off at times. She said staff did frequent checks to make sure the boots were kept on.-However, observations revealed staff were not consistently ensuring the resident’s podus boot was on (see observations above). The DON was interviewed on 5/21/26 at 3:15 p.m. The DON said any reddened skin was reported to the nursing staff and monitoring began. She said barrier cream was started with repositioning. She said the wound nurse was notified and interventions put into place. The DON said interventions included pressure relieving devices, such as an air mattress for the bed, or cushion for the chair. The DON said the interdisciplinary team (IDT) met weekly to discuss any new concerns and to follow up on any current resident needs, to include skin with pressure injuries. She said the IDT brainstormed for any new interventions needed for the resident. She said the facility tried to ensure preventative measures for pressure wounds were reviewed for implementation. The DON said she was responsible for educating the staff to anticipate the needs of the resident. She said staff were getting better on how to capture the residents’ refusals with documentation. She said Resident #9 continued to take off her protective boots and due to her cognition and inability to remember to keep them on, the IDT thought they would try a recliner chair as a new positioning technique. She said the resident’s wound could decline from poor or inconsistent interventions.

Based on observations, record review and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#60 and #84) out of six residents reviewed out of 41 sample residents and eight of 12 resident rooms reviewed. Specifically the facility failed to:-Implement a fall risk care plan for Resident #60;-Ensure thorough root cause analysis were completed for Resident #84 after multiple falls; -Ensure Resident #84’s fall interventions were consistently in place and documented on his care plan; and, -Ensure tap water in the facility was kept within a safe temperature range. Findings include:I. Fall failuresA. Facility policy and procedureThe Falls-Clinical Protocol policy, revised March 2018, was provided by the director of nursing (DON) on 5/21/26 at 11:53 a.m. It documented in pertinent part, “The staff and the physician Will identify pertinent interventions to try to prevent subsequent Falls to address the risk of clinically significant consequences of falling. “If underlying issues cannot be readily identified a corrected staff will try various relevant interventions, based on assessment of nature or category falling, until falling reduces or stops or until a reason is identified for its continuation.“The staff with the physician's guidance will follow up on a fall with associate injury until the resident is stable and delayed complications such as a late fracture or hematoma have been ruled out or resolved. “The staff and the physician will monitor and document the individual's response to the interventions intended to reduce falls or consequences of falling . “If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the position whether these measures are still needed, for example if the problem required the intervention has been resolved by addressing the underlying cause. “If the individual continues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the residents falling and also reconsider the current interventions.” B. Resident #60 1. Resident statusResident #60, age 83, was admitted on 12/11/21. According to the January 2022 computerized physician orders (CPO) diagnoses included asthma, heart failure and cerebrovascular accident (CVA) stroke. The 3/17/26 comprehensive assessment revealed Resident #60 had moderate cognitive impairment. He required minimal assistance with activities of daily living (ADL). 2. Record reviewThe ADL care plan, dated 4/5/26, documented the resident had a decrease in independence with physical mobility related to CVA. Pertinent interventions included giving the resident reminders to use a walker and monitor for any signs or symptoms of immobility. -Review of Resident #60’s comprehensive care plan failed to reveal a fall care plan that included person centered fall interventions. The nurse note, dated 5/10/26, documented Resident #60 told a staff member that he went to the bathroom and on his way back to bed he got dizzy and fell hitting the right side of his head on the bedside table. The resident sustained an abrasion and a raised purple bruise. The skin check note, dated 5/11/26, documented the resident had an abrasion noted to the right side of resident's head with a long purple raised bruise. The fall risk evaluation note, dated 5/11/26, documented no falls in the past three months. He had a fall risk score of 5, which showed low to moderate risk. -However, the evaluation failed to include that Resident #60 sustained a fall on 5/10/26.2. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 5/20/26 at 2:02 p.m. She said when a resident had a fall, an assessment was completed by the registered nurse (RN), vital signs were taken and treatment was provided as needed. She said the resident was interviewed to find out what happened if the fall was unwitnessed and staff members. The director ofnursing (DON) was interviewed on 5/20/26 at 4:20 p.m. She said Resident #60 had a fall on 4/5/26. She said the interdisciplinary team (IDT) met weekly to discuss falls to determine new interventions. She said the resident had a sign in his room that read “Remember to use your walker.” She said there was no other interventions added except to keep a close eye on the resident, which was told verbally to the staff. C. Resident #841. Resident status Resident #84, age greater than 65, was admitted on 3/3/26 . According to the May 2026 CPO, diagnoses included end stage renal disease with dependence on renal dialysis, age-related osteoporosis without current pathological fracture, unspecified dementia, mild without behavioral disturbance, psychotic disturbances or mood disturbances, and repeated fallThe 4/21/26 comprehensive assessment revealed Resident #84 had severe cognitive impairment. He did not have wandering behaviors or rejection of care. He used a wheelchair for mobility. He was dependent on staff for lower body dressing and toileting hygiene. He required moderate assistance for getting on and off the toilet, chair to bed transferring and sit to stand. The assessment documented Resident #84 was frequently incontinent of bowel and bladder and was not on a toileting program. 2. ObservationsOn 5/19/26 at 4:24 p.m. Resident #84 was in the hallway in his wheelchair without his lap buddy on his chair. At 4:29 p.m. Resident #84 was assisted to the dining room table. At 4:37 p.m. Resident #84 self propelled himself out of the dining room and down the hall towards his room. Certified nurse aide (CNA) #3 walked passed Resident #84 in the hallway. Resident #84 entered his room and shut the door. At 4:47 p.m. an unidentified dietary aide entered the room to bring the resident’s roommate a room tray. Resident #84 was in the restroom and his wheelchair was in the doorway to the bathroom. At 4:48 p.m. an unidentified CNA entered the room and observed Resident #84 alone in the restroom. The CNA entered the restroom and assisted the resident. At 5:01 p.m. the unidentified CNA assisted Resident #84 out of his room and back into the dining room. On 5/20/26 at 5:57 p.m. Resident #84 was in his wheelchair in the commons area. He did not have his lap buddy on. 3. Record reviewThe fall care plan, revised 4/25/26, documented that Resident #84 was at risk for falls related debility, weakness and altered balance with poor safety awareness. According to the care plan, Resident #84 needed prompt response to all requests for assistance. Interventions initiated on 3/4/26 directed staff to anticipate and meet the resident's needs; ensure his call light is within reach and encourage the resident to use it for assistance as needed; educate the resident/family/caregivers about safety reminders, what to do if a fall occurs and causation of the falls; follow the facility fall protocol; and, review information on past falls and attempt to determine cause of falls, record possible root causes and alter/remove any potential fall contributing factors if possible. Interventions revised on 3/16/26 directed staff to provide the resident with a motion electronic alarm and ensure the device is in place as needed. Interventions revised on 3/23/26 directed staff to ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in his wheelchair; ensure flooring surface was even and free floor clutter; provide glare-free light, a working and reachable call light, and a bed in low position at night with his personal items within reach. According to the the revised 3/23/26 interventions, Resident #84 needed to be evaluated for and supplied with appropriate adaptive equipment or devices and re-evaluate as needed for continued appropriateness and to ensure least restrictive device or restraint. Interventions initiated on 4/17/26 directed staff to place a sign in his room to remind Resident #84 to use the call light so he did not fall and provided him with anti-rollback brakes to increase safety with transfers. Interventions initiated on 4/25/26 identified Resident #84 was to use a lap buddy (a wheelchair positioning device) when out of his room and in his wheelchair. According to the intervention, staff was to ensure it was in place every 15-minutes and release it every two hours for safety. a. Fall on 4/6/26 - unwitnessedThe 4/6/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The incident report documented Resident #84 had an unwitnessed fall on 4/6/26 at 8:30 a.m. According to the incident report, he was ambulating without assistance and lost his footing when he fell and obtained a skin tear to his right scapula (back). The incident report revealed the immediate action/intervention following the fall was to remind him to use his call light. The 4/7/26 interdisciplinary (IDT) risk note documented the resident told the staff he was trying to go to the bathroom. The IDT risk note documented the root cause of the fall was the resident’s attempt to use the bathroom and he had a recent room change. The note documented interventions put in place were to remind staff to place assistive devices within reach when he was in bed and remind staff to ensure motion alarm was in place and functioning properly. According to the IDT note, new interventions included offering the resident a urinal as needed and informing therapy and restorative nursing of the fall. The note documented therapy and restorative was notified of the incident. -The fall documentation did not identify the size or severity of the skin tear to his back. -The fall documentation did not identify if his call light was within reach or if his motion sensor was on and working properly, if the resident was in bed or in his wheelchair prior to his fall or when the resident was last toileted or if he was incontinent at the time of the fall.b. Fall on 4/7/26 - unwitnessed The 4/7/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report documented Resident #84 had an unwitnessed fall at 10:30 p.m. According to the incident report, he was ambulating without assistance, confused and lost his footing when he fell. The report documented the resident told the staff he had tried to get up. The 4/8/26 progress note identified Resident #84 was found parallel to the bed on the floor (on 4/7/26). An assessment was completed, no new injuries were found and he was assisted back to bed. According to the note, Resident #84 was very impulsive, would not use his call light and was very unsteady while up. The 4/8/26 IDT risk note documented staff added velcro to his bedside alarm and he was going to move to the long term care side of the facility. The note documented therapy and restorative was notified of the incident. -The fall documentation did not identify when the resident was last toileted or if he was incontinent at the time of the fall or if the resident was last checked on by staff. c. Fall on 4/11/26 - witnessedThe 4/11/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report documented the nurse and CNAs were in shift report when Resident #84 walked out of his room holding his shoes when he fell next to the wall without injury. The report identified the resident fell at 6:15 a.m. The 4/13/26 IDT risk note documented the root cause of the witnessed fall on 4/11/26 was very poor safety awareness and impaired cognition. According to the risk note, Resident #84 was in a transition process for the staff and the resident to get to know each and for staff to know his routine after he moved into a new room. The note identified the intervention after the fall was to remind staff of the resident’s increased fall risk and provide more frequent checks on him, especially in the early morning hours and around 10:00 p.m. The note documented therapy and restorative was notified of the incident. d. Fall on 4/14/26 - witnessed The 4/14/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report documented Resident #84 was witnessed to stand up out of his wheelchair in the dining room at 6:33 a.m. The wheelchair moved backwards and the resident fell on his buttocks without injury. The 4/16/26 IDT risk note documented the root cause of the fall. According to the note, Resident #84 stood up from his wheelchair without locking his breaks first and the wheelchair rolled backwards. The identified intervention was to screen him for an anti-roll back device on his wheelchair for safety. The note documented therapy and restorative was notified of the incident. e. Fall on 4/16/26 - witnessedThe 4/16/26 incident report documented Resident #84 fell in his room at 7:50 p.m. The report documented the resident was attempting to ambulate without assistance. The fall was witnessed by a CNA. He was assessed by his nurse and assisted back into his wheelchair. The resident received a 5 centimeter (cm) skin tear on his right elbow as a result of the fall. The 4/30/26 IDT risk note for the fall on 4/16/26 documented Resident #84 stood up from his wheelchair and took one step and fell to the floor. According to the note, the resident said he was trying to go to the bathroom. The note documented the interventions after the fall included ensuring his call light was within reach; frequently reminding the resident to utilize the call light system and to wait for staff to assist. The note documented the staff were reminded to avoid leaving the resident in his room alone, encourage him to participate in activity of choice and sit in the commons area of the facility, socializing with other residents or watch television. The note documented therapy and restorative was notified of the incident. -The interventions directing staff to avoid leaving the resident in his room alone, encourage him to participate in activity of choice and sit in the commons area of the facility, socializing with other residents or watch television was not included in the residents care plan (see care plan above).-The fall documentation did not identify when the resident was last toileted or if was incontinent at the time of the fall. -The IDT note identified the resident’s 4/16/26 fall was reviewed by IDT two weeks after the fall and after the resident had multiple falls (see below). f. Fall on 4/23/26 - unwitnessedThe 4/23/26 nursing note identified Resident #84 was found next to his wheelchair, laying on his right side. He was bleeding from his right eye brow and he had a lump on his right cheek bone. The resident was alert and was able to be turned on his back so pressure could be applied to his eye brow laceration. He was assessed back into his wheelchair and wound care was provided to the laceration. The second nursing note on 4/23/26 identified Resident #84 was sent to the hospital for an evaluation of his head injury at 7:10 p.m. and returned back to the facility at 9:45 p.m. According to the note, a CT (computed tomography) scan of his head and neck and there were no underlining concerns. The 4/23/25 incident report documented the 4/23/26 fall occurred at 6:45 p.m. in the dining room and was unwitnessed. According to the report, factors of the fall included poor memory, confusion, gait imbalance and ambulating without assistance. The 4/24/25 at 12:23 a.m. skin check identified Resident #84 had bruising/hematoma right lateral back of thigh, down to his right lower leg. The 4/24/26 IDT note documented Resident #84 had poor safety awareness and was not able to say what he was doing that led to the unwitness fall on 4/23/26. The note indicated the interventions put into place after the fall was for staff to encourage the resident to sit in the commons area where he is more visible to staff and encourage the resident to attend activities of choice. The note documented therapy and restorative was notified of the incident. The 4/26/26 post fall evaluation note documented the 4/23/26 fall was witnessed by a CNA in his room that resulted in injuries to a right eye laceration, and bruising to his arm, leg and back and a visit to the emergency room. According to the evaluation, the resident was wearing shoes at the time of the fall and his bedside light was on and his bathroom and his personal light was sounding when he was found. -The fall documentation documented two different scenarios of the 4/23/26 fall. The progress note and the incident reported documented the fall was unwitnessed. The incident report documented the resident fell in the dining room. The post evaluation documented he was in his room and his fall was witnessed by a CNA. -The fall documentation did not identify if he was offered an activity or another location that would be more supervised/visible by staff, prior to the fall or if the resident was continent at the time of fall or when he was last toileted. g. Falls on 4/24/26 witnessed and unwitnessedThe 4/24/26 nursing note identified the resident had another fall on 4/24/26. According to the note, Resident #84 was sitting in his wheelchair taking his clothes off when the nurse entered the room. The resident started to lean forward, when his wheelchair cushion slid forward at an angle and he started to fall. The note documented the nurse was able to assist him to the floor. The staff assisted him back into his wheelchair and then into bed. The 4/24/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report identified the fall was witnessed at 8:30 p.m. and the resident was not injured as a result of the fall. The 4/30/26 IDT risk note documented the witnessed fall on 4/24/26 at 8:30 p.m. root cause was the sliding forward of his wheelchair cushion when he leaned forward. According to the note, Dysum (non-slip material) was placed under his wheelchair cushion to keep it from sliding. The note documented therapy and restorative was notified of the incident. The 4/24/26 nursing note documented the resident was found on the floor next to his bed without injury. The 4/24/26 incident report identified the fall was unwitnessed and Resident #84 was found on the floor in his room at 11:30 p.m. He was not able to give staff a description of the fall. According to the report, the resident was assessed and assisted to his wheelchair and near the nursing station to be monitored closer. The 4/25/26 nursing note documented the therapy department recommended a lap buddy due to his frequent falls and orders for the lap buddy were requested with his hospice physician. The 4/25/26 restorative note documented the restorative nurse aide placed a lap buddy on Resident #84’s wheelchair and gained verbal consent from the resident’s representative. The 4/30/26 IDT risk note for Resident #84’s 4/24/24 unwitnessed fall was provided by the DON on 5/21/26 at 11:53 a.m. The report identified the fall was reviewed on 4/30/26 with IDT. The note documented the resident rolled out of bed. The intervention discussed in the IDT review was to place a motion alarm to alert staff when the resident attempted to get out of bed unassisted, place bed in lowest position and encourage staff to do frequent rounds to ensure resident safety. The note documented therapy and restorative was notified of the incident. -The fall documentation did not identify if his motion alarm was in place, working properly and sounding when the resident rolled out of bed or the resident was last checked on, toileted and if he was continent at the time of the fall. h. Fall on 4/26/26 - witnessed The nurse progress note documented a CNA brought the resident to a recliner near the nurses station and transferred him to a recliner and walker. According to the note, 15-minutes had passed and the CNA then told the nurse Resident #84 fell earlier that night. The resident was then assessed by the nurse without injury. The 4/26/26 incident report documented Resident #84 had an assisted staff fall on 4/26/26 at 1:00 a.m. The report documented a CNA notified the nurse the resident had a fall after the incident occurred. The 4/30/26 IDT risk note was provided by the DON on 5/21/26 at 11:53 a.m. The report documented a staff member was walking by Resident #84’s room when she heard his motion alarm and saw the resident mostly out of bed. She entered the room and the resident grabbed her and would not let her go so she lowered him down to the floor without injury. The interventions documented after the floor were Ensure the motion alarm is in the proper place and functioning properly. Ensure call light is within reach and frequently remind the resident to utilize the call light system and wait for staff to assist. Ensure bed is in the lowest position -The fall documentation did not identify the resident was assessed by a nurse before he was moved off the floor and into a reclining chair by the CNA or if the bed was in a low position.i. Fall on 4/28/26 - witnessed The 4/28/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report identified Resident #84 had another fall. The report identified the fall was witnessed on 4/28/26 at 3:15 p.m. According to the incident report, a nurse was sitting at the computer at the nursing desk when she heard a gasp and commotion. The nurse got up saw Resident #84 on the floor of the commons area, laying on his left side and in front of his wheelchair. The foot petals were on the wheelchair. The report indicated the resident was brought back to the facility from an outside provider and staff was not notified that he returned. The incident report documented the resident had a large skin tear on his upper left arm that was bleeding and measured 7 cm long and 8 cm wide. The 4/30/26 IDT risk note documented the 4/28/26 fall root cause. According to the note, he was left unattended in the commons area after he was returned from an outing with an outside provider/care team. The facility staff was not aware that he had returned to the facility and placed in the common area. The note documented the facility worked with the outside care team to communicate with the facility staff when the resident was returned to the facility so the facility could ensure oversight and supervision. The note indicated the staff would be encouraged to place the resident in a reclining chair in the common area for comfort. The note documented therapy and restorative was notified of the incident. 4. Staff interviewsThe DON, the facility assessment coordinator and the therapy director were interviewed on 5/21/26 at 9:38 p.m. Resident #84 repeated falls and intervention, clarification of the fall on 4/23/26 that resulted in the resident going to the hospital, and the above observations were reviewed. The DON said on 4/23/26 the resident fell in the dining room and not in his room. She said the fall was witnessed by a family member of another resident and was not witnessed by the staff. She said the investigation did not identify where the staff was when he fell in the dining room. The DON said the investigation did not include staff or the family member’s interview. She said the investigation was not clear if the family member actually witnessed the fall or if they were the ones who found the resident in the dining room. She said she did not know what the resident was doing prior to the fall, if he needed to use the restroom or when he was last toileted. The therapy director said she was made aware of the repeated falls, but did not receive orders from his outside provider/care team to evaluate him for therapy until 4/28/26, after the resident had the 10 falls in April 2026. The facility assessment coordinator said there was a long process to approve and receive orders from his outside care team. The DON said the facility should have reviewed the concern and delay with the medical director to help with the timeliness of the request. The therapy director said therapy was able to evaluate the resident on 4/29/26. The DON said the facility could have looked into one to one supervision to help decrease the risk of falls while the facility was waiting on therapy orders. The DON said Resident #84 would remove the lap buddy but should be encouraged to use it. She said based on observations made on 5/19/26. The DON said the staff should have asked him if he needed to use the restroom and provided assistance when they observed him leave the dining room table, go down the hall and enter his room. The facility assessment coordinator said some of the April 2026 fall interventions were not care planned to ensure staff communication. The facility assessment coordinator said one of the nurses told her that Resident #84 liked to sit in the reclining chair and a drink/snack. She said the resident seemed to enjoy the fall intervention. She said she would add it to the care plan and spread the information to other staff that work with him. She said she would continue to encourage staff to let her know what interventions were working to help prevent falls. The DON said there were patterns to the falls that were not fully identified. She said the investigations needed to be more thorough and include relevant information such as when Resident #84 was last toileted and checked on. She said the investigations should have included what the staff was doing at the time of the unwitnessed fall and who witnessed the falls. She said interviews with the staff who were working with Resident #84 at the time of the fall would help identify more factors and information related to falls. The DON and the facility assessment coordinator said thoroughly completed investigations could help prevent recurrence of the falls. The DON the resident has had no new falls since 4/28/28 but she would implement fall training to help decrease Resident #84 and other residents’ risk for falls. 5. Facility follow up The fall in-service conducted on 5/21/26 through 5/26/26 was provided by the DON on 5/26/26 at 11:49 a.m. (after the survey exit) via email. The inservice identified the 29 members of the nursing department who were educated on fall prevention techniques and communication to include identification of routines, preferences, toileting needs and abilities, motivation to more and need for supervision. The inservice directed staff to communicate and document the observations of residents they were working with. II. Failure to ensure safe water temperaturesA. Professional referenceAccording to the Consumer Product Safety Commission (CPSC) Safety Alert, Avoiding Tap Water Scalds, retrieved on 5/27/26 from https://www.cpsc.gov/s3fs-public/5098.pdf “The majority of injuries and deaths involving tap water scalds are to the elderly and children under the age of five. The U.S. Consumer Product Safety Commission (CPSC) urges all users to lower their water heaters to 120 degrees Fahrenheit (F).”B. Facility policy and procedureThe Test and Log Hot Water Temperatures policy, undated, was provided by the DON on 5/22/26 at 12:47p.m. via email The policy read in pertinent part,"The facility must ensure that the residents’ environment remains free of accidents as much as possible and each resident receives adequate supervision assistance to prevent accidents."For burn prevention, federal guidelines advise you to keep domestic water temperatures below 120 degrees Fahrenheit although this temp can still cause burns if exposure reaches 5 minutes.”C. Observations and resident interviewsThe tap hot water temperatures from resident rooms were obtained on 5/21/26 between 9:15 a.m. and 9:50 a.m. The hot water in each resident room ran for approximately one minute prior to taking the water temperature. The hot water temperatures were as follows:-At 9:19 a.m. the water temperature from the sink in room #E6 registered at 120 degrees F.One resident who resided in room #E6 said the water took a while to warm up and he liked it hot. -At 9:23 a.m. the water temperature from the sink in room #F1 registered at 123 degrees F.-At 9:26 a.m. the water temperature from the sink in room #F2 registered at 122 degrees F.One resident who resided in room #F2 said the water got pretty hot.-At 9:31 a.m. the water temperature from the sink in room #A12 registered at 128 degrees F.One resident who resided in room #A12 said the water got pretty hot. -At 9:41 a.m. the water temperature from the sink in room #A5 registered at 129 degrees F.-At 9:48 a.m. the water temperature from the sink in room #B13 registered at 128 degrees F.One resident who resided in room #B13 said the water took a while to get hot and should get hotter faster. -At 9:50 a.m. the water temperature from the sink in room #B5 registered at 128 degrees F.D. Record reviewThe resident room water temperature log for February 2026, March 2026 and April 2026 was provided by the DON on 5/21/26 at 4:48 p.m. The water temperature log documented water temperatures were taken monthly in one resident room in each hall. In February 2026 the hot water temperature ranged from 107 degrees F to 114 degrees F. In March 2026 the hot water temperature ranged from 107 degrees F to 115 degrees F. The water temperature logs documented the facility's most recent water temperature audit was conducted on 4/10/26, with hot water temperatures ranging from 107 degrees F to 113 degrees F.E. Staff interviewsThe maintenance assistant was interviewed on 5/21/26 at 1:35 p.m. The maintenance said the hot water tanks were usually set at 113 degrees F. He said the water temperatures ranged between 105 degrees F and 113 degrees F. He said they should keep water temps under 120 for safe resident use. He said he obtained the temperature of the water in the sink in room #A12 today (5/21/26) at 12:00 p.m. He said the resident sink water was 128 degrees F, which was too hot for a resident room. He said looked at the water heater and it was leaking, which was potentially affecting water temperatures. He said he turned the water heater temperature down. He said in the past there was a drip, but the drip stopped. He said with the 5/21/26 identification of the leak, the facility learned they need a new hot water heater. The DON was interviewed on 5/21/26 at 5:00 p.m. The DON said the hot water heater had a significant leak identified by maintenance on 5/21/26. She said there had not been any burns or injuries related to the hot water. F. Facility follow-upAn email provided by the DON on 5/26/26 at 2:20 p.m. (after the survey exit) documented a plumber inspected the hot water heater and determined the bottom of the heater was rusted and needed to be replaced. According to the email, the maintenance department adjusted the temperature valve to compensate for the deficiency and are doing two hour checks to ensure it was staying in the appropriate temperature range until the heater could be replaced.

