VISTA GRANDE REHABILITATION AND HEALTHCARE CENTER

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a) This survey was conducted on June 22, 2026, for compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012); and all referenced standards. The facility will meet these requirements when the following deficiencies are corrected. This structure is a one (1) story, Type V (000) construction. The facility is licensed for 101 beds and the census on the date of the survey was 55.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101 and NFPA 25 Inspection and Testing of Water-Based Systems. Findings include: Administration hall linen closet contains storage which is too high and within 18 inches of the sprinkler deflector. Maintain minimum clearance of 18 inches below the sprinkler deflector. Regulatory Reference:NFPA 101 (12)Chapter 19 - Existing Health Care Occupancies19.1 - General Requirements 19.1.1.1.1The requirements of this chapter shall apply to existing buildings or portions thereof currently occupied as health care occupancies…… 19.3.5 Extinguishment Requirements 19.3.5.1Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7 Automatic Sprinklers and Other Extinguishing Equipment 9.7.5 Maintenance and TestingAll automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 (11)Chapter 5 - Sprinkler systems5.1 - General 5.1.1This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. 5.2 - Inspection 5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors. A.5.2.1.2 NFPA 13, Standard for the Installation of Sprinkler Systems, allows stock furnishings and equipment to be as close as 18 in. (457 mm) to standard spray sprinklers or as close as 36 in. (914 mm) to other types of sprinklers such as early suppression fast-response (ESFR) and large drop sprinklers. Objects against walls are permitted to ignore the minimum spacing rules as long as the sprinkler is not directly above the object. Other obstruction rules are impractical to enforce under this standard. However, if obstructions that might cause a concern are present, the owner is advised to have an engineering evaluation performed. The fire sprinkler deficiency has the potential to affect some building occupants, who might include staff, patients and visitors within 1 of 6 smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain doors that protect corridor openings in accordance with NFPA 101. Findings include: The corridor door for resident room B04 failed to latch. During the survey the corridor door was fixed and retested to ensure the door latched properly. Regulatory Reference:NFPA 101 (12)19.1 - General Requirements 19.1.1.1.1The requirements of this chapter shall apply to existing buildings or portions thereof currently occupied as health care occupancies…… 19.3 - Protection19.3.6 - Corridors19.3.6.3 - Corridor Doors 19.3.6.3.5Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. The corridor door deficiency has the potential to affect building occupants, who might include staff, patients and visitors within 1 of 6 smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101 and NFPA 25 Inspection and Testing of Water-Based Systems. Findings include: Social Services office contained a heavy-duty appliance consisting of a refrigerator plugged into a power strip designed and listed for light duty electronics. The deficient practice was corrected during the survey. The refrigerator was plugged directly to an electrical wall outlet. Regulatory Reference: NFPA 99 (12)Chapter 10 - Electrical EquipmentSection 10.2.3.6 Multiple Outlet ConnectionSection 10.2.4 Adapters and Extension Cords The electrical deficiency has the potential to affect room occupants, who might include staff, patients and visitors within 1 of 6 smoke compartments; items were discussed during the survey and again during the exit conference.

A recertification survey with Incident #2638030, Incident #3017341 and Incident #3017366 was conducted on 5/31/26 to 6/3/26. Eleven deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/31/26 to 6/3/26. No deficiencies were cited.

Based on interviews and record review, the facility failed to ensure residents were kept free from abuse for one (#2) of two residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to protect Resident #2 from sexual abuse by Resident #73 on 12/11/25. Findings include: I. Facility policy and procedureThe Resident Right to Freedom from Abuse, Neglect and Exploitation policy and procedure, revised 2025, was provided by the nursing home administrator (NHA) on 5/31/26 at 2:55 p.m. It read in pertinent part, “The facility shall have and implement written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. The facility shall monitor the resident including the identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as sexually aggressive behavior such as saying sexual things and inappropriate touching and grabbing. Identify, correct and intervene in situations in which abuse, neglect, exploitation and or misappropriation of resident property is more likely to occur.”II. Incident of sexual abuse of Resident #2 by Resident #73 on 12/11/25 A. Facility investigation The 12/11/25 summary of investigation revealed the allegation was substantiated. The summary documented that video surveillance revealed Resident #73 summoned Resident #2 over. Resident #2 went to Resident #73 and they held hands at the table. Resident #2 talked to Resident #73. Resident #73’s response was mumbled and Resident #2 could not understand what he said. Resident #73 stroked Resident #2’s sweater and her breast on top of her clothing. Resident #73 did not grab Resident #2. Resident #2 grabbed Resident #73’s hand and moved it back to the table. Resident #2 held Resident #73's hand for a few more seconds and then moved to another table to eat her breakfast. Resident #2 reported the incident to a nurse after breakfast. There were two staff members in the dining room and they saw Resident #2 and Resident #73 holding hands but neither saw Resident #73 touching Resident #2’s breast. The 12/11/25 facility report revealed the brief summary of the allegation was Resident #2 reported to registered nurse (RN) #2 at approximately 8:30 a.m. that Resident #73 touched her breast while they were in the dining room. The immediate intervention was to separate the residents and 15 minute checks were implemented for Resident #73. Resident #2’s statement was completed on 12/11/25. It revealed Resident #2 went to the kitchen and Resident #73 waved Resident #2 to come over. Resident #2 went over and Resident #73 put his hands out. Resident #2 put her hands on his hands. Resident #73 was rubbing Resident #2’s hands. Resident #73 took and looked at her hands. Resident #73 touched Resident #2’s sweater and put his hand and rubbed down on her. Resident #2 shook her hand “no” and left. Resident #2 went down to the table to sit at the table. Dietary aide #1 brought Resident #2 her food. Resident #2 told dietary aide #1 “thank you for getting me out of the situation.” Resident #2 ate her breakfast and left the dining room and talked to RN #2. Dietary aide #1’s witness statement was completed on 12/11/25. Dietary aide #1 said she was in the dishroom when Resident #2 went into the kitchen. Dietary aide #1 came out of the dishroom and she saw Resident #2 and Resident #73 holding hands. The residents were not talking. Dietary aide #1 said Resident #73 tried to pull her closer but the table was in the way. Dietary aide #1 asked Resident #2 what she wanted to eat and if she wanted to sit with Resident #73 or at another table she normally sat at. Resident #2 said “No, I want to sit over there.” Dietary aide #1 walked away into the kitchen to prepare Resident #2’s food. When dietary aide #1 came back out, Resident #2 was sitting at the other table. Dietary aide #1 served Resident #2’s food and Resident #2 said thank you. Dietary aide #2’s witness statement was completed on 12/11/25. Dietary aide #2 said Resident #2 went into the dining room and went straight to the table Resident #73 was at and asked “Can I sit by you?” Dietary aide #2 went to deliver food to another resident. When dietary aide #2 walked back, she saw Resident #73 put his hands out toward Resident #2 and she placed her hands in his hands. Resident #73 leaned forward and grabbed her sweater. Dietary aide #2 said she went to the window for more food, turned around to deliver food and Resident #2 was heading to the other table. Dietary aide #2’s staff interview was completed on 12/11/25. It revealed she witnessed a resident being touched inappropriately by another resident. Dietary aide #2 said she saw Resident #73 reach out and grab Resident #2’s hand. Resident #73 touched Resident #2’s breast outside of her sweater. The investigation documented that Resident #2’s care plan was not updated following the incident. Resident #73’s care plan was updated to include new medication orders, staff were to attempt to redirect Resident #73, encourage Resident #73 to participate in activities, offer non-judgmental support to the resident and to remind Resident #73 to keep hands to himself due to him not understanding some people did not like to be touched. B. Resident #2 - victim 1. Resident status Resident #2, age 76, was admitted on 10/19/23. According to the June 2026 computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies (dementia with protein clumping built up in the brain causing problems with thinking, moving, and sleep), epilepsy, chronic kidney disease stage 3, transient ischemic attack (TIA - a mini-stroke), cerebral infarction (a stroke), atherosclerotic heart disease of native coronary artery (plaque builds up inside the arteries supplying blood to the heart restricting blood flow and oxygen to the heart muscle), atrial fibrillation (heart arrhythmia), essential hypertension (high blood pressure), type 2 diabetes mellitus, post-traumatic stress disorder, major depressive disorder, insomnia and hallucinations. According to the 3/24/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview mental status (BIMS) score of 14 out of 15. She used a walker and wheelchair. She required set up assistance with eating and supervision with oral hygiene, showering, and personal hygiene. She required partial assistance with toileting. The assessment revealed Resident #2 did not exhibit any behaviors. 2. Resident interview Resident #2 was interviewed on 6/2/26 at 9:10 a.m. Resident #2 said she was in the dining room when Resident #73 touched her arms and went up her arm to touch her breast. She said it made her feel horrible. Resident #2 said Resident #73 touched her breast over her clothes. Resident #2 said staff told her Resident #73 had a stroke and had dementia. Resident #2 said staff told her to “roll with the punches.” Resident #2 said it did not happen again. 3. Record review -Review of Resident #2’s comprehensive care plan revealed there was no care plan focus or interventions implemented to protect Resident #2 from further incidents with Resident #73 following the incident on 12/11/25. -Review of Resident #2’s electronic medical record (EMR) revealed there was no documentation to indicate that Resident #2 was monitored after the incident with Resident #73 to ensure there were no changes to Resident #2’s baseline. - Review of Resident #2’s EMR revealed there were no progress notes related to the 12/11/25 incident with Resident #73. C. Resident #73 - assailant 1. Resident status Resident #73, age 68, was admitted on 5/7/18 and passed away in the facility on 2/19/26. According to the February 2026 CPO, diagnoses included hypertension, insomnia, cerebrovascular disease affecting right dominant side, unspecified dementia, behavior disturbance, sexual dysfunction, atrial fibrillation, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (chest pain), TIA, ischemic cardiomyopathy (heart disease when the heart muscle weakens and becomes unable to pump blood effectively) and peripheral vascular disease (a slow progressive circulation disorder). According to the 12/8/25 MDS assessment, the resident was moderately cognitively impaired with a BIMS score of nine out of 15. He required set up assistance with eating and substantial assistance with oral hygiene and toileting. He was dependent on showering. The assessment revealed the resident did not exhibit behaviors towards others. 2. Record review The attention-seeking care plan, initiated 3/15/23 and revised 2/13/26, revealed Resident #73 had behaviors of inappropriately touching others. Interventions included if he tried to hold hands with others, staff were to remind him to keep his hands to himself; administering medication per physician’s orders, approaching him in a calm manner to avoid frustration and behavior escalation, attempting to redirect the resident when he was exhibiting behaviors, encouraging the resident to participate in activities, giving non-judgmental support, monitoring and documenting episodes of inappropriate behaviors and providing a structured schedule for daily care when possible. The 12/11/25 change in condition nurse progress note revealed staff reported Resident #73 inappropriately touched another resident (Resident #2). The physician was notified and gave new orders for finasteride and medroxyprogesterone (medications that are sometimes used to decrease hypersexual behavior). The resident's representative was notified and verbal consent was provided for the medications. The director of nursing (DON) and the NHA were made aware of the incident. III. Staff interviewCertified nurse aide with medication authority (CNA-Med) #2 was interviewed on 6/2/26 at 3:17 p.m. CNA-Med #2 said he reported abuse to the nurse on duty and management including the NHA and the DON. He said when he saw abuse, he separated the residents and made sure the residents were safe before reporting the abuse allegation to the nurse. CNA-Med #2 said he told the nurse and the nurse started the investigation. CNA-Med #2 said the incident was documented as a progress note and as behavior monitoring in the residents’ medication administration records (MAR). He said a plan of action was made right away and was documented in the residents’ charts to include what interventions were put in place. He said some interventions were keeping residents separated, offering activities they liked to do and monitoring for pain. CNA-Med #2 said interventions were documented in shift report, a communications book, and alert charting. CNA-Med #2 said he knew what escalated a resident’s sexual behavior by getting to know them when they were first admitted. He said when behaviors were observed, he told the nurse and charted. CNA-Med #2 said he knew what de-escalated a resident’s sexual behavior by finding the right staff member to care for the resident and educating the resident not to do it because it was not appropriate. He said some residents were always flirty, so he charted and staff knew the behavior. CNA-Med #2 said he knew if a resident had sexual behaviors because it was in the care plan, the progress note and the MAR. CNA-Med #2 said there were residents who had sexual behaviors. He said he was familiar with Resident #73. He said he never saw him exhibit any sexual behaviors with other residents, including Resident #2. RN #1 was interviewed on 6/2/26 at 3:46 p.m. RN #1 said she reported abuse to the DON and the NHA. She said if she saw abuse, she separated the residents, entered a progress note, notified the physician and the resident’s representative. She said a progress note indicated what interventions were in place and said 15-minute checks were one intervention. RN #1 said residents were monitored post-incident for 24 hours. RN #1 said she knew what escalated a resident’s sexual behavior based on the resident’s diagnoses. She said some residents had dementia and when they sundowned (a state of late day confusion, anxiety and agitation related to dementia) they exhibited behaviors. RN #1 said residents did not understand and did not have awareness of the behaviors, so it was important to explain why they could not do what they wanted to do. RN #1 said interventions to de-escalate a resident's behavior was documented as a health status note. RN #1 said she was familiar with Resident #73 and said 15-minute checks and medications were added to decrease his sexual behavior. She said redirection and telling him not to do the behavior were interventions to prevent the sexual behavior. RN #1 said she was the nurse who Resident #2 reported the sexual abuse from Resident #73. She said the residents were both in the dining room and Resident #2 approached Resident #73. RN #1 said Resident #73 touched her arm and then went up to brush her breast. RN #1 said the event scared Resident #2. The NHA, the DON and the social services director (SSD) were interviewed together on 6/2/26 at 5:05 p.m. The NHA said she was the abuse coordinator for the facility. The NHA said the abuse investigations were divided between the NHA and the DON. The NHA said the SSD was training to be a NHA and she talked to the family during an investigation. The NHA said when abuse was reported, she obtained the details on what happened and determined if it needed to be reported. The NHA said the nurses reported abuse and she also reviewed camera footage following an incident. The NHA said she and the DON interviewed the staff and residents following an incident. The NHA said if a resident was unable to communicate, nursing staff monitored their behavior to see if there was a change in their baseline for 72 hours to seven days following an incident, depending on the circumstances. She said the monitoring was documented as alert charting and a progress note. The NHA said she determined what residents to interview by interviewing residents who were alert and oriented, who resided in the same unit or were in the same vicinity of where the incident occurred. The NHA said nurses, the DON and she determined what immediate interventions to put in place when investigating the allegation.-However, there was no documentation in Resident #2’s EMR to indicate the resident was monitored for changes to her baseline following the incident with Resident #73 on 12/11/25 (see record review above). The NHA, the DON and the SSD were interviewed together a second time on 6/3/26 at 5:14 p.m. The NHA, the DON and the SSD said they were familiar with the 12/11/25 incident between Resident #2 and Resident #73. The DON said she did not know if anyone asked how Resident #2 felt after the incident. The NHA said they did not put interventions in place for Resident #2 because the resident did not want to be near Resident #73 and she did not think there needed to be interventions in place. The NHA said the facility knew Resident #73 had sexual behavior prior to the 12/11/25 incident and the interventions in place were not effective in preventing the 12/11/25 incident with Resident #2.