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on one out of six units. Specifically, the facility failed to ensure hand hygiene was conducted appropriately during wound care for Resident #9 and Resident #55. Findings include:I. Professional reference According to The Centers for Disease Control and Prevention’s (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 5/27/26 from https://www.cdc.gov/cleanhands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, “Hand hygiene protects both healthcare personnel and patients.“Cleaning your hands reduces the potential spread of germs.“Clean your hands before and after changing wound dressings or bandages. “Clean your hands immediately before touching a patient and after touching a patient or the patient’s surroundings.”II. Facility policy and procedureThe Wound Care policy, revised October 2010, was provided by the director of nursing (DON) on 5/20/26 at 6:47 p.m. It read in pertinent part,“The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.“Steps in the procedure: wash and dry your hands thoroughly. Put on exam gloves. Loosen tape, remove dressing and pull soiled gloves over the dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound.“Remove disposable gloves and discard them into designated containers. Wash and dry your hands thoroughly. “Wipe reusable supplies with alcohol as indicated outsides of containers that were touched by unclean hands, scissor blades). Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. Wash and dry your hands thoroughly. Notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice.”III. Observations On 5/19/26 at 10:17 a.m. the wound doctor was completing wound care for Resident #55. The wound doctor donned a mask, gloves and a gown. He removed the soiled wound dressing. He then moved his glasses to the top of his head with his gloved hands, touched his mask and the resident's headboard. Without changing gloves and performing hand hygiene, he cleaned the wound with a wound spray and applied lidocaine gel (topical pain medication). With the same gloved hands, he picked up the camera and took pictures of the wound. He then used the sterile utensils brought into the room earlier to debride the wound, placed a sterile medicated packing material inside the wound bed and covered it with a bordered bandage. He opened the door of the resident’s room with the same gloved hands and stepped out of the room before doffing mask, gown and gloves. He cleaned the camera with a disinfectant wipe and then washed his hands in the residents sink. -The wound doctor failed to change gloves and perform hand hygiene when his gloves became contaminated. On 5/19/26 at 10:45 a.m. The wound doctor was completing wound care for Resident #9. He donned a mask and gown and reached into his pocket for the gloves, he put the gloves on and entered the resident’s room. He opened the sterile utensil package upon entering the resident room and placed this on the bedside table. He doffed the gloves he had in his pocket and put on a new pair of gloves found in the resident’s room, without performing hand hygiene. He took off the soiled dressings from three different areas of the resident’s foot and cleaned the areas with a wound cleanser. He then applied lidocaine gel to the heel wound. He took pictures of the wound and then used the sterile utensils to debris the wound, placed a sterile medicated packing material inside the wound bed and covered it with a bordered bandage. He doffed the gown and gloves, cleaned his camera with a disinfectant wipe and washed his hands in the resident’s sink. -The wound doctor failed to change gloves and perform hand hygiene when his gloves became contaminated. IV. Staff interviewsThe wound doctor was interviewed on 5/19/26 at 11:10 a.m. He said the process for infection control was to keep dirty items from clean items. He said that was why he brought the sterile kit into the resident’s room, so he would not contaminate the wound cart and to keep the wound clean. The infection preventionist was interviewed on 5/20/26 at 2:55 p.m. The infection preventionist said hand hygiene was completed between glove use, going in out of resident rooms, during incontinence care, prior to meals and when hands come in contact with soiled material. She said during wound care she would expect gloves to be changed from dirty to clean procedures with hand hygiene in between. She said she had not completed any education with outside agencies coming into the facility on hand hygiene nor PPE use. The DON was interviewed on 5/21/26 at 3:15 p.m. She said staff completed hand hygiene in between resident cares and glove use. She said outside agencies, such as the wound doctor, that came into the facility were not regulated by them. She said however, she said she would hope they followed professional standards with wound care and hand hygiene procedures.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. Chapter 5 (15.6, E and F) Resident rightsThe facility was advised it must provide the resident and a family member or legal representative with written notice of such intent to be received at least 5 days before such move, including an explanation on their right to appeal. Chapter 5 (5.2) Bed Hold PoliciesThe facility shall develop policies for holding beds available for residents who are temporarily absent from the facility, provide a copy of the policy upon admission and explain these policies to residents upon admission and before each temporary absence.

A recertification survey with #CO3004226, Incident #3010143, Incident #3010509 and Incident #3010529 was conducted on 5/18/26 to 5/21/26. Six deficiencies were cited.

An Emergency Preparedness survey was completed on 5/18/26 to 5/21/26. No deficiencies were cited.

Based on record review and interviews, the facility failed to provide and document sufficient discharge preparation for two (#111 and #12) of two residents reviewed for a safe and orderly discharge out of 41 sample residents. Specifically, the facility failed to ensure a written discharge bed hold notice was provided to Resident #111 and Resident #12 or their representative completed at the time Resident #111 and Resident #12 were transferred to the hospital. III. Resident #12A. Resident status Resident #12, age greater than 65, was admitted on 2/3/26 and readmitted on 5/19/26. According to the May 2026 CPO diagnoses included acute and chronic respiratory failure, pulmonary hypertension and respirator virus. The 5/19/26 MDS assessment revealed Resident #12 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was dependent on mobility with the use of a wheelchair. B. Record reviewThe nursing progress note, dated 5/13/26, revealed Resident #12 discharged to the hospital for shortness of breath. Review of Resident #12’s EMR did not reveal a bed hold notice was provided when Resident #12 was transferred to the hospital on 5/13/26. C. Staff interviewLicensed practical nurse (LPN) #2 was interviewed on 5/21/26 at 11:50 a.m. LPN #2 said the assistant director of nursing (ADON) reviewed the bed hold policy with her today (5/21/26). She said the ADON explained to her the importance of completing the bed hold form when residents were sent to the hospital. She said the form was just added to the discharge packet. She said Resident #12 did not have a bed hold form prior to leaving for the hospital on 5/13/26.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent and treat pressure injuries for one (#9) of six residents reviewed for pressure injuries out of 41 sample residents. Specifically, the facility failed to ensure staff consistently implemented care planned interventions for Resident #9, who had an unstageable pressure injury to her right heel. Findings include:I. Professional referenceAccording to Basic Nursing third edition; Leslie S. Treas, Karen Barnett, Mable H. Smith (2022), page 1214-1215, “Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every two hours to prevent skin breakdown, muscle discomfort. People who are immobile are more prone to pressure injury as a result of reduced circulation, impaired oxygen exchange to the tissues and edema.”According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, Emily Haesler (Ed.), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 5/28/26,"Pressure ulcer classification is as follows:“Category/Stage 1: Nonblanchable Erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate ‘at risk’ individuals (a heralding sign of risk). “Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury. “Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.“Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. “Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. “Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility policy and procedureThe Pressure Ulcer Skin Breakdown policy, revised April 2018, was provided by the director of nursing (DON) on 5/20/26 at 2:00 p.m. It read in pertinent part,“The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure ulcers. “The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions, identify the type of an ulcer and define any complications related to pressure ulcers.“Healing or prevention likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic.“Healing or prevention possible: Healing may be delayed or may occur only partially; wounds may occur despite appropriate preventive efforts. “Monitoring during resident visits: The physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker.” III. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 10/8/25. According to the May 2026 computerized physician orders (CPO), diagnoses included osteoporosis, chronic obstructive pulmonary disease, peripheral vascular disease and anxiety. The 4/14/26 minimum data set (MDS) assessment revealed Resident #9 had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. She needed partial to moderate assistance for activities of daily living (ADL). The MDS assessment indicated the resident had a pressure injury and she had a pressure reducing mattress. B. ObservationsOn 5/19/26 at 8:59 a.m. Resident #9 was lying in bed on her back and her protective podus boot was laying on the floor next to the bed. During a continuous observation on 5/20/26, beginning at 9:21 a.m. and ending at 11:38 a.m., Resident #9 was lying in bed on her back. The resident’s protective podus boot was laying on the floor next to the bed. -No staff members entered the room during the two hour and 17 minute observation. On 5/21/26 at 8:38 a.m. Resident #9 was lying in bed on her back and her protective podus boot was laying on the floor next to the bed. C. Record review The pressure ulcer care plan, initiated 10/28/25 and revised 3/11/26, revealed Resident #9 had a pressure ulcer to the right heel related to immobility. The pressure ulcer would show signs of healing and remain free from infection. The resident would have intact skin, free of redness, blisters or discoloration through the next review date. Interventions included administering treatments as ordered and monitoring for effectiveness, providing an alternating air mattress with fitness setting three continuously, assessing, recording and monitoring wound healing weekly and as needed, measuring length, width and depth of the wound where possible, assessing and documenting the status of the wound perimeter, wound bed and healing progress, reporting improvements and declines to the medical director (MD), educating the resident, family and caregivers as to causes of skin breakdown, including transfer and positioning requirements; importance of good nutrition and frequent repositioning, following facility policies and protocols for the prevention and treatment of skin breakdown, heel protectors on the resident’s bilateral feet and reminding the resident and assisting the resident to turn and reposition at least frequently. A nurse skin assessment note, dated 10/25/26, revealed Resident #9’s right heel had an approximately four centimeter (cm) diameter dark red and purple discoloration that was tender to the touch. No broken skin was noted to the area. The surrounding skin area was pink and blanching (turning pale or white). Recommendations were to apply skin prep to the area, float the resident’s heels while in bed and place protective booties on her heels. The resident’s heels were to be floated at all times to mitigate potential pressure. A nurse skin assessment note, dated 11/6/25, revealed Resident #9’s right heel wound was unstageable and measured at 2.6 cm long by 3.2 cm wide and 3.2 cm deep. The resident had an air mattress placed and had heels floating. A nurse skin note, dated 1/14/26, revealed the skin to Resident #9’s heel wound was dry and no drainage was noted. The wound nurse covered the area with a bordered foam dressing after measuring the wound to be 1.54 cm long by 2.11 cm wide by 0.4 cm deep. The resident removed her protective podus boots and had to be reminded to wear them. -However the care plan did not reflect the resident’s refusals or removal of the podus boots (see care plan above). A nurse skin note, dated 2/17/26, revealed Resident #9’s wound bed had minimal slough (soft tissue), no eschar (dead tissue) and epithelial (damage) tissue to the wound. The wound had improved. A new dressing was in place and boots were on the resident’s heels. Skin issue education was provided to staff to turn the resident every two hours.-However, observations revealed staff did not consistently reposition the resident (see observations above). A nurse note, dated 5/14/26, revealed the nurse was called to Resident #9’s room because the resident had removed the blue foam boot and the heel protector pad. The nurse made a foam heel cup instead of a slip-on protector covered the entire foot with a stockinette secured at the ankle to attempt to keep the dressing in place longer and reapplied foam boot. The resident stated she would leave the dressing alone.-However the care plan did not address the resident’s noncompliance to leave the dressing and the podus boot on. Review of Resident #9’s May 2026 CPO revealed the following physician’s orders: Wound care right heel: make sure podus boots are applied and heels are floated, every day and night shift, ordered 12/19/25 and discontinued 5/8/26. Wound care right heel: make sure socks and heel protectors are on and heels are floated every day and night shift, ordered 5/8/26. IV. Staff interviewsThe infection preventionist was interviewed on 5/19/26 at 7:50 a.m. The infection preventionist said she was responsible for the wound care for the residents. She said she was alerted when a resident had a skin issue and she completed the risk assessments and the Braden scale.. She said she educated the staff on new interventions when needed, such as air mattresses, heel or elbow protectors, when to float heels and repositioning residents. She said Resident #9 often peeled her dressings off her heel and took her protective boots off. She said was repositioned every two hours and she was encouraged to keep her podus boots on her feet. -However, observations revealed staff were not consistently ensuring the resident’s podus boot was on (see observations above). Certified nurse aide (CNA) #1 was interviewed on 5/20/26 at 11:25 a.m. CNA #1 said residents were repositioned every two hours on average. She said the nurse would let her know when a new skin injury occurred for a resident and what to do to help with the care. She said the staff kept a close eye on Resident #9 because she removed her podus boots and threw them on the floor.-However, observations revealed staff were not consistently ensuring the resident’s podus boot was on (see observations above). Licensed practical nurse (LPN) #1 was interviewed on 5/20/26 at 2:02 p.m. LPN #1 said verbal education was given to the CNAs for positioning and offloading areas with pressure for residents. LPN #1 said Resident #9 was problematic because she would take her boots off. She said the resident refused to keep her heel protectors on and staff reminded her to keep them on but the resident forgot. -However, observations revealed staff were not consistently ensuring the resident’s podus boot was on (see observations above). LPN #2 was interviewed on 5/21/26 at 11:50 a.m. LPN #2 said the first line of any skin redness was to use skin barriers to avoid further breakdown. She said residents were monitored every shift and staff made sure the resident was repositioned at least every two hours. CNA #2 was interviewed on 5/21/26 at 11:45 a.m. CNA #2 said the nurses would verbally tell her when a resident had a pressure wound and staff would turn the resident every two hours and use pillows for positioning. Registered nurse (RN) #1 was interviewed on 5/21/26 at 2:32 p.m. RN #1 said residents who had pressure injuries were followed by the wound nurse and sometimes the wound doctor. She said the residents required frequent turning and had pressure relieving devices to keep pressure off the site. She said Resident #9 wore protective boots but she liked to rip them off at times. She said staff did frequent checks to make sure the boots were kept on.-However, observations revealed staff were not consistently ensuring the resident’s podus boot was on (see observations above). The DON was interviewed on 5/21/26 at 3:15 p.m. The DON said any reddened skin was reported to the nursing staff and monitoring began. She said barrier cream was started with repositioning. She said the wound nurse was notified and interventions put into place. The DON said interventions included pressure relieving devices, such as an air mattress for the bed, or cushion for the chair. The DON said the interdisciplinary team (IDT) met weekly to discuss any new concerns and to follow up on any current resident needs, to include skin with pressure injuries. She said the IDT brainstormed for any new interventions needed for the resident. She said the facility tried to ensure preventative measures for pressure wounds were reviewed for implementation. The DON said she was responsible for educating the staff to anticipate the needs of the resident. She said staff were getting better on how to capture the residents’ refusals with documentation. She said Resident #9 continued to take off her protective boots and due to her cognition and inability to remember to keep them on, the IDT thought they would try a recliner chair as a new positioning technique. She said the resident’s wound could decline from poor or inconsistent interventions.

Based on observations, record review and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#60 and #84) out of six residents reviewed out of 41 sample residents and eight of 12 resident rooms reviewed. Specifically the facility failed to:-Implement a fall risk care plan for Resident #60;-Ensure thorough root cause analysis were completed for Resident #84 after multiple falls; -Ensure Resident #84’s fall interventions were consistently in place and documented on his care plan; and, -Ensure tap water in the facility was kept within a safe temperature range. C. Resident #841. Resident status Resident #84, age greater than 65, was admitted on 3/3/26 . According to the May 2026 CPO, diagnoses included end stage renal disease with dependence on renal dialysis, age-related osteoporosis without current pathological fracture, unspecified dementia, mild without behavioral disturbance, psychotic disturbances or mood disturbances, and repeated fallThe 4/21/26 MDS assessment revealed Resident #84 had severe cognitive impairment with a BIMS score of four out of 15. He did not have wandering behaviors or rejection of care. He used a wheelchair for mobility. He was dependent on staff for lower body dressing and toileting hygiene. He required moderate assistance for getting on and off the toilet, chair to bed transferring and sit to stand. The MDS assessment documented Resident #84 was frequently incontinent of bowel and bladder and was not on a toileting program. 2. ObservationsOn 5/19/26 at 4:24 p.m. Resident #84 was in the hallway in his wheelchair without his lap buddy on his chair. At 4:29 p.m. Resident #84 was assisted to the dining room table. At 4:37 p.m. Resident #84 self propelled himself out of the dining room and down the hall towards his room. Certified nurse aide (CNA) #3 walked passed Resident #84 in the hallway. Resident #84 entered his room and shut the door. At 4:47 p.m. an unidentified dietary aide entered the room to bring the resident’s roommate a room tray. Resident #84 was in the restroom and his wheelchair was in the doorway to the bathroom. At 4:48 p.m. an unidentified CNA entered the room and observed Resident #84 alone in the restroom. The CNA entered the restroom and assisted the resident. At 5:01 p.m. the unidentified CNA assisted Resident #84 out of his room and back into the dining room. On 5/20/26 at 5:57 p.m. Resident #84 was in his wheelchair in the commons area. He did not have his lap buddy on. 3. Record reviewThe fall care plan, revised 4/25/26, documented that Resident #84 was at risk for falls related debility, weakness and altered balance with poor safety awareness. According to the care plan, Resident #84 needed prompt response to all requests for assistance. Interventions initiated on 3/4/26 directed staff to anticipate and meet the resident's needs; ensure his call light is within reach and encourage the resident to use it for assistance as needed; educate the resident/family/caregivers about safety reminders, what to do if a fall occurs and causation of the falls; follow the facility fall protocol; and, review information on past falls and attempt to determine cause of falls, record possible root causes and alter/remove any potential fall contributing factors if possible. Interventions revised on 3/16/26 directed staff to provide the resident with a motion electronic alarm and ensure the device is in place as needed. Interventions revised on 3/23/26 directed staff to ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in his wheelchair; ensure flooring surface was even and free floor clutter; provide glare-free light, a working and reachable call light, and a bed in low position at night with his personal items within reach. According to the the revised 3/23/26 interventions, Resident #84 needed to be evaluated for and supplied with appropriate adaptive equipment or devices and re-evaluate as needed for continued appropriateness and to ensure least restrictive device or restraint. Interventions initiated on 4/17/26 directed staff to place a sign in his room to remind Resident #84 to use the call light so he did not fall and provided him with anti-rollback brakes to increase safety with transfers. Interventions initiated on 4/25/26 identified Resident #84 was to use a lap buddy (a wheelchair positioning device) when out of his room and in his wheelchair. According to the intervention, staff was to ensure it was in place every 15-minutes and release it every two hours for safety. a. Fall on 4/6/26 - unwitnessedThe 4/6/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The incident report documented Resident #84 had an unwitnessed fall on 4/6/26 at 8:30 a.m. According to the incident report, he was ambulating without assistance and lost his footing when he fell and obtained a skin tear to his right scapula (back). The incident report revealed the immediate action/intervention following the fall was to remind him to use his call light. The 4/7/26 interdisciplinary (IDT) risk note documented the resident told the staff he was trying to go to the bathroom. The IDT risk note documented the root cause of the fall was the resident’s attempt to use the bathroom and he had a recent room change. The note documented interventions put in place were to remind staff to place assistive devices within reach when he was in bed and remind staff to ensure motion alarm was in place and functioning properly. According to the IDT note, new interventions included offering the resident a urinal as needed and informing therapy and restorative nursing of the fall. The note documented therapy and restorative was notified of the incident. -The fall documentation did not identify the size or severity of the skin tear to his back. -The fall documentation did not identify if his call light was within reach or if his motion sensor was on and working properly, if the resident was in bed or in his wheelchair prior to his fall or when the resident was last toileted or if he was incontinent at the time of the fall.b. Fall on 4/7/26 - unwitnessed The 4/7/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report documented Resident #84 had an unwitnessed fall at 10:30 p.m. According to the incident report, he was ambulating without assistance, confused and lost his footing when he fell. The report documented the resident told the staff he had tried to get up. The 4/8/26 progress note identified Resident #84 was found parallel to the bed on the floor (on 4/7/26). An assessment was completed, no new injuries were found and he was assisted back to bed. According to the note, Resident #84 was very impulsive, would not use his call light and was very unsteady while up. The 4/8/26 IDT risk note documented staff added velcro to his bedside alarm and he was going to move to the long term care side of the facility. The note documented therapy and restorative was notified of the incident. -The fall documentation did not identify when the resident was last toileted or if he was incontinent at the time of the fall or if the resident was last checked on by staff. c. Fall on 4/11/26 - witnessedThe 4/11/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report documented the nurse and CNAs were in shift report when Resident #84 walked out of his room holding his shoes when he fell next to the wall without injury. The report identified the resident fell at 6:15 a.m. The 4/13/26 IDT risk note documented the root cause of the witnessed fall on 4/11/26 was very poor safety awareness and impaired cognition. According to the risk note, Resident #84 was in a transition process for the staff and the resident to get to know each and for staff to know his routine after he moved into a new room. The note identified the intervention after the fall was to remind staff of the resident’s increased fall risk and provide morefrequent checks on him, especially in the early morning hours and around 10:00 p.m. The note documented therapy and restorative was notified of the incident. d. Fall on 4/14/26 - witnessed The 4/14/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report documented Resident #84 was witnessed to stand up out of his wheelchair in the dining room at 6:33 a.m. The wheelchair moved backwards and the resident fell on his buttocks without injury. The 4/16/26 IDT risk note documented the root cause of the fall. According to the note, Resident #84 stood up from his wheelchair without locking his breaks first and the wheelchair rolled backwards. The identified intervention was to screen him for an anti-roll back device on his wheelchair for safety. The note documented therapy and restorative was notified of the incident. e. Fall on 4/16/26 - witnessedThe 4/16/26 incident report documented Resident #84 fell in his room at 7:50 p.m. The report documented the resident was attempting to ambulate without assistance. The fall was witnessed by a CNA. He was assessed by his nurse and assisted back into his wheelchair. The resident received a 5 centimeter (cm) skin tear on his right elbow as a result of the fall. The 4/30/26 IDT risk note for the fall on 4/16/26 documented Resident #84 stood up from his wheelchair and took one step and fell to the floor. According to the note, the resident said he was trying to go to the bathroom. The note documented the interventions after the fall included ensuring his call light was within reach; frequently reminding the resident to utilize the call light system and to wait for staff to assist. The note documented the staff were reminded to avoid leaving the resident in his room alone, encourage him to participate in activity of choice and sit in the commons area of the facility, socializing with other residents or watch television. The note documented therapy and restorative was notified of the incident. -The interventions directing staff to avoid leaving the resident in his room alone, encourage him to participate in activity of choice and sit in the commons area of the facility, socializing with other residents or watch television was not included in the residents care plan (see care plan above).-The fall documentation did not identify when the resident was last toileted or if was incontinent at the time of the fall. -The IDT note identified the resident’s 4/16/26 fall was reviewed by IDT two weeks after the fall and after the resident had multiple falls (see below). f. Fall on 4/23/26 - unwitnessedThe 4/23/26 nursing note identified Resident #84 was found next to his wheelchair, laying on his right side. He was bleeding from his right eye brow and he had a lump on his right cheek bone. The resident was alert and was able to be turned on his back so pressure could be applied to his eye brow laceration. He was assessed back into his wheelchair and wound care was provided to the laceration. The second nursing note on 4/23/26 identified Resident #84 was sent to the hospital for an evaluation of his head injury at 7:10 p.m. and returned back to the facility at 9:45 p.m. According to the note, a CT (computed tomography) scan of his head and neck and there were no underlining concerns. The 4/23/25 incident report documented the 4/23/26 fall occurred at 6:45 p.m. in the dining room and was unwitnessed. According to the report, factors of the fall included poor memory, confusion, gait imbalance and ambulating without assistance. The 4/24/25 at 12:23 a.m. skin check identified Resident #84 had bruising/hematoma right lateral back of thigh, down to his right lower leg. The 4/24/26 IDT note documented Resident #84 had poor safety awareness and was not able to say what he was doing that led to the unwitness fall on 4/23/26. The note indicated the interventions put into place after the fall was for staff to encourage the resident to sit in the commons area where he is more visible to staff and encourage the resident to attend activities of choice. The note documented therapy and restorative was notified of the incident. The 4/26/26 post fall evaluation note documented the 4/23/26 fall was witnessed by a CNA in his room that resulted in injuries to a right eye laceration, and bruising to his arm, leg and back and a visit to the emergency room. According to the evaluation, the resident was wearing shoes at the time of the fall and his bedside light was on and his bathroom and his personal light was sounding when he was found. -The fall documentation documented two different scenarios of the 4/23/26 fall. The progress note and the incident reported documented the fall was unwitnessed. The incident report documented the resident fell in the dining room. The post evaluation documented he was in his room and his fall was witnessed by a CNA. -The fall documentation did not identify if he was offered an activity or another location that would be more supervised/visible by staff, prior to the fall or if the resident was continent at the time of fall or when he was last toileted. g. Falls on 4/24/26 witnessed and unwitnessedThe 4/24/26 nursing note identified the resident had another fall on 4/24/26. According to the note, Resident #84 was sitting in his wheelchair taking his clothes off when the nurse entered the room. The resident started to lean forward, when his wheelchair cushion slid forward at an angle and he started to fall. The note documented the nurse was able to assist him to the floor. The staff assisted him back into his wheelchair and then into bed. The 4/24/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report identified the fall was witnessed at 8:30 p.m. and the resident was not injured as a result of the fall. The 4/30/26 IDT risk note documented the witnessed fall on 4/24/26 at 8:30 p.m. root cause was the sliding forward of his wheelchair cushion when he leaned forward. According to the note, Dysum (non-slip material) was placed under his wheelchair cushion to keep it from sliding. The note documented therapy and restorative was notified of the incident. The 4/24/26 nursing note documented the resident was found on the floor next to his bed without injury. The 4/24/26 incident report identified the fall was unwitnessed and Resident #84 was found on the floor in his room at 11:30 p.m. He was not able to give staff a description of the fall. According to the report, the resident was assessed and assisted to his wheelchair and near the nursing station to be monitored closer. The 4/25/26 nursing note documented the therapy department recommended a lap buddy due to his frequent falls and orders for the lap buddy were requested with his hospice physician. The 4/25/26 restorative note documented the restorative nurse aide placed a lap buddy on Resident #84’s wheelchair and gained verbal consent from the resident’s representative. The 4/30/26 IDT risk note for Resident #84’s 4/24/24 unwitnessed fall was provided by the DON on 5/21/26 at 11:53 a.m. The report identified the fall was reviewed on 4/30/26 with IDT. The note documented the resident rolled out of bed. The intervention discussed in the IDT review was to place a motion alarm to alert staff when the resident attempted to get out of bed unassisted, place bed in lowest position and encourage staff to do frequent rounds to ensure resident safety. The note documented therapy and restorative was notified of the incident. -The fall documentation did not identify if his motion alarm was in place, working properly and sounding when the resident rolled out of bed or the resident was last checked on, toileted and if he was continent at the time of the fall. h. Fall on 4/26/26 - witnessed The nurse progress note documented a CNA brought the resident to a recliner near the nurses station and transferred him to a recliner and walker. According to the note, 15-minutes had passed and the CNA then told the nurse Resident #84 fell earlier that night. The resident was then assessed by the nurse without injury. The 4/26/26 incident report documented Resident #84 had an assisted staff fall on 4/26/26 at 1:00 a.m. The report documented a CNA notified the nurse the resident had a fall after the incident occurred. The 4/30/26 IDT risk note was provided by the DON on 5/21/26 at 11:53 a.m. The report documented a staff member was walking by Resident #84’s room when she heard his motion alarm and saw the resident mostly out of bed. She entered the room and the resident grabbed her and would not let her go so she lowered him down to the floor without injury. The interventions documented after the floor were Ensure the motion alarm is in the proper place and functioning properly. Ensure call light is within reach and frequently remind the resident to utilize the call light system and wait for staff to assist. Ensure bed is in the lowest position -The fall documentation did not identify the resident was assessed by a nurse before he was moved off the floor and into a reclining chair by the CNA or if the bed was in a low position.i. Fall on 4/28/26 - witnessed The 4/28/26 incident report was provided by the DON on 5/21/26 at 11:53 a.m. The report identified Resident #84 had another fall. The report identified the fall was witnessed on 4/28/26 at 3:15 p.m. According to the incident report, a nurse was sitting at the computer at the nursing desk when she heard a gasp and commotion. The nurse got up saw Resident #84 on the floor of the commons area, laying on his left side and in front of his wheelchair. The foot petals were on the wheelchair. The report indicated the resident was brought back to the facility from an outside provider and staff was not notified that he returned. The incident report documented the resident had a large skin tear on his upper left arm that was bleeding and measured 7 cm long and 8 cm wide. The 4/30/26 IDT risk note documented the 4/28/26 fall root cause. According to the note, he was left unattended in the commons area after he was returned from an outing with an outside provider/care team. The facility staff was not aware that he had returned to the facility and placed in the common area. The note documented the facility worked with the outside care team to communicate with the facility staff when the resident was returned to the facility so the facility could ensure oversight and supervision. The note indicated the staff would be encouraged to place the resident in a reclining chair in the common area for comfort. The note documented therapy and restorative was notified of the incident. 4. Staff interviewsThe DON, the MDS coordinator and the therapy director were interviewed on 5/21/26 at 9:38 p.m. Resident #84 repeated falls and intervention, clarification of the fall on 4/23/26 that resulted in the resident going to the hospital, and the above observations were reviewed. The DON said on 4/23/26 the resident fell in the dining room and not in his room. She said the fall was witnessed by a family member of another resident and was not witnessed by the staff. She said the investigation did not identify where the staff was when he fell in the dining room. The DON said the investigation did not include staff or the family member’s interview. She said the investigation was not clear if the family member actually witnessed the fall or if they were the ones who found the resident in the dining room. She said she did not know what the resident was doing prior to the fall, if he needed to use the restroom or when he was last toileted. The therapy director said she was made aware of the repeated falls, but did not receive orders from his outside provider/care team to evaluate him for therapy until 4/28/26, after the resident had the 10 falls in April 2026. The MDS coordinator said there was a long process to approve and receive orders from his outside care team. The DON said the facility should have reviewed the concern and delay with the medical director to help with the timeliness of the request. The therapy director said therapy was able to evaluate the resident on 4/29/26. The DON said the facility could have looked into one to one supervision to help decrease the risk of falls while the facility was waiting on therapy orders. The DON said Resident #84 would remove the lap buddy but should be encouraged to use it. She said based on observations made on 5/19/26. The DON said the staff should have asked him if he needed to use the restroom and provided assistance when they observed him leave the dining room table, go down the hall and enter his room. The MDS coordinator said some of the April 2026 fall interventions were not care planned to ensure staff communication. The MDS coordinator said one of the nurses told her that Resident #84 liked to sit in the reclining chair and a drink/snack. She said the resident seemed to enjoy the fall intervention. She said she would add it to the care plan and spread the information to other staff that work with him. She said she would continue to encourage staff to let her know what interventions were working to help prevent falls. The DON said there were patterns to the falls that were not fully identified. She said the investigations needed to be more thorough and include relevant information such as when Resident #84 was last toileted and checked on. She said the investigations should have included what the staff was doing at the time of the unwitnessed fall and who witnessed the falls. She said interviews with the staff who were working with Resident #84 at the time of the fall would help identify more factors and information related to falls. The DON and the MDS coordinator said thoroughly completed investigations could help prevent recurrence of the falls. The DON the resident has had no new falls since 4/28/28 but she would implement fall training to help decrease Resident #84 and other residents’ risk for falls. 5. Facility follow up The fall in-service conducted on 5/21/26 through 5/26/26 was provided by the DON on 5/26/26 at 11:49 a.m. (after the survey exit) via email. The inservice identified the 29 members of the nursing department who were educated on fall prevention techniques and communication to include identification of routines, preferences, toileting needs and abilities, motivation to more and need for supervision. The inservice directed staff to communicate and document the observations of residents they were working with. II. Failure to ensure safe water temperaturesA. Professional referenceAccording to the Consumer Product Safety Commission (CPSC) Safety Alert, Avoiding Tap Water Scalds, retrieved on 5/27/26 from https://www.cpsc.gov/s3fs-public/5098.pdf “The majority of injuries and deaths involving tap water scalds are to the elderly and children under the age of five. The U.S. Consumer Product Safety Commission (CPSC) urges all users to lower their water heaters to 120 degrees Fahrenheit (F).”B. Facility policy and procedureThe Test and Log Hot Water Temperatures policy, undated, was provided by the DON on 5/22/26 at 12:47p.m. via email The policy read in pertinent part, "The facility must ensure that the residents’ environment remains free of accidents as much as possible and each resident receives adequate supervision assistance to prevent accidents."For burn prevention, federal guidelines advise you to keep domestic water temperatures below 120 degrees Fahrenheit although this temp can still cause burns if exposure reaches 5 minutes.”C. Observations and resident interviewsThe tap hot water temperatures from resident rooms were obtained on 5/21/26 between 9:15 a.m. and 9:50 a.m. The hot water in each resident room ran for approximately one minute prior to taking the water temperature. The hot water temperatures were as follows:-At 9:19 a.m. the water temperature from the sink in room #E6 registered at 120 degrees F.One resident who resided in room #E6 said the water took a while to warm up and he liked it hot. -At 9:23 a.m. the water temperature from the sink in room #F1 registered at 123 degrees F.-At 9:26 a.m. the water temperature from the sink in room #F2 registered at 122 degrees F.One resident who resided in room #F2 said the water got pretty hot.-At 9:31 a.m. the water temperature from the sink in room #A12 registered at 128 degrees F.One resident who resided in room #A12 said the water got pretty hot. -At 9:41 a.m. the water temperature from the sink in room #A5 registered at 129 degrees F.-At 9:48 a.m. the water temperature from the sink in room #B13 registered at 128 degrees F.One resident who resided in room #B13 said the water took a while to get hot and should get hotter faster. -At 9:50 a.m. the water temperature from the sink in room #B5 registered at 128 degrees F.D. Record reviewThe resident room water temperature log for February 2026, March 2026 and April 2026 was provided by the DON on 5/21/26 at 4:48 p.m. The water temperature log documented water temperatures were taken monthly in one resident room in each hall. In February 2026 the hot water temperature ranged from 107 degrees F to 114 degrees F. In March 2026 the hot water temperature ranged from 107 degrees F to 115 degrees F. The water temperature logs documented the facility's most recent water temperature audit was conducted on 4/10/26, with hot water temperatures ranging from 107 degrees F to 113 degrees F.E. Staff interviewsThe maintenance assistant was interviewed on 5/21/26 at 1:35 p.m. The maintenance said the hot water tanks were usually set at 113 degrees F. He said the water temperatures ranged between 105 degrees F and 113 degrees F. He said they should keep water temps under 120 for safe resident use. He said he obtained the temperature of the water in the sink in room #A12 today (5/21/26) at 12:00 p.m. He said the resident sink water was 128 degrees F, which was too hot for a resident room. He said looked at the water heater and it was leaking, which was potentially affecting water temperatures. He said he turned the water heater temperature down. He said in the past there was a drip, but the drip stopped. He said with the 5/21/26 identification of the leak, the facility learned they need a new hot water heater. The DON was interviewed on 5/21/26 at 5:00 p.m. The DON said the hot water heater had a significant leak identified by maintenance on 5/21/26. She said there had not been any burns or injuries related to the hot water. F. Facility follow-upAn email provided by the DON on 5/26/26 at 2:20 p.m. (after the survey exit) documented a plumber inspected the hot water heater and determined the bottom of the heater was rusted and needed to be replaced. According to the email, the maintenance department adjusted the temperature valve to compensate for the deficiency and are doing two hour checks to ensure it was staying in the appropriate temperature range until the heater could be replaced.