Based on record review and interviews, the facility failed to report allegations of abuse in accordance with state law for two of two allegations of abuse. Specifically, the facility failed to: -Report an allegation of sexual abuse by Resident #73 towards Resident #2 on 12/11/25 to the ombudsman; and, -Report an allegation of sexual abuse by Resident #18 towards Resident #48 on 5/15/26 to the State Agency and the ombudsman. Findings include: I. Facility policy and procedureThe Resident Right to Freedom from Abuse, Neglect and Exploitation policy and procedure, revised 2025, was provided by the nursing home administrator (NHA) on 5/31/26 at 2:55 p.m. It read in pertinent part, “When the facility has identified abuse, the facility will increase enforcement action, including reporting the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations.”II. Allegation of sexual abuse by Resident #73 towards Resident #2 on 12/11/25The facility investigation for the sexual abuse by Resident #73 towards Resident #2 on 12/11/25 was provided by the NHA on 6/2/26 at 5:25 p.m. The investigation documented the following: The sexual abuse between Resident #73 and Resident #2 occurred on 12/11/25 at 7:23 a.m. -However, there was no documentation the ombudsman was notified of the incident (see interview below). III. Allegation of sexual abuse by Resident #18 towards Resident #48 on 5/15/26A. Resident #48 -victim 1. Resident status Resident #48, age 88, was admitted on 5/8/24. According to the June 2026 computerized physician orders (CPO), diagnoses included transient ischemic attack (TIA - a mini stroke), cerebral infarction (a stroke), dementia, anxiety, depression and chronic respiratory failure with hypoxia. The 5/25/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She had an impairment on one lower extremity and used a wheelchair. She required setup assistance with eating and partial assistance with oral hygiene, toileting, showering and personal hygiene. She did not exhibit any behaviors. B. Resident #18 - alleged assailant 1. Resident status Resident #18, age 67, was admitted on 1/13/24. According to the June 2026 CPO, diagnoses included chronic obstructive pulmonary disease (emphysema - a progressive lung disease restricting airflow), hypertension (high blood pressure), intracranial injury with loss of consciousness, osteoarthritis and dementia with agitation. The 3/24/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He had an impairment on one lower extremity and used a wheelchair. He required set up assistance with eating. He required supervision with oral hygiene and moderate assistance with toileting, showering, and personal hygiene. The assessment revealed he did not exhibit any behaviors. 2. Record review The 5/15/26 nurse behavior note revealed Resident #18 was taken to smoke and became verbally sexually abusive to a female certified nurse aide (CNA) and again to another female resident (Resident #48). The nurse spoke to Resident #18 and he just laughed.-There was no further documentation regarding the incident. Cross-reference F610 for failure to investigate and alleged violation. -On 6/2/26 at 5:25 p.m., the facility was unable to provide documentation that the 5/15/26 allegation of sexual abuse was reported to the State Agency and the ombudsman. IV. Frequent visitor interview A frequent visitor, with knowledge of the facility, was interviewed on 6/2/26 at 4:10 p.m. The frequent visitor said the facility was required to report all allegations of abuse to the ombudsman. She said she was not aware of any abuse allegations made to the ombudsman for the past 12 months. She said there had been an ombudsman assigned to the facility for the past 12 months. V. Staff interviews The NHA, the director of nursing (DON), and the social services director (SSD) were interviewed together on 6/2/26 at 5:05 p.m. The NHA said staff should report potential abuse immediately to the DON or the NHA. The NHA said she was the abuse coordinator for the facility . The NHA said she reported abuse to the State Agency. The NHA said the initial incident report should be submitted to the State Agency within two hours if the resident experienced injury or harm. The NHA said she did not report abuse to the ombudsman. The NHA said she did not know allegations of abuse needed to be reported to the ombudsman. The NHA and the SSD said there had not been an ombudsman assigned to the facility until the past six months to a year.-However, according to the frequent visitor, there had been an ombudsman assigned to the facility for the past 12 months (see interview above).

Based on record review and interviews, the facility failed to investigate an allegation of sexual abuse for one (#48) of two residents of 36 sample residents. Specifically, the facility failed to investigate an allegation of sexual comments made by Resident #18 towards Resident #48 on 5/15/26. Findings include: I. Facility policy and procedureThe Resident Right to Freedom from Abuse, Neglect and Exploitation policy and procedure, revised 2025, was provided by the nursing home administrator (NHA) on 5/31/26 at 2:55 p.m. It read in pertinent part, “When the facility identifies abuse, it will take all appropriate steps to immediately remediate the noncompliance and protect residents from further abuse. The facility will conduct a thorough investigation of the alleged violation, and implement appropriate corrective actions. In addition, the facility will revise the resident's care plan when the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.”II. Incident involving Resident #18 and Resident #48 on 5/15/26 A. Facility investigationA request was made for an investigation regarding the allegations of sexual comments by Resident #18 towards Resident #48 on 5/15/26. -However, the facility was unable to provide documentation to indicate an investigation was completed (see interviews below). B. Resident #18 - alleged assailant 1. Resident status Resident #18, age 67, was admitted on 1/13/24. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (emphysema - a progressive lung disease restricting airflow), hypertension (high blood pressure), intracranial injury with loss of consciousness, osteoarthritis and dementia with agitation. The 3/24/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He had an impairment on one lower extremity and used a wheelchair. He required set up assistance with eating. He required supervision with oral hygiene and moderate assistance with toileting, showering, and personal hygiene. The assessment revealed he did not exhibit any behaviors. 2. Record reviewThe behavior care plan, initiated 10/18/24 and revised 2/13/26, revealed Resident #18 had behaviors related to inappropriate touching of other residents and agitation toward staff, accusations toward staff, inappropriate and unwanted lewd and sexual comments to staff and others. Interventions included administering medications per physician orders, approaching the resident calmly to avoid frustration and behavior escalation, attempting to redirect the resident when exhibiting behaviors, encouraging Resident #18 to ask questions to reduce anxiety, giving non-judgmental support and monitoring and documenting episodes of inappropriate behaviors. The 5/15/26 nurse behavior note revealed Resident #18 was taken to smoke and became verbally sexually abusive to a female certified nurse aide (CNA) and again to another female resident (Resident #48). The nurse spoke to Resident #18 and he just laughed.-There was no further documentation regarding the incident. C. Resident #48 - alleged victim 1. Resident status Resident #48, age 88, was admitted on 5/8/24. According to the June 2026 CPO, diagnoses included transient ischemic attack (TIA - a mini stroke), cerebral infarction (a stroke), dementia, anxiety, depression and chronic respiratory failure with hypoxia. The 5/25/26 MDS assessment revealed the resident was cognitively impaired with a BIMS score of five out of 15. She had an impairment on one lower extremity and used a wheelchair. She required setup assistance with eating and partial assistance with oral hygiene, toileting, showering and personal hygiene. She did not exhibit any behaviors. III. Staff interviews The NHA, the director of nursing (DON), and the social services director (SSD) were interviewed together on 6/2/26 at 5:05 p.m. The NHA said she reviewed the nurse progress note in Resident #18’s electronic medical record (EMR) from 5/15/26. She said the progress note described what happened between the CNA who took Resident #18 out to smoke and not to another resident. The NHA said she did not know why the nurse wrote that a resident was involved. The NHA said the nurse who wrote the note no longer worked at the facility and the CNA worked per diem (as needed) and was unavailable to be interviewed. The NHA, the DON and the SSD were interviewed together a second time on 6/2/26 at 6:05 p.m. The NHA said she contacted the nurse who wrote the 5/15/26 progress note in Resident #18’s EMR and the nurse said it was not just the CNA who Resident #18 made sexual comments to, but he additionally made comments to Resident #48. The NHA said she did not ask what the exact comment made towards Resident #48 was. The NHA said the facility’s investigation was ongoing. -However, the incident was not investigated until 6/2/26, 18 days after staff were aware of the alleged sexual abuse allegation. The NHA, the DON and the SSD were interviewed together a third time on 6/3/26 at 6:45 p.m. The NHA said if a resident did not like how they were spoken to, the resident should report the incident to management so the facility could investigate. The NHA said residents had a right regarding how they were spoken to, including the right not to be spoken to in a sexual way. The NHA said the facility was aware that Resident #18 had a history of making sexual comments towards residents. Cross-reference F742 for failure to provide treatment/services for mental/psychosocial concerns.

Based on record review and interviews, the facility failed to provide a rationale to act upon a third party guarantee of payment to the facility for one (#3) of one resident out of 36 sample residents. Specifically, the facility failed to ensure they did not violate federal guidelines for placing a lien on Resident #3’s property for $28,000. Findings include:I. Professional referenceAccording to Justice In Aging’s Nursing Home Debt Collection Practices Put Residents’ Family And Friends At Risk (11/1/24), retrieved on 6/15/26 from https://justiceinaging.org/nursing-home-debt-collection-practices/#post-50332-footnote-1,“Federal law prohibits a nursing home from conditioning a nursing home resident’s admission or continued stay on a third party’s personal guarantee to be financially responsible for the resident’s bills. Despite this prohibition, nursing homes still attempt various stratagems, through contracting and otherwise, to force financial liability upon residents’ family members, friends, and other third parties. These practices impose significant and unnecessary financial strain on family members and other third parties, including lawsuits seeking hundreds of thousands of dollars. This pressure frequently compels adult children and others to pay alleged debts out of their own pockets to protect the nursing home resident. In response to this problem, the Consumer Financial Protection Bureau (CFPB) conducted a public hearing and released an issue spotlight on problematic nursing home collection practices in September 2022. The CFPB also issued a joint letter with the Centers for Medicare and Medicaid Services (CMS) directed to the nursing home industry and collection lawyers to remind them of their responsibilities under the Nursing Home Reform Act (NHRA), Fair Debt Collection Practices Act (FDCPA), and Fair Credit Reporting Act (FCRA). Despite the work of CMS and the CFPB, abusive nursing home debt collection actions against third parties continue to be filed.”According to CFPB and CMS joint letter addressing Nursing Facility Debt Collection Practices (9/8/22), retrieved on 6/15/26 from https://files.consumerfinance.gov/f/documents/cfpb_nursing-home-debt-collection_joint-letter_2022-09.pdf,“The Consumer Financial Protection Bureau (CFPB) and the Centers for Medicare & Medicaid Services (CMS) remind you of your responsibilities under the Nursing Home Reform Act (NHRA), Fair Debt Collections Practices Act (FDCPA), and Fair Credit Reporting Act (FCRA). “The NHRA prohibits nursing facilities from requesting or requiring that a third party personally guarantee payment to the facility as a condition of a resident’s admission or continued stay in the facility. Contract terms that conflict with the NHRA are unlawful, and alleged debts resulting from such unlawful contract terms are invalid and unenforceable. Some nursing facilities have attempted to evade this prohibition by creating admission contracts that attempt to hold third parties liable for a resident’s debt. When a nursing facility claims that a non-resident is personally financially responsible for a resident’s bill and engages a third-party debt collector to collect the debt, the debt collector may violate the FDCPA by attempting to collect debts that are invalid under the NHRA. They may also violate the FCRA by furnishing information regarding such invalid debts to consumer reporting agencies. “Nursing facilities that violate the NHRA’s requirements may be subject to enforcement action by state agencies and by CMS. Debt collectors who violate the FDCPA and FCRA may be subject to enforcement actions by the CFPB and other federal and state government agencies, as well as to private actions brought by consumers. “We urge nursing facilities and their debt collectors to examine their practices to ensure that they comply with the NHRA, FDCPA, and FCRA.” II. Promissory Note “The Promissory Note secured by Deed of Trust, dated 2/3/26, for Resident #3, documented the following:”For value received, the undersigned family representative and Resident #3 promise to pay the facility the principal sum of $28, 201.00, together with all future advances, with interest at the rate of eight percent per annum. Principal and interest shall be payable at the facility or at such place as the note holder may designate.“The entire principal amount outstanding and accrued interest thereon shall be due upon the sale of any of the subject properties, Resident #3, undivided one third interest in the sub lot. “Payments received for application to the note shall be applied first to the payment of any late charges, if any, second to the payment of accrued interest at the rate specified, if any, and the balance applied in reduction of the principal amount hereof. Any payment made more than 15 days after the due date thereof shall be assessed a 10 percent late penalty. “If any payment required by this note is not paid when due, or if any default under any deed of trust securing this notes occurs, interest shall immediately begin to accrue at the default rate of 18 percent per annum until paid, and the entire principal amount outstanding and accrued interest thereon shall at once become due and payable. Interest on lender disbursements shall be eight percent per annum. The note holder shall be entitled to collect all reasonable costs and expenses of collection and or suit, including, but not limited to reasonable attorney’s fees.“Borrower may prepay the principal amount outstanding under this note at any time, in whole or in part without penalty. “Borrower waives presentation, notice of dishonor and protest. “Any notice to borrower provided for in this note shall be in writing and shall be given and be effective upon mailing such notice by first class mail, addressed to borrower at the borrowers address stated below, or to such other address as borrower may designated by notice to the note holder. Any notice to the note holder shall be in writing and shall be given and be effective upon delivery to note holder at the address stated in the first paragraph of this note, or such other address as note holder may designate by notice to borrower. “The indebtedness evidenced by this note secured by a deed of trust dated or even dated herewith, and until released, said deed of trust contains additional rights of the note holder. Such rights may cause acceleration of the indebtedness evidenced by this note. Reference is made to said deed of trust for such additional terms. Such deed of trust grants rights in the following described property. Resident #3, undivided one third interest in the sub lot.“Signed by the power of attorney for Resident #3.”III. Resident #3A. Resident status Resident #3, age 83, was admitted on 4/25/24. According to the June 2026 computerized physician orders (CPO), diagnoses included non Alzheimer's dementia, anxiety, depression and diabetes. The 4/8/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She required partial assistance with activities of daily living (ADL). B. Resident’s representative interview Resident #3’s representative was interviewed on 6/1/26 at 8:45 a.m. The representative said the facility put a lien on the shared property she had with Resident #3 for back payment that was due to the facility, which Medicaid did not pay. She said the facility approached her with the lien information. Resident #3’s representative was interviewed a second time on 6/3/26 at 2:35 p.m. The representative said the facility asked her to put a lien on the property. She said she was paying the facility privately when Resident #3 admitted to the facility, but she eventually applied for Medicaid. She said the Medicaid application took a while to get approved because Medicaid kept requesting more information from her to proceed with the application. She said the lien was completed after Medicaid had reimbursed the facility, but did not cover all of the resident’s stay while the application was in process. She said she did not deal with Medicaid. She said the social services director (SSD) and the corporate business office manager assisted her with the Medicaid application. She said Medicaid kept asking for one more item to complete the application, which delayed the Medicaid approval for Resident #3. She said the facility told her she owed the facility for costs that were not reimbursed by Medicaid once the funding was approved. She said this amounted to approximately $28,000 for the three month period, about $9000 per month, which was a nightmare for her. She said she was not sure how much the facility received from Medicaid.. IV. Staff interviewsThe SSD was interviewed on 6/3/26 at 3:13 p.m. She said when a resident moved into the facility, the referral was followed by the hospital either under Medicare payment, long term care payment or respite. She sat down with families to explain the admission process. When a resident was off Medicare after 20 days and the resident chose to stay either they paid privately or she assisted in filling out the Medicaid paperwork for payment. She said the facility worked with all residents and payor sources giving families resources and working with Medicaid. She said families would give her the information needed and she would send this information to the state for approval. She said the usual time for Medicaid approval was within 45 days and most residents were a good criteria for approval. The SSD sometimes Medicaid had been denied for residents because of date discrepancies and families were then set up on payment plans, pending the Medicaid approval. She said if a family had a life insurance policy and the funeral was not prepaid out of the life insurance, Medicaid would deny payment. The SSD said this happened for Resident #3 and the resident’s representative completed an appeal for Medicaid. The SSD said the lien was completed on Resident #3’s property because Medicaid denied approval for the resident due to date discrepancies. She said Resident #3’s Medicaid application was super extensive because of multiple life insurance policies and Medicaid would not cover $28,000 dollars owed to the facility for the resident’s care. She said the corporate business office manager completed the lien on Resident #3’s property and she (the SSD) had the representative sign with her (the SSD) notarizing the lien and she (the SSD) then filed the lien with the state. She said the facility received payment from Resident #3’s monthly social security payments and the resident’s representative also paid privately, in addition to Resident #3 being funded by Medicaid. The nursing home administrator (NHA) was interviewed on 6/3/26 at 5:55 p.m. The NHA said she understood liens would help cover backpay when discrepancies happened with Medicaid applications. She said she was not aware of the lien on Resident #3’s property. The director of operations was interviewed on 6/3/26 at 6:00 p.m. The director of operations said he was aware of the lien on Resident #3’s property. He said there were date discrepancies which had delayed the resident’s application for Medicaid and in the meantime, a lien was placed on Resident #3’s property with the approval of the resident’s representative. He said he had spoken with the corporate business office manager, who reported the resident’s representative was worried about back payment and the representative voluntarily signed the lien for the property. He said the company, as a whole, had three or four residents with liens on their properties. -However, according to the joint letter from CFPB and CMS, the facility was not authorized by federal law to place a lien on a resident’s home who received Medicaid benefits (see professional reference above).