Based on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure staff followed appropriate hand hygiene practices during the meal service. Findings include:I. Professional referenceAccording to the Colorado Retail Food Regulations (3/16/24), chapter 2-301.12, retrieved on 5/29/26, “Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands.” (2-301.14)II. Facility policy and procedureThe Handwashing/ Hand Hygiene policy, revised November 202s, was provided by the director of nursing (DON) on 5/26/26 at 11:13 a.m. The policy read in pertinent part,“Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.“All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.“Employees must wash their hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks“Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. III. Observations 1. Kitchen meal serviceDuring a continuous observation of the lunch meal service in the kitchen on 4:05 p.m. beginning at 4:05 p.m. and ending at 5:38 p.m., the following was observed:At 4:38 p.m. cook #1 began plating residents’ meals. At 5:11 p.m. cook #1 left the steam table. She pulled soup from a box with her gloved hands, touching the bottom shelf and the outside of the box. She returned to the steam table and continued to plate food. At 5:22 p.m. the dietary manager (DM) placed her left gloved hand to touch her shirt collar and wipe her cheek. The DM removed her gloves and pulled out a pan of mancotti from the oven with pot holders. She did not perform hand hygiene after removing her gloves. At 5:25 p.m. cook #1 pushed the trash down in the bin with her gloved hands, she removed the gloves and donned new gloves without performing hand hygiene. At 5:26 p.m. with the same gloved hands, cook #1 used the thermometer to take the temperature of the pan of manicotti. 2. Room tray deliveryDuring a continuous observation of the lunch meal service in the a resident hall on 5/18/26 beginning 12:50 p.m. and ending at 1:30 p.m., the following was observed:At 1:05 p.m. certified nurse aide (CNA) #5 picked up a cart delivered to the first room tray room. She did not use hand hygiene before collecting the tray. CNA #5 proceeded to help set up the resident’s meal for her. CNA #5 exited the resident’s room and filled another resident's water cup without performing hand hygiene. CNA #5 collected another resident tray out of the food cart without performing hand hygiene. She exited the room and performed hand hygiene. At 1:20 p.m. CNA #5 pulled out another room tray without hand hygiene, shut the cart door with her foot and served the meal to a resident. She exited the room, picked up an item off the floor, knelt down with her hands on the floor near the cart. She stood up, pulled another tray out of the room cart without performing hand hygiene. At 1:25 p.m. CNA #5 delivered the tray to a resident’s room. She exited the room without hand hygiene, picked up another tray and entered another resident’s room without hand hygiene. At 1:30 p.m. CNA #5 performed hand hygiene and delivered the last room tray. V. Staff interviewsThe DM was interviewed on 5/21/26 at 3:21 p.m. The DM said hand hygiene should be completed thoroughly for 30 seconds, conducted after every task change and before putting new gloves on. The DM said she saw cook #1 not perform hand hygiene in between glove changes. Room tray observations were shared with the DM. She said staff should perform hand hygiene in between passing trays in resident rooms. She said she had not conducted recent staff training with staff on hand hygiene during meal service and delivery.

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on one out of six units. Specifically, the facility failed to ensure hand hygiene was conducted appropriately during wound care for Resident #9 and Resident #55. Findings include:I. Professional reference According to The Centers for Disease Control and Prevention’s (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 5/27/26 from https://www.cdc.gov/cleanhands/ hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, “Hand hygiene protects both healthcare personnel and patients.“Cleaning your hands reduces the potential spread of germs.“Clean your hands before and after changing wound dressings or bandages. “Clean your hands immediately before touching a patient and after touching a patient or the patient’s surroundings.”II. Facility policy and procedureThe Wound Care policy, revised October 2010, was provided by the director of nursing (DON) on 5/20/26 at 6:47 p.m. It read in pertinent part,“The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.“Steps in the procedure: wash and dry your hands thoroughly. Put on exam gloves. Loosen tape, remove dressing and pull soiled gloves over the dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound.“Remove disposable gloves and discard them into designated containers. Wash and dry your hands thoroughly. “Wipe reusable supplies with alcohol as indicated outsides of containers that were touched by unclean hands, scissor blades). Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. Wash and dry your hands thoroughly. Notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice.”III. Observations On 5/19/26 at 10:17 a.m. the wound doctor was completing wound care for Resident #55. The wound doctor donned a mask, gloves and a gown. He removed the soiled wound dressing. He then moved his glasses to the top of his head with his gloved hands, touched his mask and the resident's headboard. Without changing gloves and performing hand hygiene, he cleaned the wound with a wound spray and applied lidocaine gel (topical pain medication). With the same gloved hands, he picked up the camera and took pictures of the wound. He then used the sterile utensils brought into the room earlier to debride the wound, placed a sterile medicated packing material inside the wound bed and covered it with a bordered bandage. He opened the door of the resident’s room with the same gloved hands and stepped out of the room before doffing mask, gown and gloves. He cleaned the camera with a disinfectant wipe and then washed his hands in the residents sink. -The wound doctor failed to change gloves and perform hand hygiene when his gloves became contaminated. On 5/19/26 at 10:45 a.m. The wound doctor was completing wound care for Resident #9 He donned a mask and gown and reached into his pocket for the gloves, he put the gloves on and entered the resident’s room. He opened the sterile utensil package upon entering the resident room and placed this on the bedside table. He doffed the gloves he had in his pocket and put on a new pair of gloves found in the resident’s room, without performing hand hygiene. He took off the soiled dressings from three different areas of the resident’s foot and cleaned the areas with a wound cleanser. He then applied lidocaine gel to the heel wound. He took pictures of the wound and then used the sterile utensils to debris the wound, placed a sterile medicated packing material inside the wound bed and covered it with a bordered bandage. He doffed the gown and gloves, cleaned his camera with a disinfectant wipe and washed his hands in the resident’s sink. -The wound doctor failed to change gloves and perform hand hygiene when his gloves became contaminated. IV. Staff interviewsThe wound doctor was interviewed on 5/19/26 at 11:10 a.m. He said the process for infection control was to keep dirty items from clean items. He said that was why he brought the sterile kit into the resident’s room, so he would not contaminate the wound cart and to keep the wound clean. The infection preventionist was interviewed on 5/20/26 at 2:55 p.m. The infection preventionist said hand hygiene was completed between glove use, going in out of resident rooms, during incontinence care, prior to meals and when hands come in contact with soiled material. She said during wound care she would expect gloves to be changed from dirty to clean procedures with hand hygiene in between. She said she had not completed any education with outside agencies coming into the facility on hand hygiene nor PPE use. The DON was interviewed on 5/21/26 at 3:15 p.m. She said staff completed hand hygiene in between resident cares and glove use. She said outside agencies, such as the wound doctor, that came into the facility were not regulated by them. She said however, she said she would hope they followed professional standards with wound care and hand hygiene procedures.

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program to include antibiotic use protocols and a system to monitor antibiotic use for one (#92) of two residents reviewed for antibiotic stewardship out of 41 sample residents. Specifically, the facility failed to ensure Resident #92’s antibiotic therapy for doxycycline medication was reviewed for continued use on an ongoing basis. Findings include: I. Facility policy and procedure The Antibiotic Stewardship Review and Surveillance policy, revised December 2016, was provided by the director of nurses (DON) on 5/19/26 at 10:17 a.m. It read in pertinent part,“Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. “As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee’“The infection preventionist or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if: therapy was ordered for prolonged surgical prophylaxis and clinical findings do not indicate continued need for antibiotic.“At the conclusion of the review, the provider will be notified of the review findings.“All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include, symptoms, start date of antibiotics, site of the infection, total days of therapy, outcome, adverse events and stop date.” II. Resident statusResident #92, age greater than 65, was admitted on 1/14/21. According to the May 2026 computerized physician orders (CPO) diagnoses included Alzheimer disease, infection with inflammation to a reaction with an internal orthopedic device and osteomyelitis. The 3/20/26 minimum data set (MDS) assessment revealed Resident #92 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She was dependent on activities of daily living (ADL). The assessment indicated she was on an antibiotic. III. Record reviewThe May 2026 CPO revealed the following physician's order:Doxycycline 100 milligrams (mg) one tablet orally daily for osteomyelitis related to infection with inflammation to a reaction with an internal orthopedic device, ordered on 6/15/23. The nurse practitioner note, dated 1/9/25, was provided by the director of nursing (DON) on 5/20/26 at 8:30 a.m. The note revealed Resident #92 was on doxycycline as a suppressive therapy (continued use of medication) from an infected hardware to the left ankle. The medical director note, dated 1/20/25, was provided by the DON on 5/20/26 at 8:30 a.m. The note revealed Resident #92 was on doxycycline for infected hardware in the ankle, with associated osteomyelitis. On suppressive antibiotics and tolerating the medication well.-Review of Resident #92’s electronic medical record (EMR) did not reveal any further documentation regarding justification or monitoring of the continued use of the doxycycline. The medication regimen review dated 7/30/25 and 2/26/26 were provided by the DON on 5/20/26 at 7:09 p.m. -The medication reviews did not reveal the doxycycline was reviewed. IV. Staff interviewsThe infection preventionist was interviewed on 5/19/26 at 1:47 p.m.. The infection preventionist said Resident #92 was on a prophylactic antibiotic for inflammation from an infected internal hardware. She said the nurse practitioner assessed the need for the continued medication and recommended any changes. She said she reviewed progress notes and talked to the interdisciplinary team for follow up. She she had not followed up with the antibiotic use for Resident #92 since the order was originally placed in 2023The DON was interviewed on 5/21/26 at 3:15 p.m. The DON said the facility completed medication reviews right after the interdisciplinary team meetings. She said the medical director talked to families and looked at the medical history before making any changes to the medications. She said when a resident was on antibiotics, they used the McGeers (identify and track infection) criteria and discussed each case with the physician for continued use or discontinuation. She said they had not looked at Resident #92 antibiotic regimen regularly to see if the medication continued to be appropriate. V. Facility follow-up A facsimile (fax) dated 5/20/26 which was sent to the physician, was provided by the DON on 5/20/26 at 3:30p.m. The fax documentedResident #92 was on doxycycline medication 100 mg one tablet daily for osteomyelitis related to infection with inflammation to a reaction with an internal orthopedic device. The fax documented she started the medication on 6/15/23. The fax asked the physician to review if the resident was still appropriate to be on the medication at this time, if there were any concerns or or if a risk versus benefit was needed.-However, record review revealed Resident #92’s antibiotic use had not been reviewed since January 2025 (see record review above).-The facility did not provide follow-up from the physician.

A survey for Incident #2641133 was conducted 10/20/22 to 12/92025. Two deficiencies were cited. The actual survey exit date was 10/20/25. 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 12/9/25.

Based on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity for one (#1) of three residents reviewed for dignity out of four sample residents. Specifically, the facility failed to ensure Resident #1's behavior contract was not used as a threat. Findings include:I. Facility policy and procedureThe Resident rights policy, revised February 2021, was provided by the nursing home administrator (NHA) on 10/20/25 at 1:34 p.m. It read in pertinent part,“Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity; be free from abuse, neglect, misappropriation of property, and exploitation; be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; self-determination; communication with and access to people and services, both inside and outside the facility; exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; be supported by the facility in exercising his or her rights; exercise his or her rights without interference, coercion, discrimination or reprisal from the facility.”II. Resident #1A. Resident statusResident #1, greater than 65, was admitted on 4/5/24. According to the October 2025 computerized physician's orders (CPO), diagnoses included stroke with left-sided paralysis and aphasia (difficulty with speech and language). The 7/8/25 MDS assessment revealed the resident was cognitively intact with a brief interview for mental statu s(BIMS) score of 15 out of 15. The resident was dependent on staff for bathing, toileting, footwear and lower body dressing. Resident #1 required substantial assistance with oral hygiene, personal hygiene and upper body dressing. The resident used a manual wheelchair and was able to self-propel himself for mobility. Resident #1 required substantial assistance from staff for his activities of daily living. According to the assessment, Resident #1 had no history of behaviors directed toward others. -However, a review of electronic medical record (EMR) revealed Resident #2 had verbal outbursts towards others on 4/15/25, 5/21/25 and 7/7/15. B. Resident interviewResident #1 was interviewed on 10/21/25 at 2:33 p.m. Resident #1 requested social services assistant (SSA) #1 was also present during the interview. Resident #1 said he did not recall having any recent verbal outburst or arguments during recent activities and denied having any issues with any staff or residents in the facility. Multiple times during the interview, Resident #1 said he did not want to get anyone in trouble and asked SSA #1 multiple times if he was in trouble. Resident #1 said he used to be on a behavior contract, but said he was not aware if he was currently on a behavior contract. Resident #1 then asked SSA #1 to check for him after the interview. Resident #1 said he remembered a previous family member who was forced to leave a facility for her behavior and did not want to be kicked out of the facility. C. Record reviewResident #1's comprehensive care plan, initiated 12/10/24, included a care focus to explain what behavior was unacceptable. Pertinent interventions included: anticipating care needs and providing them before the resident becomes overly stressed, discussing behaviors with Resident #1, explaining and reinforcing why the behavior was unacceptable, using a behavior contract to help guide Resident #1 with outbursts, intervening to protect the rights and safety of others, and approaching calmly to divert to a less stimulating environment. The behavior contract, dated 11/27/24, documented Resident #1 had behaviors of yelling, hitting the table with my hand, hat or drink, and demanding my own way. The contract documented if Resident #1 expressed the listed behaviors, he would be removed from the environment and placed in a calm environment until he was able to resolve the situation in a more appropriate manner. The contract listed goal dates for managing Resident #1’s behavior of 11/28/24 to 12/28/24. -However, the behavior contract remained in place with no updated goal date. The progress note, dated 5/21/25 at 11:53 a.m., documented the social services director (SSD), the SSA, the floor nurse and the floor CNA met with Resident #1 after interaction with the CNA where Resident #1 cursed out the CNA. The progress note documented Resident #1 said he was upset with the CNA because he spent too long waiting for assistance off of the commode. The progress note documented the SSD checked logs and saw residents waited five minutes from the time the call light was pressed. The Progress note documented Resident #1 became aggressive, then the SSD reminded Resident #1 of his behavior contract and told Resident #1 if he had one more aggressive episode that the staff would have to look at a facility that more meets the residents needs. The progress note documented the director of nursing (DON) was aware. The progress note, dated 8/25/25 at 5:22 p.m., documented the SSD, the SSA, the assistant NHA and the activities director (AD) met with Resident #1 to review an updated behavior contract. The progress note documented Resident #1 became visibly upset at the start of the meeting and immediately questioned whether he was being discharged. The SSD reassured him that he was not being discharged and that the purpose of the meeting was to review the updated behavior contract. The progress note documented Resident #1 expressed frustration, and stated no other residents were receiving behavior contracts. The progress note documented Resident #1 was asked three separate times to review the updated behavior contract. Each time, he declined and repeatedly requested to speak with a former staff member who was no longer part of the social services department. After the third attempt to engage Resident #1 to review the contract, the assistant NHA informed Resident #1 he was free to go to dinner. The SSD, AD, SSA, and assistant NHA all signed the behavior contract noting that Resident #1 refused to sign. III. Staff interviewsSSA #1 was interviewed on 10/20/25 at 2:53 p.m. SSA #1 said they were not sure why Resident #1 appeared concerned about being “kicked out of the facility.” SSA #1 said they were aware Resident #1 had behaviors of verbal outbursts and cursing at staff and they were aware Resident #1 had a behavior contract, but SSA #1 said to their knowledge Resident #1 was not at any risk of being discharged against their will. The social services director (SSD) and the MDS coordinator were interviewed together on 10/21/25 at 11:32 a.m. The SSD said to her knowledge, Resident #1 was the only resident in the facility who had a behavior contract. The MDS coordinator said the purpose of the contract was to hold Resident #1 accountable for his actions since he was alert and oriented. The SSD said she started working in the facility June of 2025 and she was not involved in writing the initial behavior contract, but was involved in updating his updated behavior contract on 8/22/25. The SSD said she did not want Resident #1 to feel he was at risk for being kicked out of the facility due to his behavior, and that was not the intention of the behavior support plan she created on 8/22/25. The SSD said she was not aware Resident #1 was unsure whether or not he was still on a behavior contract. . The SSD and the MDS coordinator said they did not know why the behavior contract was not changed and why the contract remained in place after the specified goal date. The SSD and the MDS coordinator said they were not aware of the interaction Resident #1 had with the SSD previously working at the facility and do not know why he would tell Resident #1 he would not be able to stay at the facility if he did not follow his behavior contract The SSD said she planned to re-approach Resident #1 after the interview to ensure the resident was aware his new behavior support plan was not meant to be used as a punishment and he was not at risk for discharge from the facility for failure to follow the behavior contract.