Based on observations, record review and interviews, the facility failed to to ensure residents received treatment and care in accordance with professional standards of practice for one (#7) of six residents out of 36 sample residents. Specifically, the facility failed to ensure a registered nurse (RN) completed a head-to-toe assessment after a fall resulting in a hip fracture for Resident #7. Findings include:I. Professional referenceAccording to Nurse Journal’s Licensed Practical Nurses (LPN) Versus Registered Nurses (RN) (9/8/25), retrieved on 6/11/26 from https://nursejournal.org/resources/lpn-vs-rn-roles/,“LPNs and RNs both monitor patients, administer medications, perform wound care, help patients with basic tasks like bathing and feeding, and often educate and support patients and their loved ones. However, there are differences in the education requirements and scope of practice between RNs and LPNs.“LPNs and RNs share many duties and have significant flexibility and job security. RNs, however, typically have more professional autonomy, with LPNs often unable to take certain actions without approval from an RN, physician, or other appropriate member of the care team. “LPNs perform vital work in collaboration with RNs, physicians and other healthcare professionals. LPNs work alongside or under the supervision of RNs to deliver care and support to patients. Compared to LPNs, RNs generally operate independently. In certain settings, they may delegate some tasks to LPNs. RNs use their specialized judgment, skills, and knowledge to provide direct patient care in various settings. “RNs and LPNs share many nursing tasks, but their scope of practice differs depending on their state. In all situations, RNs have a broader scope of practice than LPNs. Generally speaking, only RNs provide initial assessments. Therefore, an RN must perform all tasks that require close monitoring and frequent assessment, such as initiating blood products, the first round of antibiotics and initial patient assessments.”II. Facility policy and procedureII. Facility policy and procedureThe Accidents and Incidents Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 6/3/26 at 6:39 p.m. It documented in pertinent part,“All accidents or incidents involving residents, employees, visitors, vendors occurring on our premises shall be investigated and reported to the administrator.“The nurse supervisor or charge nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.”The Assessing Falls and Their Causes policy, revised March 2018, was provided by the NHA on 6/3/26 at 6:39 p.m. It documented in pertinent part,“The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.“Falls are a leading cause of morbidity and mortality among the elderly in nursing homes.“Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and or environmental risk factors.“Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly.“When a fall results in a significant injury or condition change, notify the practitioner immediately by phone.”III. Resident #7 A. Resident statusResident #7, age greater than 65, was admitted on 11/20/24. According to the June 2026 computerized physician orders (CPO), diagnoses included respiratory failure, dementia, osteoporosis and a history of falls with fractures. The 3/26/26 minimum data set (MDS) assessment revealed Resident #7 was severely cognitive impaired with a brief interview for mental status (BIMS) score of 99 out of 15. She was dependent on staff assistance with activities of daily living (ADL). The assessment indicated the resident had had a fall with injury. B. Record reviewThe nurse progress note, dated 3/19/26 at 7:15 p.m. and written by LPN #1, documented the nurse heard a loud commotion as another resident called for help for Resident #7. Resident 37 was found lying on her left side with her knees slightly bent towards her chest. A full physical and neurological assessment was completed and neurological checks were initiated. The resident showed no signs or symptoms of injury or impairment. The resident was alert and oriented to self and was not able to give a description of the fall. The certified nurse aides (CNA) had already scooted the resident back into her chair one other time prior to the fall. The resident was wearing non-slip slippers and silk pajamas. She had a chucks pad (smooth padding) under her bottom. The resident was put into the recliner chair at the nurses’ station by the CNAs for observation following the fall. The resident shook her head no when asked if she was feeling any pain. -However, LPN #1 completed the assessment for Resident #7 immediately following the fall. -There was no documentation to indicate a RN completed a head-to-toe assessment for the resident immediately after the fall, prior to the staff placing the resident in the recliner at the nurses’ station. The nurse progress note, dated 3/19/26 at 11:07 p.m. and written by LPN #1, documented Resident #7 continued on neurological checks for a fall that evening. The resident showed no signs or symptoms of skin impairment, shortening of the leg, rotation of the legs or fracture post-fall. The resident was placed in the recliner chair for observation. The resident fell asleep for over one hour and when the nurse tried to get her up to take her to her bed and the toilet, the resident pulled back and moaned with a facial grimaced expression. The resident stated "hurts" and "terrible.” The resident was alert and oriented to herself but normally did not speak. The nurse, while waiting for the resident's representative to call back, notified the director of nursing (DON) and the physician to explain what happened. The DON observed the cameras, which revealed the resident was holding her left hip and was not able to put any weight on her hip with two CNAs helping her to stand. The resident was placed back in the recliner chair for comfort. Emergency medical services (EMS) were notified for transport of the resident to the hospital. The resident’s representative called back and was notified the resident was sent to the hospital for further evaluation.-However, the DON, who was a RN, did not provide a visual assessment of Resident #7 until almost four hours after the resident initially fell and was transferred to from the floor to the recliner after being assessed by LPN #1 (see above). The progress note, dated 3/20/26 at 2:24 a.m. and written by LPN #1, documented Resident #7 had returned from the hospital via EMS and laid in bed. Resident #7's family accompanied her to the facility. The resident was given pain medication at the hospital and EMS handed the nurse a bottle of pain medications to be administered every four to six hours as needed for pain. The resident’s diagnosis was a fracture of the left femoral neck (hip). The family had declined surgery for the resident. The resident had no bruising at the hip, slight swelling was noted and the area was tender to the touch. The interdisciplinary team (IDT) note, dated 3/20/26, documented video surveillance revealed Resident #7 was restless and self-propelling herself around the nurses’ station multiple times in her wheelchair (on 3/19/26). The resident was seen repositioning herself in the wheelchair by scooting herself back. The resident was noted to be wearing silk pajamas, causing the resident to slide down in her wheelchair. The resident attempted to scoot herself back by grabbing onto the nurses’ station and partially standing to scoot herself back. The force of the scoot caused the resident’s wheelchair to roll back and the resident fell to the floor landing on her left side. Review of the hospital records, dated 3/19/26, revealed Resident #7 sustained a fracture of her left femoral neck (hip) with displacement. IV. Staff interviews Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 6/3/26 at 8:45 a.m. CNA-Med #1 said when a resident fell, the nurse had to do an assessment. She said she could not do resident assessments. She said she stayed with the resident until the nurse was there for support. CNA #1 was interviewed on 6/3/26 at 1:20 p.m. CNA #1 said when a resident had a fall, she notified the nurse. She said the CNA-Meds would also get the nurse to look at the resident. The DON and the NHA were interviewed together on 6/3/26 at 4:45 p.m. The DON and the NHA said the first step when a resident fell was to notify the nurse to complete an assessment. The NHA said the LPN completed the assessment and notified the DON. The DON said Resident #7 had a fall (on 3/19/26 and she was notified via phone by the LPN. She said she reviewed the video footage of the fall and guided the LPN from there but did not go to the facility after hours. She said the RN did not have to go in for the assessment. She said Resident #7 was sent to the hospital for further evaluation.-However, there was no documentation in Resident #7’s EMR to indicate the DON was notified by LPN #1 until almost four hours after the resident initially fell and LPN #1 and the CNAs transferred the resident from the floor to the recliner, prior to obtaining a RN assessment and guidance from the DON (see record review above).

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) to ensure the highest practicable quality of life and care for one (#7) resident reviewed for hearing problems out of 36 sample residents. Specifically, the facility failed to consistently ensure Resident #7`s hearing aids were working and placed in the resident’s ears. Findings include: I. Facility policy and procedure The Hearing Impaired Resident, Care of policy, revised February 2018, was provided by the nursing home administrator (NHA) on 6/3/26 at 6: 53 p.m. It read in pertinent part, “Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors.“This facility does not provide comprehensive audiological evaluations or devices to assist with hearing, such as hearing aids and amplifiers.“Staff will assist residents with care and maintenance of hearing devices.“When interacting with the hearing impaired or deaf resident, staff will: Evaluate the resident’s preferred method of communication with staff and other residents. Determine the resident’s awareness of and adaptation to hearing loss. Evaluate and address avoidable obstacles to effective communication. Regularly engage the resident in conversation using whatevercommunication method he or she prefers. Encourage the resident to participate in activities that he or she enjoys. Directly face the resident when speaking so he/she can follow facial expressions and lip read, if possible. When speaking, enunciate clearly, slowly, and in a normal tone. Provide pencil and paper or tablet to communicate in writing, if the resident is able. Provide a sign language translator and written material to explain care and treatment information, as appropriate. Evaluate resident’s adaptive needs and progress at regular intervals.”II. Resident #7A. Resident status Resident #7, age greater than 65, was admitted on 11/20/24. According to the June 2026 computerized physician orders (CPO), diagnoses included respiratory failure, dementia, osteoporosis and a history of falls with fractures. The 3/26/26 minimum data set (MDS) assessment revealed Resident #7 was severely cognitive impaired with a brief interview for mental status (BIMS) score of 99 out of 15. She was dependent on staff assistance with activities of daily living (ADL). The assessment indicated the resident wore a hearing device daily. B. Resident’s representative interviewResident #7s representative was interviewed on 5/31/26 at 3:56 p.m. The representative said she had to put Resident #7’s hearing aids in every time she came into the facility to see her. She said she had requested the facility to please make sure the resident wore her hearing aids daily. C. ObservationsOn 6/2/26 at 3:15 p.m. Resident #7 was sitting in her wheelchair in the common area. She did not have her hearing aids in her ears. On 6/3/26 at 8:45 a.m. Resident #7 was sitting in her wheelchair in her room. She did not have hearing aids in her ears. An attempt to interview her, but the resident did not respond when spoken to. On 6/3/26 at 11:00 a.m. Resident #7 was sitting in her wheelchair in the dining room. She did not have her hearing aids in her ears. On 6/3/26 at 1:15 p.m. Resident #7 was laying in her bed and she did not have her hearing aids in her ears. D. Record reviewThe impaired communication care plan, revised 6/4/25, revealed Resident #7 had impaired communication related to dementia. Interventions included allowing the resident ample time to comprehend what was being said and allowing time for the resident to respond, applying the resident’s hearing aids in the morning and removing them at bedtime and audiology referrals as neededIII. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/3/26 at 1:20 p.m. CNA #1 said there were a few residents in the facility who wore hearing aids. She said the hearing aids were important so the residents could hear what staff were saying in order to help them. She said Resident #7’s representative helped her with her hearing aids. Certified nurse aide with medication authority (CNA-Med) #3 was interviewed on 6/3/26 at 1:30 p.m. CNA-Med #3 said residents wore hearing aids and the staff assisted to put the hearing aids in and take them out at night. She said some residents stored the hearing aids in the nurses’ cart so as to not lose them. CNA-MEd #3 said Resident #7 wore hearing aids and was assisted by staff to put them in. The director of nursing (DON) was interviewed on 6/3/26 at 5:10 p.m. The DON said the CNAs or the CNA-Meds assisted the residents to put in their hearing aids when they got them up in the morning. She said Resident #7 wore hearing aids and the staff should assist the resident to put them in daily.