Based on observation, record review, and interviews the facility failed to ensure that one (#2) of three residents were free from abuse out of four sample residents. Specifically, the facility failed to protect Resident #2 from verbal abuse by Resident #1 Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 10/20/25 at 1:35 p.m. It read in pertinent part, "Our residents have the right to be free from abuse. “This includes but is not limited to freedom from physical abuse. Policy Interpretation and Implementation, as part of the resident abuse prevention, the administration will:-Protect our residents from abuse by anyone, including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals.-Identify and assess all possible incidents of abuse."II. Incident of verbal abuse by Resident #1 towards Resident #2 on 8/22/25The facility investigation revealed that on 8/22/25 at 3:00 p.m. Resident #2 was observed upset during a card game with other residents. Resident #2 was observed hitting the table, making a fist towards Resident #1 and yelling at Resident #1 with profanity statements. Resident #1 became fearful of Resident #2 after the staff were unable to immediately redirect Resident #2 away from the card game. The investigation revealed facility staff immediately separated Resident #1 and Resident #2 and placed Resident #2 on frequent monitoring (every 15 minutes) for safety. The registered nurse (RN) assessed Resident #1 and Resident #2 and found no physician injuries. Resident #1 was tearful and agreed to see the facility's in-house counselor. The investigation documented Resident #1 was interviewed by the social services director (SSD). Resident #1 voiced that she was afraid of Resident #2 because of his explosive behavior. Resident #2 voiced that she was very afraid of Resident #2 because she had once had an abusive relationship and Resident #2’s behavior brought up memories of the abuse. Resident #1 voiced that Resident #2 screamed, swung his arms, hit the table, and made accusatory statements about her. Resident #1 voiced that the activities staff eventually redirected Resident #2 to his wheelchair for the safety of everyone. Resident #1 told the SSD she would like to have a referral for counseling services. The investigation documented Resident #1 was interviewed by the SSD. Resident #2 voiced that Resident #1 criticized his card playing and yelled at him. Resident #2 expressed that he felt he was not good enough to play cards because he had difficulty with his vision, and women had more rights than men. Resident #2 voiced that he would stay in his room and not attend future activities, and voiced that he felt the facility tried to discharge him to another facility because the staff and residents hated him. The SSD documented that a referral to the in-house counselor had previously been sent and Resident #2 had declined counseling services. The SSD documented Resident #2 was placed on a behavior contract and educated regarding behavior expectations and ideas to reduce agitation. The investigation documented activities assistant (AA) #1 witness statement was documented at about 2:00 p.m. and revealed Resident #2 had been annoyed and accused another resident of cheating on the card game. Resident #2 was observed with increased agitation throughout the game. The AA documented she returned to her nearby office and then saw Resident #2 waving his arms and hearing him yelling at other residents. The AA documented Resident #2 said the other residents playing the card game cheated and skipped his turn. The AA documented that Resident #2 pointed, shook, and swung his fist while he explained his actions to the AA. AA #2 witness statement documented she observed Resident #2 make a fist toward Resident #1. The AA #2 documented Resident #2 was confused and upset, and AA #2 went for help from the SSD to redirect Resident #2. The 8/22/25 4:00 p.m. Resident #1 statement documented Resident #1 voiced that Resident #2 misunderstood her about the card game. Resident #1 voiced she remained afraid of Resident #2’s anger, that she had nothing against Resident #2, and thought Resident #2 sometimes upset other residents. The facility investigation revealed that the altercation was witnessed by staff members and the altercation was substantiated by the facility. III. Resident #1 (victim)A. Resident statusResident #1, age greater than 65, was admitted on 3/1/19 and readmitted on 6/23/22. According to the June 2022 computerized physician's orders (CPO), diagnoses included congestive heart disease and difficulty walking, The 7/31/25 minimum data set (MDS) assessment revealed the Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #1 had no behaviors towards others during the review period. Resident #1 required a manual wheelchair and was dependent on staff for mobility and required substantial to maximum assistance from staff for bathing, dressing, toileting, moderate assistance from staff for bed mobility, transfers, and personal hygiene. B. Resident interviewResident #1 was interviewed on 10/21/25. Resident #1 said she remembers the incident with Resident #2. Resident #1 said she was fearful of Resident #2 because she had a history of living with verbal abuse from a former spouse. Resident #1 said after the verbal altercation, she returned to her room. Resident #1 said she did not return to her room only because she was afraid of Resident #2, but because that was her regular daily routine. Resident #1 said she requested to meet with the in-house counselor, but the counselor had not scheduled an appointment with her yet. Resident #1 said in the afternoon of the altercation, she felt comfortable returning to the dining room for her evening meal and did not feel that she changed her daily routines because of the altercation. Resident #1 said Resident #2 continued to sit at the same table when they played cards, but she made a point to sit away from Resident #2. Resident #1 said she thought other residents were afraid of Resident #2 and his outburst behaviors. Resident #1 said sometimes she observed Resident #2 in the hallways, but he sat in his wheelchair and was not threatening towards her. Resident #1 said she was not afraid of Resident #2 but was afraid of being near him if he had another outburst. Resident #1 said she still wanted to talk to the counselor because she was afraid of the outburst, had grief from the death of her spouse, and economic worries about her home in the community. Resident #1 said she had no appointment notifications and had not received any contacts or communications regarding counseling services. C. Record reviewReview of Resident 32’s comprehensive care plan did not reveal the resident had a behavior, mood, or trauma care plan. The SSD progress noted, dated 8/22/25 at 4:30 p.m., the SSD followed up with Resident #2 after the altercation with Resident #1. The SSD note read Resident #2 appeared fearful and was visibly upset during the conversation. The SSD offered Resident #2 in-house counseling services and sent an email message to the counselor. Review of the October 2025 CPO did not reveal a physician’s order for counseling services or behavior monitoring that were recommended after the incident on 8/22/25. IV. Resident #2 (assailant)A. Resident statusResident #1, age 87, was admitted on 4/5/24. According to the October 2025 CPO, diagnoses included stroke with left-sided paralysis and aphasia (difficulty with speech and language). The 7/8/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. During the review period, the MDS assessment documented the resident had no physical or behavioral symptoms directed towards others, and zero days of verbal behavioral behaviors directed towards others. The resident used a manual wheelchair and was able to self-propel himself for mobility. Resident #1 required substantial assistance from staff for his activities of daily living.-However, progress notes found during the record review document Resident #1 had a history of behaviors towards others - yelling, using profanity, and making derogatory outbursts. According to the assessment, Resident #1 had no history of behaviors directed toward others. -However, a review of electronic medical record (EMR) revealed Resident #2 had verbal outbursts towards others on 4/15/25, 5/21/25 and 7/7/15. B. Resident interviewResident #1 was interviewed on 10/21/25 at 2:33 p.m. Resident #1 requested SSA #1 was also present during the interview. Resident #1 said he did not recall having any recent verbal outburst or arguments during recent activities and denied having any issues with any staff or residents in the facility. Multiple times during the interview, Resident #1 said he did not want to get anyone in trouble and asked SSA #1 multiple times if he was in trouble. Resident #1 said he used to be on a behavior contract, but said he was not aware if he was currently on a behavior contract. Resident #1 then asked SSA #1 to check for him after the interview. Resident #1 said he remembered a previous family member who was forced to leave a facility for her behavior and did not want to be kicked out of the facility. Cross reference F550: failure to treat the resident with respect and dignity. C. Record reviewResident #1's comprehensive care plan, initiated 12/10/24, included a care focus to explain what behavior was unacceptable. Pertinent interventions included: anticipating care needs and providing them before the resident becomes overly stressed, discussing behaviors with Resident #1, explaining and reinforcing why the behavior was unacceptable, using a behavior contract to help guide Resident #1 with outbursts, intervening to protect the rights and safety of others, and approaching calmly to divert to a less stimulating environment. The progress note, dated 4/15/2025 at 2:09 p.m., documented the previous SSD was called to meet with Resident #1 after Resident #1 yelled at a CNA for moving the resident’s recliner. The progress note documented when the SSD went to speak with Resident #1, Resident #1 cursed and yelled at the SSD. The SSD informed Resident #1 he needed to speak in a polite manner and reminded him of his behavioral contract. The progress documented resident #1 cursed at the SSD to which the SSD told Resident #1 he would talk with him when he has calmed down and is willing to have a conversation. The MDS note, dated 4/22/25 at 7:39 p.m., documented Resident #1 was at risk for cognitive concerns related to behaviors of verbal aggression. The care plan goal will be to minimize risks and reduce episodes of verbal aggression as tolerated. The MDS note documented Resident #1 had increasing behavioral indicators have been noted through assessments, particularly verbal outbursts directed at staff. The MDS note documented the SSD planned for continued behavioral monitoring and interventions with the goal of reducing these episodes and supporting Resident #1’s emotional well-being. The progress note, dated 5/21/25 at 11:53 a.m., documented the Sloor nurse and the floor CNA met with Resident #1 after interaction with the CNA where Resident #1 cursed out the CNA. The progress note documented Resident #1 said he was upset with the CNA because he spent too long waiting for assistance off of the commode. The progress note documented the SSD checked logs and saw residents waited five minutes from the time the call light was pressed. The Progress note documented Resident #1 became aggressive, then the SSD reminded Resident #1 of his behavior contract and told Resident #1 if he had one more aggressive episode that the staff would have to look at a facility that more meets the residents needs. The progress note documented the director of nursing was aware. The progress note, dated 7/7/25 at 1:24 p.m., documented the current SSD spoke with Resident #1 about how he approached other staff and residents in the facility. The progress note documented the SSD told Resident #1 he needed to use his manners, using please, thank you, excuse me as an example. The progress note documented Resident #1 agreed to use his manners when approaching othersThe progress note, dated 8/25/25 at 5:22 p.m. (after the abuse occurred), documented the SSD, SSA #1, the assistant NHA and the activities director (AD) met with Resident #1 to review an updated behavior contract. The progress note documented Resident #1 became visibly upset at the start of the meeting and immediately questioned whether he was being discharged; the SSD reassured him that he was not being discharged and that the purpose of the meeting was to review the updated behavior contract. The progress note documented Resident #1 expressed frustration, and stated no other residents were receiving behavior contracts. The progress note documented Resident #1 was asked three separate times to review the updated behavior contract. Each time, he declined and repeatedly requested to speak with a former staff member who is no longer part of the social services department. After the third attempt to engage Resident #1 to review the contract, the assistant NHA informed Resident #1 he was free to go to dinner. The SSD, the AD, SSA #1, and the assistant NHA all signed the behavior contract noting that Resident #1 refused to sign. The nursing note, dated 8/28/25 at 4:04 p.m., documented new orders for Resident #1 to start escitalopram 10 milligrams (mg) by mouth once per day for aggression and anxiety.-However, no updates were made to Resident #1’s care plan to assess and monitor Resident #1’s behaviors after starting a psychotropic medication. V. Staff interviewsThe SSD was interviewed on 10/21/25 at 11:23 a.m. The SSD said she sent a referral for Resident #2’s counseling request to the counselor by email. The SSD said the in-house counselor sent her a status report after every visit that included the names of residents she evaluated. The SSD said the status report messages were not part of Resident #2’s EMR. The SSD said the counselor was a contracted social worker who provided in-house counseling to residents and visited the facility every Wednesday. The SSD said she communicated with the counselor using email messages, and the counselor kept records in her own external system. The SSD was unable to locate documentation Resident #2 had received counseling services after the referral for services was placed. The SSD said she worked together with the counselor to update resident care plans when necessary. The SSD said the counselor provided feedback by text message on 10/20/25 (during the survey) and the counselor said she had made several attempts to see Resident #2 and said Resident #2 was either participating in a facility activity, was getting her hair done, or had declined the services. The SSD said the counselor did not make appointments with residents and was unsure if Resident #2 had been notified she had missed evaluations with the counselor. The MDS coordinator was interviewed on 10/21/25 at 9:06 a.m. The MDS coordinator said she was responsible for initiating resident baseline care plans, which were required to be reviewed and discussed with residents and/or family representatives. The MDS coordinator said members of the interdisciplinary team (IDT) team were responsible for updating care plans when residents needed changes to their care. The MSD coordinator said IDT members could monitor residents for changes by attending the daily IDT meetings or by reading the 24-hour report, which was a daily log of all resident EMR entries. The MSD coordinator was unable to locate a behavior or mood care plan for Resident #1. The MDS coordinator was interviewed again on 10/21/25 at 1:45 p.m. The MDS coordinator said target behaviors are identified by talking with floor staff. Behaviors would include yelling or outbursts. For depression, we talk with family about what depression symptoms they have, and if they are previously on an antidepressant. She said the facility has a psychiatric quality assurance representative that speaks with the medical director, they also discuss with the physician, and in IDT. She said she was the one responsible for updating the care plan when a new medication is added and she was not sure why Resident #1 did not have a psychotropic medication focus added to his care plan when the antidepressant was ordered. She said Resident #2's quarterly review was planned for 10/21/25 , and she planned to update Resident #1’s care plan today. She said she planned to educate staff to include a care plan when they receive a new order for a psychotropic medication so that the care plan is updated faster to reflect changes for each resident. She said she was not part of the discussion for Resident #1’s medication, but she was usually involved in similar discussions during IDT meetings. She said they had discussed it in the past, but he declined. She said nonpharmacological interventions for Resident #1 would be in his behavior care plan and she also planned to add additional nonpharmacological interventions and behavior tracking when she created the psychotropic medication care plan. Certified nurse assistant (CNA) #1 was interviewed on 10/21/25 at 10:34 a.m. CNA #1 said she was familiar with Resident #1. She said she had observed Resident #1 with behaviors such as throwing himself into his chair or trying to tip the sit-to-stand equipment. CNA #1 said Resident #1 responded well when he was approached quietly and in a friendly manner. CNA #1 said if Resident #1 had escalating behaviors, she would step in to help Resident #1 de-escalate his behavior with redirection to a quiet or calm activity. CNA #1 said she received annual training for abuse prevention and reporting.

A complaint survey, prompted by #CO2607432 was completed on 10/1/25 to 12/5/2025. Three deficiencies were cited. The actual exit date was 10/1/25. 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 12/5/25.

Based on record review, and interviews, the facility failed to periodically update resident contact information for one (#2) out of three residents reviewed out of five sample residents. Specifically, the facility failed to obtain and Resident #2’s power of attorney’s (POA) phone number. Findings include:I. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 6/20/25. According to the September computerized physician orders (CPO), diagnoses included history of a motor vehicle accident, fracture of the right pubis, fracture of the sacrum, fracture of the fifth lumbar vertebra, anemia, hypothyroidism and hypertension. The 9/23/25 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of ten out of 15. Resident #2 was independent with oral care. She required supervision and cues with toileting, dressing, and personal hygiene. Resident #2 required substantial assistance with footwear. B. Record reviewThe power of attorney declaration form, dated 7/15/25, revealed Resident #2’s POA changed from her daughter to her son. -However, review of Resident #2’s electronic medical record (EMR) on 10/1/25 at 2:00 p.m. did not reveal the resident’s POA’s contact information. C. Staff interviewsThe social service director (SSD) was interviewed on 10/1/25 at 3:00 p.m. The SSD said she was unable to find the phone number for Resident #2’s POA in the EMR. The SSD said she started working for the facility in June 2025. She said Resident #2’s son visited often and received in person updates, but the SSD said she would not be able to call Resident #2’s POA if an emergency occurred. The SSD said she would try the contact information of the daughter (who was no longer the POA) listed in the Resident #2’s electronic medical record. Registered nurse (RN) #2 was interviewed on 10/1/25 at 3:22 p.m. RN #2 said she was not able to find the phone number for Resident #2’s son/POA in the EMR. RN #2 said she saw Resident #2’s son earlier today and RN #2 said she would have updated the contact information if she was aware it was missing. RN #2 said if Resident #2 had an emergency, she would have to try to contact the other family since she did not have any way to contact the resident POA.The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on together on 10/1/25 at 5:01 p.m. The NHA and the DON confirmed the phone number for the POA was not in the EMR. The NHA said the son and the daughter members were in dispute of who should have POA for Resident #2. The NHA said she remembered a new POA form was completed in July 2025 and the phone number was probably missed when updating the information. The NHA said he contacted the staff member assigned to medical records. The NHA said the staff member reviewed Resident #2’s EMR and was not able to find the phone number for the POA. The NHA said she planned to find the contact information and include the phone number in the EMR as soon as possible. The NHA was interviewed again on 10/1/25 at 5:36 p.m. The NHA said the resident’s POA information was added to the EMR. the medical record. The NHA and the MDS coordinator were interviewed together on 10/1/25 at 6:02 p.m. The MDS coordinator said having the phone number for the new POA was important because staff needed to be able to contact him in case of an emergency. The MDS coordinator said the new POA for Resident #2 did not call often, but did visit in person frequently. The MDS coordinator said typically, the SSD or the social services assistant would obtain and enter the contact information on admission or on request. The MDS coordinator said she thought the phone number was missed when the facility received new paperwork assigning a new resident representative. The MDS coordinator said the SSD had just started at the facility around the time they received the new POA declaration form, and she may not have known at the time that it was her responsibility to update the facesheet.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents out of six sample residents received prompt efforts to resolve grievances. Specifically, the facility failed to timely address, communicate and attempt to resolve concerns related to not receiving a hair cut for Resident #1. Finding include:I. Facility policy and procedureThe Grievance/Complaints, Filing policy, revised April 2017 was provided by the assistant director of nursing (ADON) on 10/1/25 at 5:58 p.m. The policy read in part, “Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator will make prompt efforts to resolve grievances to the satisfaction of the resident and or representative. “Grievances and/or complaints may be submitted orally or in writing, and maybe filed anonymously.“Upon receipt of the grievance and/or complaint, the grievance officer will review the and review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and/or complaint.“The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken.“The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed verbally and in writing of the findings of the investigation and the actions that will be taken to correct any identified problems.”The Grievance/Complaints, Recording and Investigating policy, revised April 2017 was provided by the ADON on 10/1/25 at 5:58 p.m. The policy read in part, “All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances.“Upon receiving a grievance and complaint report the grievance officer will begin an investigation into the allegations.“The grievance officer will record and maintain all grievances and complaints on the resident grievance complaint log. “The resident grievance/complaint investigation report will be filed with the administrator within five working days of the incident.” II. Resident #1Resident #1, age greater than 65, was admitted on 1/19/21. According to the October 2025 computerized physician’s orders (CPO), diagnoses included Alzheimer's disease with late onset, dementia and other diseases classified elsewhere, unspecified severity and dysphasia. The 7/24/25 minimum data set (MDS) assessment revealed Resident #1 had short and long term memory problems. A staff assessment identified her cognition was severely impaired. According to the MDS assessment. Resident #1 was rarely to never able to understand others or make herself understood. She was dependent on staff for all activities of daily living (ADL) and used a wheelchair. III. Resident representative interviewResident #1’s representative was interviewed on 10/1/25 at 2:37 p.m. The representative said Resident #1 kept her hair short and she was scheduled for a hair cut every six weeks at the facility but then the hair cuts stopped. She said for months, she requested to have Resident #1’s hair cut. She said the only communication she received was that if a resident was in a wheelchair, the resident would not be able to get a haircut until the facility hired a new beautician. The representative said she brought up the need for a hair cut during care conferences and with any staff member she spoke with. She said it took four months and her getting upset with staff in order for Resident #1 to get a hair cut. IV. Record reviewThe mobility and self-care deficit care plan interventions identified Resident #1 was dependent on staff for her personal hygiene, used a Broda chair (specialty wheelchair) for mobility that staff propels and bolster foot positioning device, and required the use of a hoyer lift to transfer from surface to surface (7/29/25). The 7/7/25 social service note documented Resident #1’s representative requested during care conference that Resident #1 was placed on a consistent haircut schedule every six to seven weeks.-However, there was no documentation indicating the resident was placed on a consistent haircut schedule until September 2025. A 9/3/25 concern/grievance form was provided by the ADON on 10/1/25 at 5:58 p.m. The grievance card created by Resident #1’s representative on 9/3/25. According to the grievance card, Resident #1 had been waiting for a hair cut for four months. The 9/3/25 nursing note documented the nursing home administrator (NHA) met with Resident #1’s representative on 9/3/25 her concerns about Resident #1’s hair being too long. According to the note, the NHA informed the representative that they have hired a new beautician who should be starting shortly. The 9/4/25 nursing note documented the beautician would cut Resident #1’s hair when she arrived for duty after her facility onboarding. According to the note, the NHA was notified of the representative’s concerns on 9/2/25 and contacted the representative. The note indicated the social service director (SSD) was already helping her resolve the concerns. V. Staff interviewThe facility’s beautician was interviewed on 10/1/25 at 3:20 p.m. She said the Resident #1 was placed on a every four week haircut schedule. She said her hair was cut on 9/10/25. The SSD and the MDS coordinator were interviewed together on 10/1/25 at 3:57 p.m. The SSD said Resident #1’s representative told her a couple times that she wanted Resident #1 to have a haircut. The SSD said Resident #1’s representative would routinely schedule Resident #1 a hair cut with the facility’s beautician but there was a gap in time that the facility did not have one. She said Resident #1 would not be able to go to an outside beautician because of her large wheelchair, the need for a hoyer lift to transfer her from surface to surface and the facility bus did not take residents to non-medical appointments. The SSD said in August 2025, the representative said she wanted Resident #1 to have a hair cut but was told there was no other option other than the facility hiring a new beautician. The SSD said she thought that maybe an in-house staff member could cut the resident’s hair but she did not if that thought was pursued or someone coming in to cut hair temporarily. The SSD said she was not the facility’s SSD prior to July 2025, so if the resident’s representative was asking for a hair cut for Resident #1 before July 2025, she would not know. The SSD said the representative expressed that she was wanted Resident #1’s hair cut during the July 2025 care conference. The SSD said the representative asked again for a hair cut in August 2025. The SSD said the representative was told the facility need to hire a new beautician and there was no option for a haircut until one was hired. The MDS coordinator said looking for a back up or temporary beautician to help out would have been a good and necessary resource for the facility to have. The SSD said she did not fill out a grievance form or start the grievance process when Resident #1 expressed concerns about Resident #1 was receiving a hair cut as requested. The SSD said in the care conferences she would review the care plan with the resident and/or their representative. She said if a family expressed a concern or had a complaint shared during a care conference, she would make a note regarding the concern but it would not go further than that. She said she would not fill out a grievance form unless the resident or their representative asked her to. The MDS coordinator said the SSD was in training and learning her role and the grievance process. The MDS coordinator said in the future, resident and representative concerns brought to social services would be something the SSD would help facilitate and follow up with the grievances/requests so any concerns and needs could be addressed. The MDS coordinator said the facility wanted residents and their representatives to feel comfortable and have a voice in resident care and services. She said it should be the responsibility of the facility to communicate efficiently with the residents and their representatives. The NHA and the MDS coordinator were interviewed together on 10/1/25 at 6:02 p.m. The NHA said the former beautician continued to call in and then resigned. The NHA said she was not sure how long the facility went without a beautician to cut residents’ hair. She said she was not aware that Resident #1’s representative had concerns about Resident #1 not receiving a haircut. She said she did not receive a grievance form regarding the concern until 9/3/25. She said she followed up with the representative on 9/4/25. The NHA said if she received a grievance form or was made aware of the concern, she would have followed up sooner with the representative. She said she did not know if the facility would have been able to provide a haircut sooner for Resident #1, but she would have followed up with the representative and looked at potential options. The NHA said the facility needed to tighten up the grievance process. The NHA said if a resident or their representative expresses a concern or a request, the facility needs to address it and communicate back to the family or resident. The NHA said concerns identified in a care conference should have been addressed on a grievance form using the grievance process so the concerns could have been followed up with. The NHA said the SSD had been learning a lot but still needed to have on-going training on the grievance process. The NHA said she would update the grievance form to add concerns addressed in the care conferences. She said she would also review and address the grievance process in the next quality assurance and improvement meeting.