Based on record review and interviews, the facility failed to ensure residents diagnosed with mental disorder or psychosocial adjustment difficulty received appropriate treatment to attain the highest practicable mental and psychosocial well being for two (#2 and #18) of two residents out of 36 sample residents. Specifically, the facility failed to: -Consistently monitor and provide ongoing assessment to determine whether the care approaches met the emotional and psychosocial needs for Resident #2; and, -Identify and implement effective interventions for Resident #18’s sexual behaviors. Findings include: I. Facility policy and procedureThe Behavioral Health Services policy, revised February 2019, was provided by the nursing home administrator (NHA) on 6/3/26 at 7:17 p.m. It read in pertinent part, “Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorders will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable.”II. Resident #2 A. Resident status Resident #2, age 76, was admitted on 10/19/23. According to the June 2026 computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies (dementia with protein clumping built up in the brain causing problems with thinking, moving, and sleep), epilepsy, chronic kidney disease stage 3, transient ischemic attack (TIA - a mini-stroke), cerebral infarction (a stroke), atherosclerotic heart disease of native coronary artery (plaque builds up inside the arteries supplying blood to the heart restricting blood flow and oxygen to the heart muscle), atrial fibrillation (heart arrhythmia), essential hypertension (high blood pressure), type 2 diabetes mellitus, post-traumatic stress disorder (PTSD), major depressive disorder, insomnia and hallucinations. According to the 3/24/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview mental status (BIMS) score of 14 out of 15. She used a walker and wheelchair. She required set up assistance with eating and supervision with oral hygiene, showering and personal hygiene. She required partial assistance with toileting. The assessment revealed the resident scored a 13 out of 27 on the Patient Health Questionnaire 9 (PHQ-9 - a tool used to determine depression) assessment, indicating the resident had moderate depression. During the 14-day assessment look-back period, the resident reported she had little interest in doing things on seven to 11 days, felt down on seven to 11 days, had trouble falling asleep or staying asleep on seven to 11 days, had poor appetite or overeating on seven to 11 days, had trouble concentrating on things on two to six days, and was moving or speaking slowly on seven to 11 days. B. Record review The psycho-social well being care plan, initiated 10/19/23 and revised 4/7/26, revealed Resident #2 was at risk for alteration in psychosocial well being related to her loss of independence, insomnia, PTSD and dementia. Interventions included administering medications per physician’s orders, monitoring for psychosocial changes and offering psychologist and psychiatrist services as needed. The impaired psychiatric mood care plan, initiated 10/19/23 and revised 4/7/26, revealed Resident #2 had an impaired psychiatric and mood status related to loss of independence, depression, insomnia, PTSD and dementia. Interventions included administering medications and treatments as indicated, assisting the resident to cope by discussing possible solutions, behavioral health consults as needed, monitoring and reporting to the physician any signs or symptoms of acute psychosis or changes from her baseline, monitoring for signs of mood changes or distress and monitoring mood to determine if problems seemed to be related to external causes. The psychotropic medication care plan, initiated 10/19/23 and revised 8/10/26, revealed Resident #2 took aripiprazole, duloxetine and trazodone related to depression, Lewy body dementia and insomnia. Interventions included monitoring PHQ-9 assessment scores for indications of worsening signs and symptoms of depression. The 1/16/26 social services assessment revealed Resident #2’s PHQ-9 assessment revealed she felt down, depressed or hopeless on two to six days in a 14-day assessment look-back period. The 3/13/26 social services assessment revealed the residents’ PHQ-9 assessment was completed. The resident reported she had little interest in doing things on two to six days in a 14-day assessment look-back period. She felt down depressed, or hopeless on two to six days in a 14-day assessment look-back period. The 1/21/26 MDS assessment’s PHQ-9 assessment score was one out of 27, indicating minimal or no depression. The 3/24/26 MDS assessment’s PHQ-9 assessment score was 13 out of 27, indicating moderate depression. -A review of Resident #2’s electronic medical record (EMR) did not reveal any documentation that addressed the resident’s PHQ-9 scores and what follow up, interventions or services were offered to the resident. Review of Resident #2’s June 2026 CPO revealed the following physician’s orders: Aripiprazole (an antipsychotic medication) 5 milligram (mg) tablet. Take one tablet by mouth for PTSD, ordered 3/16/26. Donepezil 10 mg tablet. Take one tablet by mouth at bedtime for dementia, ordered 3/15/26. Duloxetine (an antidepressant medication) 30 mg capsule. Take one capsule by mouth one time a day for major depressive disorder, ordered 3/16/26. Duloxetine 60 mg capsule. Take one capsule by mouth one time a day for major depressive disorder, ordered 3/16/26. Trazodone 50 mg tablet. Take one tablet by mouth at bedtime for insomnia, ordered 3/15/26. Behavior monitoring for duloxetine. Monitor for the following behavior: attention seeking, ordered 3/15/26. Behavior monitoring for aripiprazole. Monitor for the following behavior: hallucinations of deceased husband, ordered 3/15/26. Behavior monitoring for trazodone. Monitor for the following behavior: inability to sleep, ordered 3/15/26. Monitor hours of sleep per shift, ordered 3/15/26. Offer non-pharmacological behavior interventions for any behavior noted. Interventions included positive reassurance, active listening, calm environment and recliner in room, ordered 3/15/26. -However, a review of Resident #2’s medication administration records (MAR) and treatment administration records (TAR), from 2/1/26 to 6/2/26, revealed the resident exhibited behaviors and interventions that were not consistently offered and there was no documentation to indicate if interventions that were offered were effective. III. Resident #18 A. Resident statusResident #18, age 67, was admitted on 1/13/24. According to the June 2026 CPO, diagnoses included chronic obstructive pulmonary disease (COPD - a progressive lung disease restricting airflow), hypertension (high blood pressure), intracranial injury with loss of consciousness, osteoarthritis and dementia with agitation. The 3/24/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He had an impairment on one lower extremity and used a wheelchair. He required set up assistance with eating. He required supervision with oral hygiene and moderate assistance with toileting, showering, and personal hygiene. The assessment revealed the resident did not exhibit any behaviors. B. Resident group interviewFive residents (#8, #17, #35, #49 and #50), who were deemed interviewable by the facility and assessment, were interviewed on 6/2/26 at 2:40 p.m. All five residents said Resident #18 would flirt with women to get money from them for alcohol or cigarettes. Resident #49 said she could not describe the flirting but it wasunwelcomed and she would have to tell him no. Resident #49 said Resident #18 had cognitive problems so she would not make a big deal of it. She said the staff were aware of his behaviors and there were video cameras everywhere that could watch him. C. Record review The behavior care plan, initiated 10/18/24 and revised 2/13/26, revealed Resident #18 had behaviors related to inappropriate touching of other residents and agitation toward staff, accusations toward staff, inappropriate and unwanted lewd and sexual comments to staff and others. Interventions included administering medications per physician’s orders, approaching the resident calmly to avoid frustration and behavior escalation, attempting to redirect the resident when exhibiting behaviors, encouraging Resident #18 to ask questions to reduce anxiety, giving non-judgmental support and monitoring and documenting episodes of inappropriate behaviors. The 8/25/25 behavioral contract revealed Resident #18 signed a contract due to inappropriate, unwanted lewd and sexual comments made to staff and others. Review of a grievance, submitted by Resident #50 on 12/10/25, revealed Resident #50 reported Resident #18 pretended to jump at her, trying to get a reaction out of her. Resident #50 said she was afraid she would lose her balance and fall. The NHA and the director of nursing (DON) spoke to Resident #18 and asked him not to do it anymore. The NHA said there were female residents who had fragile bones and if they fell, they could seriously hurt themselves. Resident #18 verbalized understanding and said he would not bother Resident #50. Review of Resident #18’s June 2026 CPO revealed the following physician’s orders: Escitalopram (an antidepressant medication) 20 mg tablet. Take one tablet by mouth one time a day, ordered 1/22/26. Behavior monitoring for escitalopram. Monitor for the following behavior: agitation towards staff and accusations towards staff, ordered 2/13/26. Behavior monitoring for inappropriate, lewd, sexual unwanted comments to staff and others, ordered 8/25/25. Behavior monitoring for inappropriate touching of other residents, ordered 10/24/24. Offer non-pharmacological interventions for any behaviors noted. Interventions include redirection, remind the resident he can convey wants and needs without verbal aggression, remind him of the current time, ordered 2/17/26. The 3/15/26 health status note revealed Resident #18 made inappropriate remarks to another resident’s daughter who was leaving the facility. Residents were redirected not to make inappropriate statements to visitors. A female resident then began going to her room, and Resident #18 continued with a loud voice at the female resident stating, there goes another one, look at her. The resident was redirected again to quit making remarks to female guests and residents. Resident #18 chose to go to his room. The 3/16/26 social services note revealed the prior week, Resident #18 had made inappropriate remarks to a female visitor and a female resident. The 3/29/26 health status note revealed Resident #18 was being inappropriate about a wheelchair wash. The resident said “Just so you know, there is semen on there.” The resident’s behavior would be passed along to the oncoming nurse. The 4/7/26 nurse assessment revealed most of the time, Resident #18 was cheerful. The resident was currently experiencing unwanted behavior. There was chronic disruptive behavior noted. He was easily upset when he had to wait to go out and smoke. When this happened, he became loud and angry and swore at everyone. He required reminders daily to be patient. The 5/15/26 behavior nurse note revealed Resident #18 was taken to smoke and became verbally sexually abusive to the female certified nurse aide (CNA) and to another female resident. The nurse spoke to the resident and he laughed. The 5/20/26 nurse note revealed Resident #18 was upset no one was available to take him for a supervised smoke break. The nurse told the resident that the CNA and the nurse explained why no one was available and instead of agreeing or accepting, he began to get loud. As the nurse walked away, he pretended to kick her and held his fists up in anger. The 5/21/26 behavior note revealed Resident #18 wanted to go out to smoke with another resident without staff present. Staff explained he had to have a staff member present and no one was available at the time. The resident was upset with the nurse. -A review of Resident #18’s EMR, from 2/1/26 to 6/2/26, revealed the resident exhibited behaviors and interventions that were not consistently offered and/or documented if interventions were effective. IV. Staff interviews Certified nurse aide with medication authority (CNA-Med) #2 was interviewed on 6/2/26 at 3:17 p.m. CNA-Med #2 said he knew if a resident had a behavior to monitor based on getting to know the resident when they were first admitted to the facility. He said once he saw a behavior as a CNA, he would tell the nurse or CNA-Med so the behavior could be charted in the MAR or a progress note. CNA-Med #2 said he was familiar with Resident #18. CNA-Med #2 said Resident #18 had sexually aggressive behavior. He said Resident #18 would tell dirty jokes or be crude to others. CNA-Med #2 said he had not seen Resident #18 display any of the behaviors for a while. He said an intervention to help Resident #18 to not say dirty jokes around female residents was to have him be around men who liked to joke around amongst each other. CNA-Med #2 said he told Resident #18 in the past to not talk in a sexual manner around female residents and Resident #18 would say he would not do it. Registered nurse (RN) #1 said she knew what escalated a resident’s sexual behavior based on the resident’s diagnoses. She said some residents had dementia and when they sundowned (a state of late day confusion, anxiety and agitation related to dementia), they exhibited behaviors. RN #1 said residents did not understand and did not have awareness of the behaviors, so it was important to explain why they could not do what they wanted to do. RN #1 said interventions to de-escalate a resident's behavior was documented as a health status note. RN #1 said she was familiar with Resident #18. RN #1 said he had sexually aggressive behavior and she had not seen him have that behavior in awhile. She said Resident #18 cackled (a loud harsh nervous laughter) at a female visitor and he rubbed arms with young female staff. RN #1 said she redirected him and he was responsive to the redirection. RN #1 said redirection was educating Resident #18 on how to speak and suggesting the resident go to a new location in the building. RN #1 said she saw Resident #18 make inappropriate remarks towards other residents but she did not remember the specifics. The social services director (SSD) and the NHA were interviewed together on 6/3/26 at 1:03 p.m. The SSD said she had been the SSD at the facility for almost three years. She said she had monthly meetings with a licensed clinical social worker to provide guidance and oversight for social services needs. The SSD said nursing staff was responsible for determining what behaviors needed to be monitored. The SSD said a social services assessment was completed at admission, quarterly and as needed. The NHA said the interdisciplinary team (IDT) discussed resident behaviors in the morning meeting. The NHA said hospitals commonly left out behaviors in the referral paperwork. The NHA said if the referral paperwork from hospitals included behaviors, the NHA and the DON reviewed the behaviors to communicate with nursing. The SSD said she visited the resident when she knew the resident had a behavior to determine what triggered the behavior and what helped the resident. The NHA and the SSD said the behaviors were documented as a progress note and on the resident’s care plan. The SSD said she did not review if interventions were effective for identified behaviors. The SSD said she was responsible for completing the social services section, including the PHQ-9 assessment, for the MDS assessment. She said the PHQ-9 assessment was used to measure the level of depression for a resident. The SSD said the PHQ-9 assessment was reviewed at admission, quarterly and as needed. The SSD said the IDT did not review PHQ-9 assessment scores. The SSD said she told the nurses if the score was elevating and the nurses notified the physician so the resident could be seen by the physician. She said she documented the conversation when the PHQ-9 assessment score was elevated and high as a progress note. The SSD said she was familiar with Resident #2. She said she had completed the PHQ-9 assessment for Resident #2 in March 2026, when her score increased. The SSD said she did not provide additional information related to the increasing PHQ-9 score. The NHA said the resident scored high because of the health changes she experienced. The SSD said she did not know if there was any referrals made to behavioral health services for Resident #2. The director of nursing (DON), the SSD and the NHA were interviewed together on 6/3/26 at 5:14 p.m. The DON said the IDT discussed as a group to determine what behaviors to monitor. She said when a resident was first admitted to the facility, the staff learned the resident’s behaviors by observing the resident and asking the family why the resident was on a psychotropic medication and what interventions helped the resident. The DON said nursing staff documented the conversations and observations as behavior monitoring notes and as an admission note. The DON said she knew if interventions were effective because behaviors were monitored on the MARs. The DON said the MAR documented what a resident’s behavior was, what interventions were used and if the interventions were effective. The DON said sometimes it was documented as a behavior note as well.-However, review of Resident #2 and Resident #18’s MARs revealed documentation of the residents’ behaviors and effectiveness of interventions was inconsistent (see above). The DON, the SSD and the NHA said they were familiar with Resident #18. The DON, the SSD and the NHA said he had sexual behaviors that were shown verbally to female staff, visitors and residents. The NHA said the interventions were to tell him that the behavior was not appropriate and to stop saying sexual comments. The NHA said the facility needed to figure out better interventions for Resident #18 so residents felt comfortable in their own home. The DON said the interventions were not effective for Resident #18 because he continued to make sexual comments.

Based on record review and interviews, the facility failed to provide a rationale to act upon the pharmacist’s recommendations in a timely manner for three (#2, #3 and #4) of five residents out of 36 sample residents. Specifically, the facility failed to provide a rationale for not acting upon the pharmacist's recommendations for Resident #2, Resident #3 and Resident #4. III. Resident #3A. Resident statusResident #3, age 83, was admitted on 4/25/24. According to the June 2026 CPO, diagnoses included non-Alzheimer's dementia, anxiety, depression and diabetes. The 4/8/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. She required partial assistance with activities of daily living (ADL). According to the MDS assessment, the resident did not have delusions, hallucinations or other behaviors exhibited during the assessment look-back period. The assessment documented Resident #1 received antipsychotic, anti-anxiety, and antidepressant high risk medications. The assessment revealed she took antipsychotic medications on a routine basis and a gradual dose reduction (GDR) was not attempted. The assessment revealed the section asking if the complete drug regimen review identified potential clinically significant medications was not completed, and the section asking if the facility contacted the physician by 12:00 a.m. of the next calendar day and completed prescribed recommended actions in response to the identified potential clinically significant medication issues was not completed. B. Record review Review of Resident #3’s MRR, dated 3/23/26, revealed the pharmacist recommended a review of the resident’s mirtazapine 15mg every night due to the resident’s recent fall. The physician’s response section indicated the resident’s fall was unrelated to the above medications and medications warranted at this time. -However, the physician did not document a clinical rationale to explain the reason for not decreasing the resident’s mirtazapine, as was recommended by the pharmacist.

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),4, retrieved on 6/9/26, “Food employees shall clean their hands and exposed portions of their arms immediately as specified under § 2-301.12 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.” (Chapter 2-301.14)II. Facility policy and procedureThe Handwashing/Hand Hygiene policy, revised December 2025, was provided by the nursing home administrator (NHA) on 6/3/26 at 12:22 p.m. The policy read in pertinent part,“Hand hygiene is the primary means for preventing healthcare-associated infections (HAs) and the transmission of multidrug-resistant organisms (MDROs). This facility requires strict adherence to evidence-based hand hygiene practices for all personnel, including licensed, unlicensed, contracted, therapy, dining, housekeeping, volunteers, and students.“Hand hygiene is indicated before touching a resident; before preparing or handling food, medications, or parenteral solutions; before clean or aseptic procedures; before moving from work on a soiled body site to a clean body site on the same resident; after exposure to blood, body fluids, excretions, or contaminated surfaces; after touching a resident; after touching the resident's environment or belongings; after glove removal; and whenever hands are visibly soiled.“The use of gloves does not substitute for hand hygiene. Always perform hand hygiene after gloves are removed.”III. Observations 1. Kitchen meal serviceDuring a continuous observation of the lunch meal service in the kitchen 6/2/26, beginning at 10:50 p.m. and ending at 12:37 p.m., the following was observed:At 11:25 a.m. cook #1 removed her gloves, placed a container in the refrigerator. She donned (put on) new gloves and proceeded to plate resident meals. Cook #1 did not wash her hands after touching the refrigerator door handle and donning new gloves to plate meals. At 11:34 a.m. dietary aide (#1) used her gloved hands to open the cabinet door, she then removed a hamburger patty from a bag and placed it directly on the grill. She did not change her gloves or perform hand hygiene after touching the cabinet handle and before directly touching the food. Dietary aide #1 then removed her gloves and performed hand hygiene. At 11:36 a.m. dietary aide #1 opened the refrigerator and retrieved a bag of hot dogs and donned new gloves. She did not perform hand hygiene before placing new gloves on. At 11:38 a.m. dietary aide #1 removed a hot dog from the bag and placed it into the microwave, touching the microwave handle with her gloved hand. She then placed the remaining hot dogs back in the refrigerator opening and closing the door. At 11:40 a.m. dietary aide #1 used the same gloved hands to touch lettuce, a sliced onion and a tomato and place the items on a plate. At 11:43 a.m. dietary aide #1 used her gloved hands to open and close the refrigerator. She placed a hamburger patty in a bun on a plate, touching the bun with her gloved hands. 2. Assisted diningDuring a continuous observation of the lunch meal service in the dining room on 5/31/26 beginning 4:00 p.m. and ending at 4:45 p.m., the following was observed:Resident assistant #1 and an unidentified certified nursing aide (CNA) were providing meal assistance for two residents at table A, one resident at table B and one resident at table C. The unidentified CNA and resident assistant #1 went from table to table, positioning the residents at the tables, touching the resident’s wheelchairs, touching each resident’s utensils and beverage cups while providing meals assistance to each of the four residents without performing hand hygiene. IV. Staff interviewsCook #1 was interviewed on 6/2/26 at 12:20 p.m. cook #1 said hand hygiene should be conducted frequently when preparing and serving meals and when touching anything that could contaminate the food. She said hand hygiene should have been done every time gloves were put on and taken off. Dietary aide #1 was interviewed on 6/2/26 at 12:28 p.m. Dietary aide #1 said hand hygiene should be performed every time a staff member returned from a break, touched anything potentially contaminated and when putting on new gloves. The dietary manager (DM) was interviewed on 6/3/26 at 11:09 a.m. The DM said hand hygiene should be conducted before touching food related equipment and before and after glove use to prevent potential cross-contamination. The DM said hand hygiene should be done every time staff returns from a break, touches anything potentially contaminated and when putting on new gloves. She said her staff have been trained on hand hygiene and she would continue to remind them. The director of nursing (DON) was interviewed on 6/3/26 at 5:15 p.m. The DON said she was the infection preventionist for the facility. The DON said she did not educate the kitchen staff or spot check them in the kitchen for appropriate infection control practices. The DON said she would watch the dining room staff to check on hand hygiene in the dining room for residents and staff in the dining room. She said the DM was responsible for ensuring infection control practices were conducted during meal preparation and meal service for the kitchen staff. The NHA was interviewed on 6/3/26 at approximately 6:40 p.m. She said the facility mainly focused on resident hand hygiene, but based on the observations, they would continue to work with staff on hand hygiene.

Based on record review and interviews, the facility failed to meet all the requirements for the provisions of hospice care for two (#67 and #41) of two residents reviewed for hospice care services out of 36 sample residents. Specifically, the facility failed to: -Ensure hospice notes were readily available in Resident #67 and Resident #41’s electronic medical records (EMR); -Ensure Resident #67 and Resident #41’s comprehensive care plans were developed with a delineation of care responsibilities between the facility staff and the hospice care services team; and, -Ensure there was a designated hospice care services coordinator for the facility. Findings include: I. Facility policy and procedure The Hospice policy and procedure, revised July 2017, was provided by the nursing home administrator (NHA) on 6/3/26 at 7:12 p.m. It read in pertinent part, “The facility has designated someone to coordinate care provided to the resident by our facility staff and the hospice staff. This person is responsible for ensuring information is obtained from hospice names and contact information for hospice personnel involved in hospice care of each resident.”II. Resident #67A. Resident statusResident #67, age 73, was admitted on 5/22/26. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - emphysema, an inflammatory lung disease that blocks airflow making it difficult to breathe), adult failure to thrive, severe protein malnutrition and a pressure ulcer. The 5/22/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required partial assistance with activities of daily living (ADL). B. Resident interview Resident #67 was interviewed on 6/3/26 at 10:15 a.m. Resident #67 said the hospice nurses changed the dressings to the wound on his bottom. He said the facility staff did not look at the wound or help with the dressing, only the hospice team did. He said he had been on hospice care services for approximately a year before admitting to the facility. He said hospice wanted him at the facility to help him gain weight, build strength and to help his wound to heal. He said the facility helped him with his indwelling Foley catheter and flushed the catheter daily. He said he had gained weight and he felt stronger since being in the facility. He said he wished the facility would help him with his wound care. He said the hospice nurse was coming in today (6/3/26) to look at his wound. C. Wound care observation and interview with hospice nurseOn 6/3/26 at 12:40 p.m. the hospice registered nurse (RN) was observed during wound care for Resident #67. The hospice RN packed the resident’s wound with sterile packing material and medihoney (wound healing cream). The hospice RN said she saw Resident #67’s wound a few weeks ago and it appeared to be larger in size now, but she said the wound measurements were smaller. She said the hospice nurse that covered her when she was gone started to pack the wound due to the wound tunneling (narrow passageways or channels form underneath the skin's surface). She said this was a change from when she was there last. She said she was Resident #67s main hospice nurse and wanted him to move to the facility in order to help him gain strength, gain weight and to help his wound heal. She said his wound developed at home and progressed to a stage 4 pressure wound in a couple of weeks because of his inability to get up and move around on his own. The hospice RN said the main area of concern for Resident #67 was his wound. She said the hospice team used their standing physician orders for wound care, but now the wound had tunneled and started having an odor. She said she was hoping the facility’s medical director (MD) would help guide them on wound care. She said she could not remember who, but someone from the facility had told her that hospice had to manage the resident’s wound because he was only at the facility for a respite stay. She said she did not coordinate with anyone specific in the facility regarding the resident’s care. The hospice RN said Resident #67 had an air mattress on his bed and a cushion on the wheelchair. She said he was able to move himself around more because he had increased his strength and he was able to ask for help when he needed it. She said the hospice admission nurse coordinated with the facility prior to the resident moving in, sent over wound care orders and the potential care plan for repositioning the resident and his diet with supplements. She said she completed a nurse progress note for each visit, but she had not left a copy with the facility. She said she verbally discussed her visits with the facility. D. Record review Review of Resident #67’s June 2026 CPO revealed the following physician’s orders: Monitor wound site to coccyx every shift. Monitor wound and document yes or no for issues. If issues noted, notify the medical director, ordered 5/22/26. Wound care to coccyx. Cleanse with wound cleanser, cover with dressing as needed when dressing is loose or soiled, ordered 5/25/26. -However, the orders did not indicate that hospice was responsible for providing the wound care.-There were no physician’s orders for hospice care services. -Review of Resident #67’s care plan revealed there was no care plan focus for hospice care services and no hospice interventions. The social services assessment note, dated 5/22/26, revealed Resident #67 was admitted to the facility for a respite stay. He was a do not resuscitate (DNR - no cardiopulmonary resuscitation). He had services with hospice and his admitting diagnosis was pressure ulcer, unstageable. The admission summary note, dated 5/22/26, revealed Resident #67 was admitted to the facility from home that morning via facility transport. Resident #67 was on hospice care services and admitted for respite with a diagnosis of a pressure ulcer to his sacral region, unstageable. E. Staff interviewsRegistered nurse (RN) #1 was interviewed on 6/3/26 at 9:00 a.m. RN #1 said the hospice nurses took care of the wound care for Resident #67. She said they came to the facility two times a week and when the facility staff called them. She said the facility nurses did not look at the wound or do wound care for the resident because he was on a respite stay with hospice care services. She said she had to talk to the medical director to at least get an as needed order for wound care in case the dressing fell off before the hospice team could be there. She said all other wound care orders were written by the hospice team. She said the hospice nurses gave the facility staff a verbal update when they were at the facility to see the resident, but she had not seen any progress notes from them. Certified nurse aide (CNA) #4 was interviewed on 6/3/26 at 10:39 a.m. CNA #4 said the hospice staff was responsible for Resident #67’s showers. She said the facility CNAs just helped the resident get out of bed for meals and emptied his Foley catheter bag. She said otherwise, the hospice staff came in to help him. She said the resident was pretty independent and turned himself in bed