Based on observations, record review and interviews, the facility failed to ensure two (#2 and #1) of three residents out of five sample residents received dental services timely. Specifically, the facility failed to:-Identify and refer Resident #2 to the dentist timely after she lost her left upper canine tooth; and, -Resident #1 was offered routine dental care. III. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 1/19/21. According to the October 2025 CPO, diagnoses included Alzheimer's disease with late onset, dementia and other diseases classified elsewhere, unspecified severity and dysphasia (difficulty swallowing). The 7/24/25 MDS assessment revealed Resident #1 had short and long term memory problems. A staff assessment identified her cognition was severely impaired. According to the MDS assessment, Resident #1 was rarely to never was able to understand others or make herself understood. She was dependent on staff for all ADL, including oral care. The MDS assessment did not identify the resident had a loose or broken tooth. -However, the resident’s care plan indicated the resident’s teeth were in poor condition (see record review below). B. Resident #1’s representative interviewResident #1’s representative was interviewed on 10/1/25 at 2:37 p.m. The resident’s representative said she came to the facility on 9/3/25 to visit Resident #3 and noticed that Resident #1 was missing most of a tooth. She said Resident #1’s lip was drooping where the tooth had been and there was a small broken piece of her former tooth that remained in place. She said she reported the broken tooth to the facility and they placed her on antibiotics. The representative said she was concerned that no one else noticed Resident #1’s broken tooth. She said the last time Resident #1 went to the dentist was three years ago. She said the facility had not offered for the resident to see the dentist. C. Record reviewThe vision, hearing, speech and dental care plan, revised 7/31/25, identified Resident #1’s teeth were in poor condition. Pertinent interventions, initiated on 7/29/25, directed staff to notify the physician of any concerns and assist the resident with appointments. The 7/15/25 long-term care quarterly evaluation documented the resident had her own teeth. According to the evaluation, her teeth were not assessed and/or there was no information. The evaluation indicated oral care was not performed on Resident #1 was because she was independent. -However the 7/24/25 MDS assessment documented to the resident was dependent with her oral care. A 9/3/25 concern/grievance card was provided by the nurse manager/assistant director of nursing (NM) on 10/1/25 at 5:58 p.m. The grievance card was created by Resident #1’s representative on 9/3/25. According to the grievance card, Resident #1 had a broken tooth in the front of her mouth and the representative was not notified. The 9/3/25 nursing note documented Resident #1’s representative alerted social services that Resident #1 had a cracked tooth. According to the note, staff would monitor the resident for any signs of infection or increased mouth pain. The 9/3/25 skin check note identified an exam of the resident’s mouth on 9/3/25 revealed Resident #1’s upper left tooth was missing and the tooth beside the missing area was red and inflamed around the base of the neighboring tooth. A 9/3/25 facility investigation was provided by the facility on 10/1/25. The investigation documented there was an unknown time frame or cause found during the investigation as to reasoning/incident surrounding the missing tooth. The representative of Resident #1 told the nursing home administrator (NHA) that she wanted to make sure that Resident #1’s dental issues were not being neglected. According to the investigation, the staff had not noticed the missing tooth because there was no change in her eating or signs of pain/discomfort. The investigation indicated the resident was provided antibiotics due to her high risk for infection. The 9/5/25 nursing note documented Resident #1 returned to the facility (after her dental appointment) after her broken tooth was extracted. The extracted area of the mouth was swollen and had five out 10 pain with use of the non-verbal pain scale. A 10/1/25 email was provided by the NHA on 10/1/25 at 3:28 p.m. The email documented the list of residents who were seen in-house by the dental hygienist during the hygienist’s last two visits. The review of the provided March 2025 and June 2025 resident lists identified Resident #1 was not seen by the hygienist. Review of Resident #1 electronic medical record (EMR) did not identify the resident was seen by or offered dental services prior to her 9/5/25 appointment. D. Staff interviewsThe social service director (SSD) and the MDS coordinator were interviewed together on 10/1/25 at 3:57 p.m. The SSD said Resident #1’s representative reported Resident #1 had a missing tooth. The SSD said the representative was upset about the missing tooth and she wanted someone to look at her mouth in case there was an infection. The SSD said the NHA was made aware of the concern. The SSD said she would usually ask residents’ representatives if they had any dental concerns during care conferences. The SSD said if a representative had dental concerns then a dental appointment would be scheduled. She said if a resident required outside dental services, the facility driver would schedule an appointment and assist the residents to the appointment. She said she did not know if there was a set schedule for a resident to receive dental services. She said dentist appointments and the dental hygienist exams were usually based on request. The MDS coordinator said the nurses do a quarterly head to toe check and then request a dental appointment if they saw a concern but residents should be routinely offered and seen for dental services. The MDS coordinator was interviewed a second time on 10/1/25 at 4:28 p.m. The MDS coordinator said resident representatives should always be informed of a resident change of condition. She said Resident #1 was not able to make her needs known and staff and need staff to anticipate her needs. She said Resident #1 was not able to do any of her ADLs and was dependent on staff for eating and oral care. She said the staff should be providing her with oral care at least a day and should have routine contact with her mouth. The MDS coordinator said the nurses examine residents’ mouths quarterly and as needed. CNA #1 was interviewed on 10/1/25 at 5:05 p.m. C.N.A #1 said he was the resident’s regular CNA. He said he did not notice she had a missing tooth until it was reported to him on or just after 9/3/25. He said it was very hard to see into her mouth. He said she never opened her mouth fully when he brushes her teeth and she would often try to bite down on the tooth brush. He said he tried to brush her teeth very gently so she does not fracture or chip a tooth. He said she frequently grinded her teeth. RN #1 was interviewed on 10/1/25 at 5:40 p.m. RN #1 said he was Resident #1’s regular nurse. He said he was not aware she had a missing or broken tooth prior to 9/3/25. He said he could not determine if the resident's tooth broken was a recent break or if it had been broken for a while. He said when he reviewed her mouth after it was reported to him, it was not bleeding, swollen, or had evidence of sharp edges. He said the resident would often grind her teeth. The medical records director was interviewed on 10/1/25 at 5:59 p.m. The medical records director identified herself as the scheduling coordinator. She said she helped coordinate dental services/appointments after she received requests from the nurses or social services. She said residents were usually seen at minimum once a year for dental services. She said most residents have biannual and annual dental services for preventive care. She said SSD was responsible for tracking when a residentwould need to be seen by a dental provider. She said all residents should have the option to see the dental hygienist who could come to the facility. The medical records director said she would get a copy of residents to be seen by the dental hygienist. She said she did not think Resident #1 had been on the list to be seen. The NHA, the MDS coordinator and the NM were interviewed together on 10/1/25 at 6:02 p.m. The NHA said Resident #1’s representative contacted her on 9/3/25 and told her that Resident #1 was missing a tooth. The NHA said she started an investigation and could find any staff member who could tell what happened to the tooth. The NM said the review of the resident’s mouth identified Resident #1’s left upper front tooth was significantly broken. The NHA said she interviewed CNA #1 who told her it was hard for staff to look at her teeth because she clamped down and would not open her mouth wide. The NHA said Resident #1’s representative was upset because she felt that someone should have seen that the resident’s front tooth was no longer there. The NHA said Resident #1 was not seen by the dental hygienist. The NHA said part of the problem was because of staff turnover. She said the facility had three different social services directors over the last year. She said the facility also needed to improve their ancillary tracking process. She said the facility identified the concern a few weeks ago and would implement a new tracking spreadsheet for ancillary services on 10/2/25. The NHA said the new tracking system should help ensure residents were seen by dental services one to two times a year. She said there was no documentation in the resident’s EMR that had been found to identify Resident #1 was offered dental services. The NHA said the resident should have been routinely assessed by the dental hygienist to help ensure dental care, reduce infection risk and risk for swallowing a broken tooth. The NHA said the resident likely swallowed the broken tooth. She said the resident would not have been able to spit out or take out a tooth that had fallen out and was in her mouth and the tooth was not located or reported to be found on the floor.

A complaint survey, prompted by #CO1923449 and #CO2586776 was conducted on 8/19/25 to8/21/25. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of seven sample residents. Specifically, the facility failed to:-Allow Resident #2 to return to the facility after an unplanned discharge to the hospital;-Provide documentation made by Resident #2’s physician, including the specific resident needs the facility could not meet, the facility’s efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility; and,-Reassess Resident #2 for readmission after he was stabilized at the hospital and ready to return to the facility. Findings include:I. Facility policy and procedureThe Transfer or Discharge, Facility-Initiated policy, revised October 2022, was provided by the assistant director of nursing (ADON) on 8/21/25 at 11:31p.m. The policy read in pertinent part, “Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. “Each resident will be permitted to remain in the facility and not be transferred or discharged unless;-The transfer discharge is necessary for the resident’s welfare and the resident's needs can not be met in this facility; and,-The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.“Residents who are sent emergently to an acute care setting, these scenarios are considered facility initiated transfers, not discharges, because the residents return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility.“If discharge is initiated by the facility after an emergent transfer to the hospital, the reason for the discharge is based on the resident status at the time the resident seeks to return to the facility and not at the time the resident was transferred to acute care.“Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: The specific resident needs that can not be met; the facilities attempt to meet those needs; and, the receiving facilities services that are available to meet those needs.” “Should the resident be transferred to discharge for any of the following reasons, the basis of the transfer or discharge is documented in the resident’s clinical record by the resident's attending physician. The transfer discharge is necessary for the residents welfare and the resident’s needs cannot be met in the facility.“Should the resident be transferred or discharged for any reasons the basis of the transfer discharge will be documented in the resident’s clinical record by a physician, the safety of the individuals of the facilities endangered due to the clinical behavior status of the resident or the health of the individuals in the facility would otherwise be endangered. “If the facility determines that the resident can not return to the facility, the medical record would indicate that the facility made efforts to determine if the resident still required the services of the facility and was eligible for Medicare skilled nursing facility or Medicaid nursing facility services; ascertain an accurate status of resident’s condition, which can be accomplished via communication between the hospital and facility staff and/or through visits by the facility staff to the hospital; find out from the hospital the treatments, medications and the services the facility would need to provide to meet the residents needs upon returning to the facility. If the facility is unable to provide the treatments, medications, and services needed, the facility may not be able to meet the residents needs; and work with the hospital to ensure the residence condition needs are within the facility’s scope of care, based on its facility assessment prior to the hospital discharge.”II. Resident statusResident #2, age greater than 65, was admitted on 7/9/25 and discharged to the hospital on 7/31/25. According to the July 2025 computerized physician orders (CPO), diagnoses included non-traumatic acute subdural hemorrhage, reduced mobility, mild cognitive impairment of uncertain or unknown etiology, repeated falls, need for assistance with personal care, unspecified lack of coordination and generalized muscle weakness. The 7/15/25 minimum data set (MDS) assessment identified Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident required partial to moderate physical assistance for transferring from surface to surface, bed mobility and walking. The MDS assessment documented Resident #2 used a motorized wheelchair. III. Resident representative interviewResident #2’s representative was interviewed on 8/20/25 at 5:10 p.m. The representative said Resident #2 was initially admitted to the facility from the hospital after a fall, for therapy and long-term placement. He said Resident #2 was sent back to the hospital two weeks later. He said he was told that Resident #2 was sent to the hospital related to a fall at the facility. He said he later learned that the facility felt Resident #2 had a psychotic episode. He said Resident #2 was not evaluated by his physician before the facility determined he had a psychotic episode and sent him out. He said he felt the facility dumped him at the hospital. The representative said the hospital and the facility had a conference together that he was not invited to. He said he was then informed by the hospital that the facility was not going to allow Resident #2 to return to the facility and it was inappropriate for them to not allow him to return. The resident representative said he was never provided a notice of discharge or information on the discharge appeal process. He said she was never told that he could try to appeal the facility’s decision. He said he just knew that Resident #2 was not welcome back at the facility. The representative said he was never recommended or referred to other facilities. He said Resident #2 was currently at another facility and had not had any problems there. Cross reference F628 for failure to provide an appropriate discharge process. IV. Record reviewThe cognition care plan, initiated 7/29/25, identified Resident #2 was at risk for cognitive decline related to mild cognitive impairment. According to the care plan, he could make his needs known but his hearing difficulties were a potential barrier for communication. Interventions, initiated 7/29/25, included approaching Resident #2 in a calm, quiet manner and offering reassurance before initiating care or providing direction, ensuring the resident was safe, re-approaching at a later time when it was safe/less distressing to the resident if he had increased confusion, frustration or agitation and asking for assistance from a different staff member. The discharge care plan, initiated 7/29/25, identified Resident #2 was a long-term care resident with no intent to discharge. Interventions, initiated 7/29/25, included providing local agency referrals as appropriate when the resident/responsible party asked about discharge and waiting for the resident/responsible party to initiate conversation regarding discharge. -Review of Resident #2’s comprehensive care plan revealed the resident did not have a care plan for a risk of behaviors, or wandering/elopement. The 7/21/25 nursing progress note documented Resident #2 was near the back door and requested to walk to the Veterans Affairs facility (VA) or just go for a walk around. The note identified he was upset that he was at his current facility and wanted to go to the VA. According to the note, the resident was redirected back to his room. He told the staff he would try to contact the VA to come and get him. The note indicated Resident #2 was told why he was in nursing care and he voiced understanding. The admission/discharge report was provided by the nursing home administrator (NHA) on 8/19/25 at approximately 11:00 am. The report indicated Resident #2 discharged to the hospital on 7/31/25. The report did not identify if he returned to the facility. The 7/31/25 administration note documented Resident #2 was at the hospital.-Review of progress notes did not identify why the resident went to the hospital or incidents occurring on or before 7/31/25 requiring hospitalization. -Review of progress notes did not indicate that Resident #2 had been formally discharged from the facility. -Review of progress notes did not identify the resident’s physician documented the safety of the individuals in the facility were endangered due to the clinical behavior status of Resident #2. The 7/31/25 wandering assessment documented Resident #2 was at moderate risk for wandering.-Review of assessments did not identify the resident was evaluated for wandering/elopement prior to 7/31/25. The 7/31/25 at 6:35 a.m. incident report for elopement was provided by the NHA on 8/20/25 at 4:35 p.m. The report documented Resident #2 eloped by using the door at the end of the hall. According to the report, the staff ran after the resident, attempting to coax him back inside. Resident #2 ran, fell and became violent. The risk assessment indicated he started to swing at anyone who tried to stop him. The report identified the resident was placed in a chair and wheeled backwards inside the facility while he attempted to hit and bite staff. The assessment revealed the resident was able to go out the same door again. The staff followed the resident, contacted his physician and requested a physician’s order to send the resident out to the hospital. The assessment identified Resident #2 remained calm as long as the staff did not approach him or attempt to bring him back into the facility. The 7/31/25 hospital final transcript documented Resident #2 was brought to the emergency department (ED) by emergency medical services (EMS) for a possible fall at his living facility and he was somewhat combative with them in the morning (7/31/25). According to the transcript, EMS reported to the hospital that Resident #2 was fine with them. The transcript identified Resident #2 arrived at the hospital without complaints or signs of trauma on exam and likely had some behavioral issues and dementia and may or may not have fallen. The transcript revealed there did not appear to be evidence of an acute emergency condition that would necessitate hospitalization or suggest a need for immediate inpatient treatment given their lack of red flags for serious illness and he remained stable in the emergency department. The hospital transcript revealed the hospital attempted to transfer Resident #2 back to his living facility but the facility declined to have him return due to his combativeness to staff members. The transcript documented the ED requested help from the hospital case managers to determine a proper disposition and to communicate with the resident’s living facility. According to the transcript, Resident #2 would be discharged from the hospital but the hospital did not know where he would be discharged to. The involuntary discharge notice, dated 7/31/25, was provided by the NHA on 8/20/25 at 4:53 p.m. The discharge notice indicated Resident #2 would be discharged to the hospital effective 7/31/25. The notice documented the facility was pursuing immediate discharge of Resident #2 from the facility in the interest of his safety and wellness, as well as the safety and wellness of other residents who resided at the facility. According to the discharge notice, the facility determined that they were no longer ableto provide the level of care that Resident #2 required due to his unsafe behavior of physical and verbal aggression. The involuntary discharge notice included the resident’s right to appeal the discharge and the appeal process. V. InterviewsLicensed practical nurse (LPN) #1 was interviewed on 8/19/25 at 3:34 p.m. LPN #1 said staff tried to redirect residents with combative behaviors. She said if the behaviors continued, the facility would call an ambulance for assistance. She said Resident #2 was combative and was trying to leave the facility on 7/31/25. She said he was swinging at staff, was not redirectable and was not safe to be around the staff. LPN #1 said a certified nurse aide (CNA) told her Resident #2 went out the back door (on 7/31/25). LPN #1 said she caught up with him on the other side of the building. She said she and other staff members were following him and always had eyes on him. She said his pants were on backwards and he fell. She said he was assisted to a wheelchair but then he started to swing at them. LPN #1 said he punched her in the chest and another nurse in the stomach. She said they were able to bring him back inside the facility but he walked out of the facility again, walked around and then sat under a tree. She said Resident #2 refused to come back into the facility so they called EMS. LPN #1 said when he saw the ambulance approaching him, he started to walk away. She said when EMS approached him, he started to swing at them too. LPN #1 said she Resident #2 said he wanted to leave the facility when he was trying to hit the staff outside. She said he had additionally said he wanted to leave the facility the day before (7/30/25). LPN #1 said she contacted the ADON, the director of nursing (DON) and the NHA to report what happened. She said another nurse involved in the incident left a message for Resident #2’s representative that he went to the hospital. LPN #1 said the representative called her back and asked why Resident #2 was sent to the hospital. She said she told the representative Resident #2 was aggressive with staff and they could not keep him at the facility. She said Resident #2 was no longer a resident at the facility. The hospital case manager was interviewed on 8/19/25 at 4:24 p.m. The hospital case manager said the facility contacted the hospital and said Resident #2 was having a psychotic episode and was violent towards a staff member. She said Resident #2 was pleasant at the hospital, had no behaviors and only required Tylenol. She said he had a sitter with him at the hospital related to his dementia and risk of him wandering off. She said he only needed to be redirected to where the restroom was. The hospital case manager said Resident #2 was calm, watched television, slept and went on walks with the sitter. The hospital case manager said a psychiatric team reviewed Resident #2 and felt he did not have a psychotic episode at the facility. She said the psychiatric team felt his behaviors were more dementia related. She said Resident #2 was medically cleared by the hospital physician to return to the facility. She said the hospital contacted the facility but the facility refused to accept him back because of his aggression towards a staff member. She said the facility told the hospital that the 7/31/25 incident with Resident #2 was the first time he had any related behaviors at the facility. The hospital case manager said she told the facility that with it only being the first incident and he was medically and psychologically cleared, they needed to take Resident #2 back. The hospital case manager said the facility did not notify the ombudsman or tell the resident’s representative what happened. The hospital case manager said further communication with the facility was difficult because they kept passing off the phone to staff who said they did not know about the situation and were not there at the time so the hospital set up a conference call with the facility and the frequent facility visitor to discuss Resident #2’s discharge. The hospital case manager said the facility continued to refuse Resident #2’s return to the facility. She said the hospital had to find him another facility to go to. She said Resident #2 had to stay at the hospital for two to three more days until he was accepted by and transferred to another facility. A frequent facility visitor was interviewed on 8/20/25 at 12:05 p.m. The visitor said the facility left Resident #2 at the hospital and did not allow him to return to the facility. She said the facility told the resident’s representative that he went to the hospital but the representative was not told why or that the resident would not be permitted to return to the facility. She said Resident #2 was confused, walked out of the facility and then fell on his buttocks without injury. The visitor said she went to the hospital to see Resident #2 on 7/31/25. She said she spoke with the resident and he said he went to the emergency department (ED) but he did not know why. She said he told her that the facility was not listening to him. The visitor said the hospital case managers told her the facility refused to take him back because they felt he was a danger to himself and others and the facility did not want their nurses in danger. The visitor said she contacted Resident #2’s representative and he was very upset because he was only told that Resident #2 went to the hospital but he was not told why or that the resident would not be permitted to return to the facility. She said he had to find out what happened from the hospital and not the facility. The visitor said she was not provided a notice of discharge for Resident #2 until 8/1/25, two days after the facility refused to have him return, and after she had to continue to ask for it. Cross reference F628 for failure to provide an appropriate discharge process. The frequent facility visitor was interviewed again on 8/20/25 at 5:05 p.m. The visitor said she did not provide Resident #2’s representative with the notice of discharge and the resident’s appeal rights. She said the facility should have provided the representative with the notice and rights. The visitor said the representative did not contact her to help with the discharge appeal. The NHA and the ADON were interviewed together on 8/20/25 at 4:01 p.m. The NHA said the staff could not get Resident #2 back in the facility after he walked out the facility doors a second time on 7/31/25. She said he remained in line of sight of the staff while he was outside. The NHA said the staff sent Resident #2 to the hospital so the hospital could do a medical and psychiatric evaluation and review. She said the 7/31/25 incident occurred in the early morning and the ADON was the main contact with the facility staff at the time. The ADON said LPN #1 contacted her and told her Resident #2’s behavior was escalating and he punched LPN #1 in the chest, LPN #2 in the stomach and tried to get away from them and Resident #2 fell. The ADON said she suggested removing the nurses involved and approaching the situation with a new face. She said a CNA offered a wheelchair to Resident #2. The ADON said the resident calmed down enough to bring him back into the facility. She said Resident #2 was placed at a table and offered coffee. She said moments later, the resident got up from the table and went out the door again. She said LPN #1 was able to stay with him. The ADON said Resident #2 walked to the other side of the facility and then across the parking lot to another neighboring property. She said Resident #2 would not deescalate, so staff called EMS for help. The NHA said the staff told her Resident #2 had to be restrained by the police and firemen. The ADON said the physician was contacted and the facility was provided with physician’s orders to send Resident #2 to the hospital. The NHA said the facility did not reevaluate Resident #2 while he was at the hospital. The NHA said the facility did not review his records at the hospital. She said the frequent facility visitor went to the hospital to see Resident #2 and she said he was calm. She said a phone conference was set up with the hospital instead. The NHA said during the phone conference with the hospital and the frequent facility visitor on 7/31/25, the facility was told Resident #2 was stable and the hospital wanted the facility to take him back. The NHA said she made the decision not to have Resident #2 return to the facility because the hospital made no medication changes. She said the facility felt that Resident #2 had a psychotic break based on his severe behaviors on 7/31/25 and he became a different person. She said that the facility told the hospital that they were not prepared or equipped to deal with psychotic episodes. She said the behavior occurred so fast without any triggers with that type of dementia. The NHA said the facility could not meet Resident #2’s needs if there was a chance his behaviors would escalate and be directed towards a resident. She said she did not feel safe taking Resident #2 back. The NHA said the hospital had a caregiver stay with the resident. She said a caregiver always being with Resident #2 was not an option at the facility. She said if the hospital had adjusted the resident’s medication, she might have taken him back. The NHA said the facility did not send out referrals to other facilities when they determined that they were not going to take Resident #2 back. She said she did not send out referrals because she did not know what was wrong with him so she did not feel comfortable referring him to anyone else. The NHA said she did not know what triggered his behaviors on 7/31/25. She said Resident #2 did not have elopement, exit seeking or aggressive behaviors prior to 7/31/25. She said she was not aware that he had requested to leave the facility and go to the VA. She said his desire to leave the facility and go to the VA could have been a potential trigger to his behaviors on 7/31/25. The NHA said all residents were evaluated for elopement on admission so the facility could establish a baseline and risk. The NHA said the resident should have been assessed on admission and again after he reported a desire to leave the facility on 7/21/25. The NHA said if she knew Resident #2 was expressing that he wanted to leave, she would have spoken to his representative and explored why he wanted to go to the VA instead of remaining in the facility. The ADON said Resident #2 did not have an elopement assessment until after his attempt to elope on 7/31/25. The ADON said if the facility had known he had signs of wanting to leave, they would have looked at a safety plan.