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. Specifically, the facility failed to:-Ensure nursing staff disinfected blood pressure cuffs and sit-to-stand mechanical lifts in between residents;-Ensure nursing staff performed appropriate hand hygiene in between assisting residents; and, -Ensure housekeeping staff performed appropriate hand hygiene while cleaning residents’ rooms. 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 6/9/26 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 immediately before touching a patient and after touching a patient or the patient’s surroundings.”II. Facility policy and procedureThe Hand Washing Hand Hygiene policy, revised December 2025, was received by the nursing home administrator (NHA) on 6/3/26 at 6:53 p.m. It read in pertinent part, “Hand hygiene is indicated: before touching a resident, before moving from work on a soiled body site to a clean body site on the same resident, after exposure to contaminated surfaces, after touching a resident, after touching the resident’s environment or belongings (after glove removal) and whenever hands are visibly soiled.”The Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised September 2022, was received by the NHA on 6/3/26 at 6:53 p.m. It read in pertinent part, “The resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the occupational safety and healthcare administration (OSHA) bloodborne pathogens standard.“The Spaulding Classification System is used to distinguish the levels of sterilization disinfection necessary for items used in resident care: Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs and crutches. Non-critical environmental surfaces include bed rails, bedside tables. Critical and semi-critical items are sterilized and disinfected in a central processing location and stored appropriately until use. Reusable items are cleaned and disinfected or sterilized between residents (durable medical equipment). Reusable resident care equipment is decontaminated and or sterilized between residents according to manufacturers’ instructions. Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident.”III. Failed to disinfect blood pressure cuffs and mechanical lifts and perform appropriate hand hygiene between residentsA. Observations On 6/1/26 at 3:25 p.m. certified nurse aide (CNA) #1 and CNA #2, along with the NHA, transferred four unidentified residents out of the recliner chairs in the common area with one sit-to-stand mechanical lift. CNA #1, CNA #2 and the NHA went between the four residents, one after the other, to transfer them into their wheelchairs. The residents held onto the mechanical lift bar during the transfer. The staff members touched the residents' clothing and assisted the residents with placing their hands on the lift bar while being transferred out of the recliner chairs and into their wheelchairs. -CNA #1, CNA #2 and the NHA failed to disinfect the mechanical lift in between using it to transfer each resident.-Additionally, the staff members failed to perform appropriate hand hygiene after touching each resident. On 6/2/26 at 9:52 a.m. certified nurse aide with medication authority (CNA-Med) #2 took the blood pressure cuff from the top of his medication cart and placed it on an unidentified resident's arm to obtain the resident’s blood pressure. After obtaining the resident’s blood pressure, CNA-Med #2 put the blood pressure cuff back on top of his medication cart without disinfecting it. On 6/2/26 at 1:50 p.m. CNA-Med #3 took the blood pressure cuff out of her medication cart and the cuff on an unidentified resident's arm to obtain the resident’s blood pressure. After obtaining the resident’s blood pressure, CNA-Med #3 put the blood pressure cuff back into the medication cart without disinfecting it. -CNA-Med #2 and CNA-Med #3 failed to disinfect the blood pressure cuffs after obtaining residents’ blood pressures. B. Staff interview CNA #4 was interviewed on 6/3/26 at 10:39 a.m. CNA #4 said hand hygiene was completed after assisting residents, going in and out of residents’ rooms and before meals. She said she washed her hands when they were soiled or when a resident had an infection which required staff to wear personal protective equipment (PPE). She said she did not clean the mechanical lifts after each use or between residents. The director of nursing (DON), who was the facility’s infection preventionist was interviewed on 6/3/26 at 5:30 p.m. The DON said hand hygiene should be performed frequently, including after resident care, going to the bathroom, during wound care, before and after eating and before and after touching equipment. She said the night shift cleaned and disinfected the wheelchairs and the medical equipment such as the mechanical lifts, as well as the blood pressure tower machines. The DON said staff did not generally clean the lifts or blood pressure equipment at any other time, unless the equipment was visibly soiled. She said the blood pressure cuffs were not cleaned in between residents because they generally touched clothing and not the skin of a resident. She said infection control education was completed on the computer annually and when it was needed because of a concern. IV. Failed to ensure housekeeping staff performed appropriate hand hygiene while cleaning residents’ rooms A. ObservationsOn 6/2/26 at 9:22 a.m. housekeeper (HK) #1 was cleaning resident room #6, which was a double-occupancy room. HK #1 donned (put on) gloves, sprayed the counters and sinks with a disinfectant spray, emptied the trash can and used a rag to wipe around the trash can before doffing (taking off) her gloves. She donned another pair of gloves without performing hand hygiene and swept the residents’ room. After sweeping the resident’s room, HK #1 doffed her gloves again and without performing hand hygiene, donned another pair of gloves and sprayed furniture polish onto a rag, wiped down the wood surfaces and repeated the procedure for both sides of the residents’ room. She then took off her gloves, exited room #6 and walked across the hallway into another resident's room to get a box of gloves without completing hand hygiene. She said she ran out of gloves and did not have time to go get a box from the housekeeping closet. HK #1 re-entered room #6, donned another pair of gloves without performing hand hygiene and used a clean rag to wipe down the counters and the sink in room #6. After wiping the counters and sink, she doffed her gloves, donned another pair of gloves and sprayed a rag with disinfectant to clean the high touch surfaces of the room and mopped the floor. Once she finished mopping the floor, HK #1 doffed her gloves, exited room #6 and pushed her housekeeping cart to resident room #7. Without performing hand hygiene, HK #1 donned another pair of gloves and proceeded to begin cleaning the second resident room. -HK #1 failed to perform hand hygiene before donning and after doffing her gloves during the duration of the entire room cleaning process. B. Staff interviewsHK #1 was interviewed on 6/2/26 at 9:35 a.m., immediately after the above observation. HK #1 said she completed training on how to clean a resident room when she started working at the facility. She said she did not know how often the facility provided additional room cleaning education. She said she performed hand hygiene when she was done cleaning the residents’ rooms. The environmental director was interviewed on 6/3/26 at 5:45 p.m. The environmental director said he completed hand hygiene education with the housekeeping staff and the laundry services department. He said he completed one-on-one training with staff when needed. He said hand hygiene should be performed after disinfecting residents’ rooms and in between putting on and taking off each pair of gloves.

A revisit survey was completed on 5/27/25 for all previous deficiencies cited on 4/10/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO39666 was conducted on 4/9/25 to 4/10/25. One deficiciency was cited.