Based on record review and interviews, the facility failed to revise and implement an effective discharge plan for one (#2) of three residents reviewed for discharge planning out of seven sample residents. Specifically, the facility failed to:-Ensure the discharge planning was process was documented, including the reason for discharge in Resident #2's electronic medical record (EMR); -Notify Resident #2 and/or Resident #2's representative, in writing, of the discharge, including the reason for the move, the effective date of discharge, the location where the resident was being discharged to, a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman; and,-Notify the facility's ombudsman of Resident #2's discharge in writing in a timely manner. Findings include: I. Facility policy and procedureThe Transfer or Discharge, Facility-Initiated policy, revised October 2022, was provided by the assistant director of nursing (ADON) on 8/21/25 at 11:31p.m. The policy read in pertinent part,“Once admitted to the facility, residents have the right to remain in the facility. Facility initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. “Each resident will be permitted to remain in the facility and not be transferred or discharged unless;-The transfer discharge is necessary for the resident’swelfare and the resident's needs can not be met in this facility; and,-The safety of individuals in the facility is endangereddue to the clinical or behavioral status of the resident.“Residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges, because the residents return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. “If discharge is initiated by the facility after an emergent transfer to the hospital, the reason for the discharge is based on the resident status at the time the resident seeks to return to the facility and not at the time the resident was transferred to acute care.“If the facility does not permit a resident’s return to the facility based on the inability to meet the resident’s needs, the facility will notify the resident, and or his or her representative in writing of the discharge, including notification of appeal rights. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. The notice of theOffice of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident and the resident representative. If the resident chooses to appeal the discharge, the facility will not discharge residents while the appeal is pending.“Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: The specific resident needs that can not be met; the facilities attempt to meet those needs; and, the receiving facilities services that are available to meet those needs. “When a resident is transferred or discharged from the facility, the following information is documented in the medical record: the basis of the transfer of the discharge; if the resident is being transferred or discharged because of his or needs can not be met at the facility the documentation would include the specific resident needs that can not be met; the facility’s attempt to meet those needs; the receiving facilities services that are available for those needs; That an appropriate notice was provided to the resident and/or legal representative; the date and the time of the transfer or discharge; the new location of the resident; the mode of transportation; a summary of the resident overall medical physical and mental condition. “Should the resident be transferred or discharged for any of the following reasons, the basis of the transfer or discharge is documented in the resident’s clinical record by the resident's attending physician. The transfer discharge is necessary for the resident’s welfare and the resident’s needs can not be met in the facility. “Should the resident be transferred or discharged for any reasons the basis of the transfer discharge will be documented in the resident’s clinical record by a physician, the safety of the individuals of the facilities endangered due to the clinical behavior status of the resident or the health of the individuals in the facility would otherwise be endangered.” II. Resident status Resident #2, age greater than 65, was admitted on 7/9/25 and discharged to the hospital on 7/31/25. According to the August 2025 computerized physician orders (CPO), diagnoses included non-traumatic acute subdural hemorrhage, reduced mobility, mild cognitive impairment of uncertain or unknown etiology, repeated falls, need for assistance with personal care, unspecified lack of coordination and generalized muscle weakness. The 7/15/25 minimum data set (MDS) assessment identified Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident required partial to moderate physical assistance for transferring from surface to surface, bed mobility and walking. The MDS assessment documented Resident #2 used a motorized wheelchair. III. Resident representative interview Resident #2’s representative was interviewed on 8/20/25 at 5:10 p.m. The representative said Resident #2 was initially admitted to the facility from the hospital after a fall, for therapy and long-term placement. He said Resident #2 was sent back to the hospital two weeks later. He said he was told that Resident #2 was sent to the hospital related to a fall at the facility. He said he later learned that the facility felt Resident #2 had a psychotic episode. He said Resident #2 was not evaluated by his physician before the facility determined he had a psychotic episode and sent him out. He said he felt the facility dumped him at the hospital. The representative said the hospital and the facility had a conference together that he was not invited to. He said he was then informed by the hospital that the facility was not going to allow Resident #2 to return to the facility and it was inappropriate for them to not allow him to return. The representative said he was never provided a notice of discharge or information on the discharge appeal process. He said he was never told that he could try to appeal the facility’s decision. He said he just knew that Resident #2 was not welcome back at the facility. The representative said he was never recommended or referred to other facilities. He said Resident #2 was currently at another facility and had not had any problems there. IV. Record reviewThe discharge care plan, initiated 7/29/25, identified Resident #2 was a long-term care resident with no intent to discharge. Interventions, initiated 7/29/25,included providing local agencyreferrals as appropriate when the resident/responsible party asked aboutdischarge and waiting for the resident/responsible party to initiateconversation regarding discharge. The 7/21/25 nursing progress note documented Resident #2 was near the back door and requested to walk to the Veterans Affairs facility (VA) or just go for a walk around. The note identified he was upset that he was at his current facility and wanted to go to the VA. According to the note, the resident was redirected back to his room. He told the staff he would try to contact the VA to come and get him. The note indicated Resident #2 was told why he was in nursing care and he voiced understanding. The admission/discharge report was provided by the nursing home administrator (NHA) on 8/19/25 at approximately 11:00 am. The report indicated Resident #2 discharged to the hospital on 7/31/25. The report did not identify if he returned to the facility. The 7/31/25 administration progress note documented Resident #2 was at the hospital. -Review of progress notes did not identify why the resident went to the hospital or incidents occurring on or before 7/31/25 which required hospitalization. -Review of progress notes did not indicate that Resident #2 had been formally discharged from the facility on 7/31/25. The 7/31/25 at 6:35 a.m. incident report for elopement was provided by the NHA on 8/20/25 at 4:35 p.m. The report documented Resident #2 eloped by using the door at the end of the hall. According to the report, the staff ran after the resident, attempting to coax him back inside. Resident #2 ran, fell and became violent. The risk assessment indicated he started to swing at anyone who tried to stop him. The report identified the resident was placed in a chair and wheeled backwards inside the facility while he attempted to hit and bite staff. The assessment revealed the resident was able to go out the same door again. The staff followed the resident, contacted his physician and requested a physician’s order to send the resident out to the hospital. The assessment identified Resident #2 remained calm as long as the staff did not approach him or attempt to bring him back into the facility. The 7/31/25 hospital final transcript documented Resident #2 was brought to the emergency department (ED) by emergency medical services (EMS) for a possible fall at his living facility and he was somewhat combative with them in the morning (7/31/25). According to the transcript, EMS reported to the hospital that Resident #2 was fine with them. The transcript identified Resident #2 arrived at the hospital without complaints or signs of trauma on exam and likely had some behavioral issues and dementia and may or may not have fallen. The transcript revealed there did not appear to be evidence of an acute emergency condition that would necessitate hospitalization or suggest a need for immediate inpatient treatment given their lack of red flags for serious illness and he remained stable in the emergency department. The hospital transcript revealed the hospital attempted to transfer Resident #2 back to his living facility but the facility declined to have him return due to his combativeness to staff members. The transcript documented the ED requested help from the hospital case managers to determine a proper disposition and to communicate with the resident’s living facility. According to the transcript, Resident #2 would be discharged from the hospital but the hospital did not know where he would be discharged to. Cross reference F627 for failure to allow a resident to return to the facility. The involuntary discharge notice, dated 7/31/25, was provided by the NHA on 8/20/25 at 4:53 p.m. The discharge notice indicated Resident #2 would be discharged to the hospital effective 7/31/25. The notice documented the facility was pursuing immediate discharge of Resident #2 from the facility in the interest of his safety and wellness, as well as the safety and wellness of other residents who resided at the facility. According to the discharge notice, the facility determined that they were no longer able to provide the level of care that Resident #2 required due to his unsafe behavior of physical and verbal aggression. The involuntary discharge notice included the resident’s right to appeal the discharge and the appeal process.-However, a review of Resident #2's EMR did not reveal documentation to indicate the resident or the resident’s representative was notified of the discharge in writing, including the reason for the move, the effective date of discharge, the location where the resident was discharged to, a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman. -A review of Resident #2's EMR did not reveal the ombudsman was notified of the resident's discharge in writing in a timely manner (see frequent facility visitor interview below). V. InterviewsA frequent facility visitor was interviewed on 8/20/25 at 12:05 p.m. The visitor said the facility left Resident #2 at the hospital and did not allow him to return to the facility. She said the facility told the resident’s representative that he went to the hospital but the representative was not told why or that the resident would not be permitted to return to the facility. She said Resident #2 was confused, walked out of the facility and then fell on his buttocks without injury. The visitor said she went to the hospital to see Resident #2 on 7/31/25. She said she spoke with the resident and he said he went to the emergency department (ED) but he did not know why. She said he told her that the facility was not listening to him. The visitor said the hospital case managers told her the facility refused to take him back because they felt he was a danger to himself and others and the facility did not want their nurses in danger. The visitor said she contacted Resident #2’s representative and he was very upset because he was only told that Resident #2 went to the hospital but he was not told why or that he would not be permitted to return to the facility. She said he had to find out what happened from the hospital and not the facility. She said she was not provided a notice of discharge for Resident #2 until 8/1/25, two days after the facility refused to allow him to return to the facility, and after she had to continue to ask for the notice. The frequent facility visitor was interviewed again on 8/20/25 at 5:05 p.m. The visitor said she did not provide Resident #2’s representative with the notice of discharge and the resident’s appeal rights. She said the facility should have provided the representative with the notice and rights. The visitor said the representative did not contact her to help with the discharge appeal. The NHA and the assistant director of nursing (ADON) were interviewed together on 8/20/25 at 4:01 p.m. The NHA said the facility did not reevaluate Resident #2 while he was at the hospital. The NHA said she made the decision not to allow Resident #2 to return to the facility because the hospital made no medication changes. She said the facility felt that he had a psychotic break based on his severe behaviors on 7/31/25 and he became a different person. She said that the facility told the hospital that they were not prepared or equipped to deal with residents’ psychotic episodes. She said the behavior occurred so fast without any triggers with that type of dementia. The NHA said the facility could not meet Resident #2’s needs if there was a chance his behaviors would escalate and be directed towards another resident. She said she did not feel safe taking Resident #2 back. The ADON said the discharge notice was emailed to the frequent facility visitor on 8/1/25 at 1:32 p.m. The ADON said the frequent facility’s visitor and the hospital told Resident #2’s representative that Resident #2 was not coming back to the facility. The ADON said she did not know if the frequent facility visitor provided the resident’s representative with the discharge notice or information on the appeal process. The ADON said the facility did not provide the resident or the resident’s representative with the discharge notice or the rights to appeal the discharge. The NHA said Resident #2’s representative did not request to appeal the discharge. She said he came to the facility and collected the resident’s belongings but did not say anything about an appeal. The NHA said the discharge of Resident #2 was emergent and the frequent facility visitor was involved, so it was assumed that the frequent facility visitor provided the representative with the notice and appeal rights. She said it was not the responsibility or normal practice for the frequent visitor to give the notice. The NHA said the facility should not have assumedthe representative was already given the notices and appeal rights. The NHA said she wanted to make sure Resident #2’s representative knew his appeal rights. The NHA said she would make sure the resident’s representative received the discharge notice and the rights to appeal. The ADON said she would send out the discharge notice and the rights to appeal process overnight (on 8/20/25). VI. Facility follow-up The ADON provided a priority overnight mail receipt for Resident #2’s discharge notice and appeal rights on 8/21/25 at 10:50 a.m. According to the receipt, the discharge notice and appeal rights were to be delivered to Resident #2’s representative on 8/22/25 (22 days after the resident was discharged from the facility).

A revisit survey was completed on 6/6/25 for all previous deficiencies cited on 4/24/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO39786 was conducted on 4/23/25 and 4/24/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure a copy of medical records were provided in a timely manner for one (#1) of three residents out of five sample residents. Specifically, the facility failed to ensure medical records were provided in a timely manner upon request for Resident #1 from his resident representative. Findings include:I. Facility policy and procedure The Release of Information policy, revised November 2009, was provided by the nursing home administrator (NHA) on 4/24/25 at 1:10 p.m. It read in pertinent part,"The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed and dated request from the resident or representative."A resident may have access to his or her records within ____ hours (excluding weekends or holidays) of the resident's written or oral request."-The facility did not indicate on the policy how many hours the facility had to provide the requested medical records. II. Resident representative interviewResident #1's representative was interviewed on 4/23/25 at 3:45 p.m. via phone. She said she requested Resident #1's medical records from the facility in February 2025 after he passed away. She said she did not receive the records for over two weeks. III. Record reviewThe request for access to health information was provided by the medical records director (MRD) on 4/24/25 at 11:30 a.m. The form was completed by Resident #1's representative on 2/24/25 at 3:30 p.m. The form revealed the resident's representative received the records on 3/13/25 at 11:58 a.m.-The representative did not receive the medical records for 12 weekdays after she requested them. IV. Staff interviewsThe MRD was interviewed on 4/24/25 at 10:20 a.m. The MRD said she did not know the time frame the facility had to provide the resident or the representative with the medical records after they were requested. She said Resident #1's medical durable power of attorney (MDPOA) requested his medical records on 2/24/25. She said the records were released to the MDPOA on 3/13/25. She said the process was to send the records to the facility's attorney and once the "okay" was given, the records were released to the resident or representative. The MRD said this request took a little longer because the facility had a hard time reaching the attorney because the phone number had changed. The MRD said she tried to complete medical record requests as fast as possible but did not know it needed to be completed within 24 hours except when requested on a weekend or holiday. The nursing home administrator (NHA) was interviewed on 4/24/25 at 1:50 p.m. She said she was not sure what the facility's policy indicated the time line the facility needed to provide medical records upon request. The NHA said she thought the facility had 72 hours to provide the medical records when they were requested by the resident or representative. The NHA said the facility would review the policy to ensure it matched the regulation.

A revisit survey was completed on 4/17/25 for all previous deficiencies cited on 3/11/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO38530, Incident #38573, Incident #39456, Incident #39457, Incident #39458 and Incident #39458 was conducted from 3/10/25 to 3/11/25. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure three (#1, #8 and #6) of three residents were kept free from abuse out of nine sample residents. Specifically, the facility failed to:-Protect Resident #1 and Resident #8 from being sexually abused by Resident #2; and, -Protect Resident #6 from physical abuse by Resident #5. Findings include:I. Facility policy and procedureThe Abuse Prevention, Investigation and Reporting policy and procedure, revised November 2022, was provided by the nursing home administrator (NHA) on 3/11/25 at 5:14 p.m. It read in pertinent part, "To ensure to the extent possible, that every resident is free from abuse, neglect, misappropriation of resident property, and exploitation."The resident has the right to be free from abuse (including verbal, mental, sexual and physical), neglect, misappropriation of resident property and exploitation. This includes freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat a resident's medical condition. Management will take specific steps to reduce the potential for abuse to occur at the facility including, but not limited to education, monitoring and investigating thoroughly if abuse, misappropriation, neglect, or exploitation is suspected."Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. "Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment."The admissions coordinator will do a pre-assessment on all potential admissions to see if there is a history of abusive behavior. If any potential admission has a history of abusive behavior, the admissions coordinator will notify the administrator and/or the director of nursing services. The administrator will make the final determination on whether or not to admit, upon consultation with the director of nursing services and/or other appropriate personnel."The facility will conduct assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect including self-injurious behaviors. "Resident to resident incident: The abusive resident will be separated from other residents for a limited period as a therapeutic intervention to reduce agitation and potential for harm and ensure the safety of other residents. Other interventions will also be considered to include, but not limited to, family assistance, change of roommates, physician review of appropriate medication(s), consult with psychology, and other interventions as outlined in the resident's person-centered plan of care."II. Sexual abuse of Resident #1 and Resident #8 by Resident #2 A. Facility investigation for sexual abuse of Resident #1 by Resident #2 on 12/18/24The facility investigation, dated 12/18/24, documented at approximately 1:15 p.m. revealed Resident #1 was walking throughout the facility. Resident #2 invited Resident #1 into his room and closed the door. It was not normal behavior for Resident #2 to want his door closed so the staff followed them into the room. Upon opening the door, the staff member saw Resident #2 had his hand on Resident #1's crotch, over her clothing. The staff member was able to separate the two residents. Resident #1 was tearful after the event but she was not able to explain her emotions to staff due to her severely impaired cognition. The investigation documented Resident #1 was assisted back to her hallway. Resident #2 and Resident #1 were both placed on line-of-sight supervision and both residents were to be redirected from interacting with each other. Resident #1 was encouraged to participate in activities programming to prevent unsafe wandering. The interim social services director (ISSD) interviewed Resident #2 on 12/19/24. Resident #2 was defensive about the incident. He initially said he ignored Resident #1 and she was not in his room. Resident #2 was educated that Resident #1 was not able to consent to engage in sexual intimacy. Resident #2 responded by telling the ISSD that Resident #1 understood more than she let on and that he felt sorry for her when she was crying. The ISSD educated Resident #2 that his behavior was unacceptable and was not to continue. The ISSD interviewed certified nurse aide (CNA) #2 on 12/19/24. CNA #2 said she had witnessed Resident #2 inviting other female residents into his room on several prior occasions. CNA #2 said she was uncomfortable when she observed him inviting Resident #1 into his room and shutting the door. The facility substantiated the allegation of sexual abuse. B. Facility investigation for sexual abuse of Resident #8 and Resident #1 by Resident #2 on 2/22/25The facility investigation, dated 2/22/25 documented at 1:09 p.m., revealed Resident #2 was self-propelling in his wheelchair in the common area hallway when he approached Resident #8, who was sitting in the hall in her wheelchair. The investigation documented it appeared that the residents were having a conversation. As staff approached, it was noted that Resident #2 had his hand on Resident #8's thigh and was moving his hand towards her inner thigh. Resident #8 said, "No, stop!" and motioned for Resident #2 to move his hand. The CNA told Resident #2 to stop and Resident #2 left the area. -Interviews later in the day revealed that the CNA who intervened in the 1:30 p.m. incident with Resident #8 did not report the incident until being questioned after the second similar incident with Resident #1 occurred at 5:30 p.m. (see below). -There was no documentation in the investigation report indicating that either resident was interviewed about the details of the incident. The second facility investigation, dated 2/22/25, documented at 5:30 p.m. Resident #1 was walking near the nurse's station and Resident #2 was self-propelling in his wheelchair behind Resident #1. As Resident #1 got closer to Resident #2 he reached out and placed his hand on the back of Resident #1's thigh and began to move his hand higher up her thigh. Resident #1 turned and tried to swat his hand away. The investigation documented her action of trying to swat his hand away did not stop him from his actions. A nearby CNA had to intervene and remove Resident #2's hand from Resident #1's leg before he was able to move his hand to her private areas. The residents were separated. The CNA took Resident #1 to a safe area and a second CNA took Resident #2 to another location. The investigation revealed Resident #1 was very tearful after the incident. The staff were unsure if the tearfulness was due to the incident or due to her baseline of having tearfulness on and off. -There was no documentation that the facility assessed Resident #1's level of tearfulness throughout the day to determine if she was more tearful than usual following the incident. -Despite Resident #2 being placed on 15-minute checks when out of his room, he was able to sexually abuse two female residents in the common area of the facility on the same day (see Resident #2's care plan below). C. Resident #1 - victim 1. Resident statusResident #1, age 81, was admitted on 5/10/24. According to the March 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with severe mood disturbance and depression. According to the 2/12/25 minimum data set (MDS) assessment, Resident #1 was unable to complete the brief interview for mental status (BIMS). The staff assessment revealed she had short-term and long-term memory deficits. The staff assessment further revealed she was severely impaired in her daily decision-making and that she had difficulty focusing her attention and was disorganized with her thinking. The MDS assessment documented that Resident #1 did not wander and could ambulate independently but needed staff assistance with most of her activities of daily living (ADL). -However, interviews and further record review revealed Resident #1 did wander (see interviews and record review below). 2. Resident #1's representative interviewResident #1's representative was interviewed on 3/10/25 at 3:20 p.m. The representative said the facility did tell him the inappropriate touching had happened twice. He said the facility was trying to keep an eye on both of the residents. 3. ObservationsDuring a continuous observation on 3/10/25, beginning at 3:45 p.m. and ending 4:36 p.m., the following was observed: At approximately 3:45 p.m. Resident #1 walked past Resident #2 in his hallway, but there was no interaction between the two residents. Resident #1 stopped to talk with other residents as she wandered the hall and then walked back up the hall to another resident unit without direct staff supervision or interaction. At 4:07 p.m. Resident #1 was sitting in a recliner in the common area eating a sucker. At 4:11 p.m. Resident #1 was sitting in a recliner in the common area with her eyes closed. At 4:21 p.m. Resident #1 was sitting in a recliner in the common area with her eyes closed. At 4:28 p.m. Resident #1 was walking around in the common area, she would stop at the nurse's station. The staff did not acknowledge her. At 4:32 p.m. Resident #1 was touching an unidentified male resident on his arm. She then placed her arm under and around his arm to walk arm and arm with him while he was walking. The social services assistant (SSA) was working with the male resident. -The SSA did not offer any prompting or cueing to Resident #1 to ensure she did not place herself in a vulnerable position while interacting with the male resident. At 4:36 p.m. Resident #1 was wandering around the nurse's station, the nurses did not acknowledge her. On 3/11/25 at 2:35 p.m. Resident #1 was wandering around the hallways and front lobby. There were no staff present. She wandered into the administrative offices and one of the administrative staff escorted her back to the nurse's station.-The staff failed to follow the interventions on Resident #1's care plan to monitor her wandering and offer meaningful activities or socialization to ensure a safe comfortable environment. 4. Record reviewThe behavior care plan, revised on 10/28/24, documented Resident #1 had the potential for wandering and exit seeking. The care plan documented a wander guard was placed as a precautionary measure. The interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books, identifying patterns in her wandering and monitoring that the wander guard was functioning properly. The risk for wandering/elopement care plan, revised on 12/9/24, documented Resident #1 engaged in unsafe wandering. Pertinent interventions included staff were to engage the resident in purposeful activities, guide the resident to the recliners (but were not to put the footrest up due to her wandering) and schedule a time for regular walks. Review of Resident #1's electronic medical record (EMR) revealed that her behaviors were to be monitored. -However, the resident's EMR did not document her wandering activity or any efforts to provide meaningful activity. -Additionally, observations throughout the survey (3/10/25 to 3/13/25) revealed Resident #1 continuously wandered up and down the hallways off of the main nursing station (see observations above). The social services note, dated 11/11/24, documented that staff called Resident #1's representative about Resident #1 engaging in a kiss with Resident #2. It documented that due to Resident #1's cognitive state, the facility would be monitoring the situation closely. D. Resident #8 -victim 1. Resident statusResident #8, age greater than 65, was admitted on 1/14/21. According to the March 2025 CPO, diagnoses included Alzheimer's disease, dementia with psychotic disturbance and depressive episodes. The 12/20/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. The assessment revealed Resident #8 needed partial to moderate assistance with most of her ADLs. She used a wheelchair and was able to self-propel herself. 2. Record reviewThe wandering behavior care plan, revised on 10/28/24, revealed Resident #8 had the potential to be verbally aggressive with staff and had the potential for delusional episodes. The care plan revealed that she wandered into other hallways and other resident's rooms and that her behavior may impact her behaviors. Interventions included monitoring the resident's behaviors, redirecting the resident with positive conversations and notifying the physician of increased behaviors. -A review of the resident's EMR did not reveal documentation regarding the 2/22/25 incident of sexual abuse with Resident #2. E. Resident #2 - assailant1A. Resident statusResident #2, age greater than 65, was admitted on 6/28/24. According to the March 2025 CPO, diagnoses included cerebrovascular disease (stroke), Alzheimer's disease and diabetes. The 1/3/25 MDS assessment revealed Resident #2 had moderate cognitive impairments with a BIMS score of 12 out of 15. The assessment revealed Resident #2 needed supervision or minimal assistance with most of his ADLs. The assessment revealed he used his wheelchair but was able to self-propel on his own. The assessment indicated that Resident #2 did not display inappropriate behaviors. -However, record review and interviews revealed that Resident #2 displayed sexually inappropriate behaviors on 12/18/25, prior to the assessment. 2. Record reviewThe behavior care plan, revised 12/26/24 and 1/17/25, documented Resident #2 was at risk for potential sexual advances toward others. Interventions included discussing the resident's behavior with the resident, reinforcing why the behavior was inappropriate, diverting other residents from wandering or entering Resident #2's room and intervening, as appropriate, to protect the rights and safety of others. -The care plan was not initiated until a week after the 12/18/24 incident with Resident #1. Review of Resident #2's EMR revealed that his behaviors were being monitored. -However, the behavior monitoring did not document that he was sexually inappropriate on 2/22/25. The behavior monitoring (reviewed from 2/10/25 to 3/10/25) further revealed that the monitoring was not being done consistently. Several shifts and entire days lacked documentation of any potential behaviors or absence of behavior. The 11/11/24 social services note documented that Resident #2 had kissed a female resident. After the incident was observed, social services staff met with Resident #2 to provide education that his behavior was inappropriate because the female resident (Resident #1) was considered a vulnerable person and unable to engage in intimate relationships. The 11/13/24 nursing note documented that Resident #2 placed his hand on Resident #1's leg while she was walking and that she almost fell due to his touching. The note documented that he was instructed to avoid Resident #1 and to stop touching her. -Neither of the above incidents resulted in a care plan focused on interventions to address Resident #2's inappropriate sexual behavior towards a resident who was assessed to be unable to consent to sexual intimacy. The resident's care plan was not revised until after the 12/18/24 incident (see above). The 12/18/24 nursing note documented that Resident #1 was found in Resident #2's room and Resident #2 was touching Resident #1 inappropriately. The note documented that Resident #2 received education on keeping his hands to himself and that he told staff he understood the education. -Review of Resident #2's EMR failed to reveal documentation related to the incident on 2/22/25. An email, dated 2/23/25, was provided by the NHA on 3/11/25. The email documented communication between the facility leadership team and Resident #2's physician's office. The email revealed that the facilityinitiated a request for assistance to find a more appropriate placement for Resident #2 in the interest of keeping the female residents in the facility safe. The 3/4/25 social services note documented that Resident #2's representative and Resident #2 were both informed that Resident #2 was being issued a 30-day discharge notice due to his continued inappropriate sexual behavior towards female residents in the facility. -Review of Resident #2's EMR revealed Resident #2 was educated that Resident #1 was unable to engage in any type of intimate relationship and he was instructed to not pursue any type of intimate relationship with Resident #1. E. Staff interviewsRegistered nurse (RN) #2 was interviewed on 3/10/25 at 3:45 p.m. RN #2 said Resident #1's physician stopped her olanzapine on 3/4/25, which made her more tearful due to the lack of medications. She said Resident #1 wandered unsafely into other resident's rooms and tried to exit the facility to the outside so the staff kept an eye on her because she wandered into another resident's rooms and had gotten taken advantage of in the past. CNA #1 was interviewed on 3/11/25 at 9:00 a.m. CNA #1 said the staff were expected to monitor all residents with wandering behaviors, especially if the resident wandered off the unit. She said Resident #1 liked to wander and did not spend a lot of time in her room. CNA #1 said staff watched Resident #1 because she liked to go into other residents' rooms and tried to use their bathrooms. She said they had to watch Resident #1 when she was near Resident #2's room but that he was on 15-minute checks and was supposed to be in staff's line of sight when he was out of his room to ensure he did not interact inappropriately with Resident #1. CNA #1 said staff specifically watched for Resident #2's interactions with Resident #1 and Resident #8 since he had been sexually inappropriate with both of them. The SSA was interviewed on 3/11/25 at 11:30 a.m. The SSA said she was unaware of the incidents of inappropriate touching that occurred between Resident #1 and Resident #2. She said she did not know that staff were to monitor Resident #1 to ensure she was kept safe. The assistant nursing home administrator (ANHA) was interviewed on 3/11/25 at 4:37 p.m. The ANHA said Resident #2 was put on ongoing line of sight monitoring when he was out of his room after the 12/18/24 incident (see above). She said all staff were responsible for taking part in monitoring the resident, regardless of discipline, to make sure he did not engage in inappropriate behavior with other residents. The ANHA said Resident #2's daughter took him out to lunch after she was informed of the 12/18/24 incident (see above) and talked to Resident #2 about his behavior and told him that he could not be touching female residents. The ANHA said the resident's representative told the ANHA she believed Resident #2 clearly understood that he was not to touch a female. The ANHA said she also believed that Resident #2 understood the education he was provided because someone from adult protection services (APS) came and spoke with him and also told him he could not touch female residents who were unable to consent to the activity. The ANHA said Resident #2 told the staff, his representative and the APS worker that he understood and would stay away from the female resident he was instructed to stay away from. The ANHA said Resident #2 was issued a 30-day discharge notice because the resident continued to display inappropriate sexual behaviors and they were not able to keep the other residents safe with him in the building. The ANHA said the facility was working closely with the resident's physician's office and other outside providers to secure more appropriate living arrangements for Resident #2. III. Incident of physical abuse between Resident #5 and Resident #6 on 1/21/25A. Facility investigationThe 1/21/25 abuse investigation documented a witnessed resident-to-resident physical altercation occurredon 1/21/25 between Resident #5 and Resident #6. The staff observed Resident #5 and Resident #6 in the common area. Resident #5 lunged at Resident #6 and struck Resident #6 across the face with a piece of duct tape that was folded over upon itself. Resident #6 yelled and attempted to use a reacher (assistive device) to hit Resident #5 with no further contact made between residents. The staff separated the two residents. The staff had to physically remove and prevent Resident #5 from the continued act of physical aggression toward Resident #6. Resident #6 was assisted out of the common area and assessed for injuries. Resident #5 remained combative and attempted to hit and kick staff. Additional staff members surrounded Resident #5 to protect other residents in the area from being targeted by Resident #5. Other additional staff escorted onlooking residents and visitors out of the common area. Resident #5 sat in his wheelchair at the nurse's station while staff tried to calm him down. Staff called the resident's physician and received an order to to transport Resident #5 to the hospital for evaluation. Resident #5 was given an immediate discharge from the facility due to the inability of the facility to be able to meet the resident's behavioral health needs and keep the other residents in the facility safe from physical abuse. The facility's investigation of the incident included an interview with Resident #6. Resident #6 said he was hit with a piece of folded tape and no other contact occurred. Resident #6 said he was angry with Resident #5 after the incident. The facility investigation also interviewed other residents living in the same hall as Resident #5. The other residents on the hall said Resident #5 seemed very confused and was hard to communicate with. B. Resident #6 - victim 1. Resident statusResident #6, age greater than 65, was admitted on 9/12/23. According to the March 2025 CPO, diagnoses included stroke and dementia. The 11/25/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He used a wheelchair for mobility and was dependent on staff to complete toileting and transfers. He required substantial/maximal assistance with bathing and dressing. 2. Record review-Review of Resident #6's EMR did not reveal documentation regarding the incident with Resident #5 on 1/21/25. Resident #6's Kardex (staff directive tool) directed staff to remove the resident to a calm safe environment and allow him to vent and share his feelings when conflict arose. Review of the comprehensive care plan, revised on 12/24/24, revealed Resident #6 had the potential for impaired psychosocial well-being and/or adjustment problems and may be at increased risk for alteration in psychosocial well-being related to continued adjustments to infection control protocol. The care plan documented he had difficulty adjusting to change and could be accusatory. It further documented that English was not his primary language. Interventions included redirecting the resident to a calm, safe environment when conflict arose and allowing him to vent/share feelings. C. Resident #5 - assailant 1. Resident status Resident #5, age greater than 65, was admitted on 1/18/25 and discharged to the hospital on 1/21/25. According to the January 2025 CPO, diagnoses included dementia with behavioral disturbance. The 1/21/25 MDS assessment revealed tResident #5 had short-term and long-term memory deficits and disorganized thinking per staff assessment. The resident sometimes was able to effectively express himself with verbal and non verbal expressions and sometimes understood simple direct communication. The MDS assessment indicated the resident had threatening physical and verbal behavior directed at others, wandering, and delusions. He was dependent with eating and oral hygiene and required some assistance with dressing, bathing and toileting. 2. Record reviewThe 1/15/25 pre-admission referral documented Resident #5's spouse expressed concerns with Resident #5 having intermittent behavior outbursts at home. It documented concerns from the resident's adult daycare revealing that the resident was presenting with increasing behavioral aggression, including pushing a staff member and squeezing his spouse's arm when he did not get what he wanted. Resident #5's baseline care plan, initiated 1/18/25, documented the resident was cognitively impaired. He was unable to understand staff and was unable to communicate easily with staff. The resident was independent with mobility tasks but needed assistance with dressing and grooming. The nursing note, dated 1/21/25 at 5:35 p.m., documented Resident #5 had a change in behavior when he physically assaulted another male resident by hitting him in the face with a strip of folded-up duck tape. The staff were unable to redirect and calm the resident's aggressions so he was discharged to the hospital due to unmanaged aggressive behavior. The note documented since admission, verbal and physical aggression toward other residents and staff had been noted several times. He injured a staff member and was physically combative with another, requiring staff intervention and separation from other residents for their safety. The resident had entered other residents' rooms multiple times, sometimes taking possessions with him upon exiting. At times he entered other residents' rooms and undressed and redressed wearing another resident's clothes. He had physically touched other residents and woke them up from their sleep. Resident #5 lacked understanding and was unable to follow directions or comply with instructions. Resident #5 wandered frequently and had to be redirected several times from heading out an exit door. A wanderguard bracelet was placed on his arm to alert staff of his exit-seeking. The note documented that the resident's spouse said she was afraid of Resident #5 because he had become more paranoid and aggressive toward family members so she was expecting him to be aggressive while at the facility. The nursing note, dated 1/21/25 at 5:29 p.m., documented that at approximately 4:45 p.m., Resident #5 was observed leaning over Resident #6 hitting him with a folded-up piece of duct tape. Resident #5 did not respond to instructions from staff to stop hitting Resident #6. RN #1 had to physically hold and pull Resident #5 away from Resident #6 to stop the assault. The note further documented that when Resident #5 was pulled off of Resident #6, Resident #5 proceeded to stomp and kick the staff. RN #1 held Resident #5's hands so he could not scratch at those near him. RN #1 then placed the resident on the floor and sat behind him so he could hold on to the resident and not get injured while the resident calmed down. Once Resident #5 calmed down, nursing staff assisted him into a wheelchair. Emergency medical services (EMS) and the police were called and the resident was taken to the hospital for evaluation and treatment. D. Staff interviewsRN #1 was interviewed on 3/11/25 at 2:00 pm. RN #1 said Resident #5 was confused and aggressive toward staff since he was admitted to the facility. RN #1 said he provided care to Resident #5 on multiple shifts and he was difficult to redirect. RN #1 said Resident #5's aggressive behaviors included verbal threats as well as physical aggression, such as hitting, kicking and pushing staff. RN #1 said on the day of the incident, 1/21/25, he saw Resident #5 pull tape off of the carpet in the hall that was placed there to keep and remind Resident #5 to stay away from another resident's room which he frequently wandered into. RN #1 said when he saw the resident tearing up the tape, he tried to redirect Resident #5, but the resident only became more agitated than he already was and did not follow cues to stop. RN #1 said he went down the hall to inform maintenance that the tape would need to be replaced. He said he heard a commotion and he observed Resident #5 leaning over Resident #6 and he appeared to be hitting Resident #6 repeatedly. He said he responded and separated the residents. He said he told Resident #5 that if did not stop hitting Resident #6 he would pull him away from Resident #6. RN #1 said when Resident #5 did not respond to verbal cues, he felt he was forced to separate the residents physically while the CNA removed Resident #6 from the common area for his safety. RN #1 said additional staff came quickly and got Resident #5 into a wheelchair and he stayed with Resident #5 in the nurse's station until EMS arrived. RN #1 said he was not aware if staff were informed of Resident # 5's aggressive behavior when he was admitted, but Resident #5 was aggressive towards others from the start of his admission. The ANHA was interviewed on 3/11/25 at 4:37 p.m. The ANHA said a staff member was dedicated to screening and coordinating referrals for new residents. She said the facility did not receive the referral for Resident #5 until they had already accepted him. She said the staff were notified of the needs of new residents, including behaviors, in the electronic charting system and a physical report sheet. She said that sometimes the facility did not find out about a resident's behavioral issues until after they were admitted to the facility.

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