Based on record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries for one (#1) of three residents reviewed for pressure injuries out of five sample residents. Specifically, the facility failed to implement interventions to prevent the development of a pressure injury for Resident #1. Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com on 4/17/25, "Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) 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 1 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. The Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."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/Stage3 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 ulcer 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) on 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 Injuries Overview policy, revised April 2020 was provided by the nursing home administrator (NHA) on 4/10/25 at 5:59 p.m. The policy read in pertinent part, "Pressure ulcer/injury refers to localized damage to the skin and or underlining soft tissue, usually over a bony promise or related to a medical or other device. "A pressure injury will present as intact skin and maybe painful."A pressure injury will present as an open ulcer, the appearance of which will vary depending on the stage and it may be painful."Pressure injuries occur as a result of intense and or prolonged pressure or pressure combined with a shear." The Prevention of Pressure Injuries policy, revised April 2020, was provided by the NHA on 4/10/25 at 5:59 p.m. According to the policy, staff should review the resident's care plan, identify the pressure injury risk factors and interventions designed to reduce or eliminate the risk factors. The policy read in pertinent part,"Assess the resident on admission for existing pressure injury factors. Repeat the risk assessment weekly and upon any changes of condition. Use a standardized pressure injury screening tool to determine and document risk factors. Supplement the use of a risk assessment tool with assessment of additional risk factors."Check the skin on a daily basis when performing or assisting with personal care or activities of daily living."Identify any signs of developing pressure injuries, including non-blanchable erythema (redness)."Inspect pressure points, including sacrum, heels, buttocks, coccyx, elbows, ischium (base of pelvis) and trochanter (upper thigh)."Reposition resident as indicated on the care plan."Do not rub or otherwise cause friction on skin that is at risk for injuries."Select appropriate support surfaces based on the resident's risk factors in accordance with the current clinical practice."Evaluate, report and document potential changes in the skin."Review the interventions and strategies for effectiveness on an ongoing basis." III. Resident #1A. Resident statusResident #1, age greater than age 65, was admitted on 4/5/19, readmitted on 3/7/25 and discharged on 3/12/25 to home with hospice services. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia, type 2 diabetes mellitus without complications, muscle weakness, muscle wasting and atrophy, personal history of transientischemic attack (TIA) and cerebral infarction without residual deficits (stroke). The 3/9/25 minimum data set (MDS) assessment revealed Resident #1's cognition was moderately impaired and she exhibited a memory problem. The resident was dependent on staff for her activities of daily living (ADL) and used a wheelchair for mobility. According to the MDS assessment, the resident was at risk for developing pressure ulcers and had an unhealed pressure ulcer. The MDS assessment revealed the resident had an unstageable pressure ulcer. B. Record reviewThe care plan for skin, initiated 3/23/23, indicated Resident #1 was at risk for impaired skin integrity related to muscle wasting, atrophy and moisture associated skin damage. The care plan interventions directed staff to provide a redistribution mattress to the resident's bed, provide a non-irritating service to reduce friction or shearing forces, assist the resident with turning and repositioning as needed, encourage her to reposition herself if able, complete a wound evaluation to monitor the progress of her skin, encourage the resident to comply to the interventions/treatments to minimize further skin impairment, complete a skin inspection every seven to 10 days and as needed, notify the physician/nurse practitioner (NP) of noted worsening skin or any new areas of skin breakdown and notify the nurse of any new areas of skin breakdown noted during bathing or daily care, including redness, blisters, bruises and skin discoloration. The 12/2/24 quarterly nursing evaluation was provided by the NHA on 4/10/25 at 11:56 a.m. The evaluation identified Resident #1's factors of risk to pressure injury. The nursing evaluation identified Resident #1's ability to respond to pressure related discomfort was slightly limited, she could not always communicate discomfort or had some sensory impairment which limited her ability to feel pain, her skin was occasionally exposed to moisture, she was chairfast, her ability to change and control her body position was very limited, her usual food intake pattern was probably inadequate and she had a skin friction and sheering potential problem. The 2/25/25 skin care plan intervention directed staff to provide pressure reducing boots to Resident #1's bilateral feet as tolerated with an option to remove during care. The 3/10/25 skin care plan intervention directed staff to elevate Resident #1's heels off the mattress as needed and tolerated. Review of the electronic medical record (EMR) identified Resident #1 was diagnosed with adult failure to thrive on 12/13/24, indicating the resident had a decline in her health (see interview below). Review of Resident #1's March 2025 CPO revealed the following physician's physician's orders: Pressure relieving mattress, protective footwear/heel protectors while in bed and decubitis (pressure ulcer/injury) precautions as needed, ordered 2/12/23. Mighty shake (high calorie supplement) three times a day for risk of malnutrition, ordered 12/3/24. Heel protectors to bilateral heels at all times for every shift, ordered 2/6/25. Air mattress overlay to be placed on the bed due to poor skin integrity, ordered 3/8/25.-However, review of the physician's orders revealed the resident had a physician's order for a pressure relieving mattress and heel protectors in bed ordered on 2/12/23 (see above). Review of Resident #1's December 2024, January 2025 and February 2025 medication administration records (MAR) and treatment administration records (TAR) did not identify that a pressure redistribution mattress was being utilized for the resident. Further review of Resident #1's December 2024 and January 2025 MAR and TAR did not identify heel protectors were being used for the resident. Review of Resident #1's February 2025 MAR documented heel protectors were used beginning on 2/6/25. From 2/1/25 through 2/5/25 there was no documentation the resident was using heel protectors. -However, according to the March 2025 CPO, the resident had a physician's order for a pressure relieving mattress and heel protector to be available for the resident's use, ordered on 2/12/23 (see physician's orders above). The 2/6/25 Braden Scale assessment (a tool for predicting pressure ulcer risk) was provided by the NHA on 4/10/25 at 11:33 a.m. The Braden Scale assessment identified Resident #1 was at risk for pressure ulcer development. The 2/6/25 change of condition note identified a certified nurse aide (CNA) notified the nurse of a discoloration to Resident #1's right heel. A physical assessment documented the discoloration to her right heel measured 2 centimeters (cm) by 2 cm by 2 cm and was non-blanchable (skin discoloration, usually redness, that doesn't turn lighter or disappear when pressed upon). The 2/6/25 wound evaluation was provided by the NHA on 4/10/25 at 11:33 a.m. The evaluation identified the new right heel wound was facility-acquired. The physician and the resident's representative were notified. According to the wound evaluation, the intervention was to encourage Resident #1 to reposition herself and use a pressure redistribution mattress on her bed. The evaluation documented the wound was evaluated by licensed practical nurse (LPN) #1.-However, according to the physician's orders, Resident #1 already had a physician's order for a pressure redistribution mattress which was ordered on 2/12/23 (see physician's orders above). -The wound evaluation did not identify the source of pressure to the resident's right heel. A 2/6/25 skin impairment incident report documented Resident #1 had been on a steady decline. The 2/13/25 wound evaluation was provided by the NHA on 4/10/25 at 11:33 a.m. Thewound evaluation documented Resident #1 had discoloration to her right heel measuring 2 cm by 2 cm and was improving. The evaluation did not identify the determining factors of the improvement. According to the evaluation, the wound was evaluated by registered nurse (RN) #1. -The evaluation did not identify if the wound was evaluated by a physician/nurse practitioner or wound care specialist. -The evaluation did not identify the determining factors of the improvement. The 2/20/25 wound evaluation was provided by the NHA on 4/10/25 at 11:33 a.m. Thewound evaluation documented Resident #1 had discoloration to her right heel measuring 2 cm by 2 cm and was improving. According to the evaluation, the wound was evaluated by registered nurse (RN) #1. -The evaluation did not identify if the wound was evaluated by a physician/nurse practitioner (NP) or wound care specialist.-The evaluation did not identify the determining factors of the improvement. A 2/24/25 skin inspection form completed by LPN #1 documented there were no new skin injuries. -The skin inspection form did not identify the condition of Resident #1's right heel wound. The 2/27/25 Braden Scale assessment was provided by the NHA on 4/10/25 at 11:33 a.m. The 2/27/25 Braden Scale assessment identified Resident #1 was at moderate risk for pressure ulcer development. The 2/28/25 change in condition evaluation identified Resident #1 would open her eyes but not respond vocally. The evaluation documented the resident was seen by the NP on 2/25/25 due to her recent decline. The evaluation did not identify the NP evaluated or saw Resident #1's right heel wound. A 2/28/25 health status note identified Resident #1's family took the resident to the emergency department at the hospital. Hospital records between 2/28/25 and 3/7/25 documented Resident #1 was admitted to the hospital and was treated for pneumonia symptoms with complications and was provided wound care to her right heel. The hospital records identified the resident's wound on her heel as a pre-existing right heel unstageable pressure injury that was present from the facility. A wound consultation conducted at the hospital documented Resident #1's right heel injury was identified as the pressure injury unstageable and measured 2 cm by 3 cm with unknown depth. The right heel pressure injury had semifirm eschar (a hardened, dry, black or brown dead tissue) and peeling of the epidermis (outer layer of skin). The unstageable pressure injury was not open and there was no drainage and no erythema. The resident's heel was painted with Betadine, a border dressing was applied and both her heels were offloaded with pillows. The hospital discharge orders directed caregivers to float Resident #1's heels, apply Betadine and keep a padded dressing on her right heel. The 3/7/25 admission summary note identified Resident #1 was admitted back to the facility on 3/7/25. The 3/7/25 wound report identified the NP saw the Resident #1's pressure injury on 3/7/25. According to the wound report, the NP documented the measurements of the right heel wound on 3/7/25 as 4.5 cm by 4 cm by 0.1 cm. The NP documented the wound as a stage 2 pressure injury. The wound report directed staff to continue Bedadine daily and have the residents wear heel protectors at all times. The 3/7/25 Braden Scale assessment was provided by the NHA on 4/10/25 at 11:33 a.m. The Braden Scale assessment identified Resident #1 was at risk for pressure ulcer development. IV. Staff interviewsThe NHA, the director of nursing (DON) and RN #1 were interviewed together on 4/10/25 at 1:53 p.m. RN #1 identified herself as the facility's wound nurse. She said she was not wound care certified and the NP would assess wounds that were stage 2 or greater. She said if a wound was identified, the facility nurses would start standing wound physician's orders and then RN #1 and the NP would look at the wound on the following Monday. The DON said on 2/6/25, LPN #1 identified Resident #1 had a reddened area on her right heel. RN #1 said LPN #1 initiated a change of condition, requested the physician's order for heel protectors and notified RN #1 and the NP of the discoloration to Resident #1's heel. RN #1 said she saw Resident #1's heels on 2/10/25 but did not document it. She said she assessed Resident #1's heel on 2/13/25. She said the resident's heel was non-blanchable with discoloration and the wound was not open. RN #1 said the immediate intervention was to relieve the pressure from Resident #1's right heel so a heel protector was implemented on 2/6/25. She said there were no changes in her interventions because the heel did not worsen. She said the coloring started to improve and a blister was not formed. RN #1 said Resident #1 had been declining since December 2024. She said the resident had been losing weight and was less active. She said Resident #1 was at risk for pressure injuries. She said the resident's condition continued to decline. RN #1 said the more the resident declined in condition, the more she was at risk for pressure injury development. She said Resident #1 wore tennis shoes on her feet until 2/6/25 when the heel protectors were implemented. The NHA said a pressure relieving mattress was not implemented after Resident #1 was identified as being at risk for pressure injuries or after discoloration was identified on her right heel on 2/6/25. The NHA said the resident was at high risk for falls and used a scoop mattress instead to help decrease the risk of her falling. She said the resident was turned every couple hours when in bed, as standard practice. RN #1 said the NP saw Resident #1 on 2/25/25 but did not look at the resident's right heel. She said the NP reviewed the resident's overall decline and swallowing concerns. RN #1 said she did not assess Resident #1's for any changes to her heel after 2/20/25 and before she went to the hospital on 2/28/25. She said the resident's skin was looked at by the floor nurse (on 2/24/25), but only to identify if there were new wounds. She said the floor nurse did not assess the condition of the resident's right heel. RN #1 said Resident #1's heel was not seen by the NP until the resident returned from the hospital on 3/7/25. She said the NP saw the resident and implemented a pressure relieving air mattress when she returned from the hospital. RN #1 was interviewed again on 4/10/25 at 6:48 p.m. RN #1 said the facility needed to do a better job at identifying the root cause of pressure injuries. RN #1 said she thought Resident #1's shoes and leg rests caused the pressure to the resident's right heel when Resident #1 was in a declining condition, had weight loss and was moving less.

A revisit survey was completed on 4/8/25 and 4/9/25 for all previous deficiencies cited on 3/6/25. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 4/9/25 for all previous deficiencies cited on 3/6/25. The facility is in compliance with all regulations surveyed.

A survey prompted by #CO39593 was completed on 3/5/25 to 3/6/25. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#2) of three residents reviewed for accidents out of three sample residents. Resident #2 admitted to the facility on 11/20/24 with a history of falls. Resident #2 sustained a fall on 11/21/24, 11/29/24, 1/4/25 and 1/23/25. After the resident sustained falls, the facility failed to implement timely interventions. On 1/23/25 the resident attempted to self transfer in the shower room where she fell and sustained a hip fracture. Review of Resident #1's electronic medical record (EMR) identified the facility failed to implement timely and effective interventions and ensure environmental hazards did not contribute to Resident #1's falls. Findings include:I. Facility policy and procedureThe Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, "All accidents or incidents involving residents, employees, visitors, vendors, occurring on premises shall be investigated and reported to the administrator. The policy identified the following steps that should be taken after the initial data was collected: "The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing (DON) services within 24 hours of the incident or accident. "The DON shall ensure that the administrator receives a copy of the incident/accident form on each occurrence."The incident/accident reports will be reviewed by the safety committee for trends related to the accident or safety hazards in the facility and to analyze any individual resident vulnerabilities."II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 11/20/24. According to the March 2025 computerized physician's orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia, history of falling, generalized muscle weakness, abnormalities of the gate and mobility, need for assistance with personal care, cognitive communication deficit, difficulty walking and unspecified dementia, severe, without behavioral disturbance. The 2/19/25 facility assessment documented Resident #2 had severe cognitive impairments . Resident #2 required substantial/maximal assistance from a sit to stand position and was dependent on staff for a toilet transfer. She used a wheelchair for mobility. The facility assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The facility assessment identified Resident #2 had a history of falls. According to the facility assessment, Resident #2 had two falls without injury and one fall with a major injury since her admission or in the past six months and one fall without injury since her last assessment. B. Record reviewThe fall care plan, initiated 11/20/24 and revised 12/10/24, identified Resident #2 was at risk for falls related to bladder and/or bowel incontinence, generalized weakness, history of falls and needing assistance with activities of daily (ADL). The fall interventions, initiated on 11/20/24, directed staff to implement preventative fall interventions/devices, ensure call light was in reach and needed items were within reach, educate the resident how to use the call light and monitor her for changes in mobility. The fall interventions, initiated on 12/10/24, directed staff to provide Resident #2 with non-skid footwear, conduct physical therapy (PT)/occupational therapy (OT) and speech therapy evaluations, educate the resident and her family to call for assistance before transferring and provide food and drinks within reach. The fall interventions, initiated on 12/12/24, indicated Resident #2 was impulsive, over estimated her abilities and needed to be kept within line of sight. The 12/12/24 fall intervention directed staff to place her in a recliner. The 12/12/24 fall intervention, revised on 1/22/25, directed staff to place anti-roll backs on her wheelchair. The fall intervention, initiated on 1/7/25, identified Resident #2 was placed on a toileting program.-The facility failed to implement timely interventions after Resident #2 sustained a fall on 11/21/24, 11/29/24 and 1/23/25.1. Fall on 11/21/24 - unwitnessedThe fall occurrence note, dated 11/21/24, identified Resident #2 was found on the floor in her room by a certified nurse aide (CNA). According to the note, Resident #2 was found on her back between the foot of the bed and the bathroom. The resident was toileted and brought to the nurse's station to keep within sight. The note documented the nurse completed a physical assessment to include range of motion. The resident was not able to move her right arm related to the presence of a right arm sling after a fall prior to her admission. The note documented the resident had a bump on the crown of her head but it was not known if the bump occurred at the time of the 11/21/24 fall or if the resident had the bump prior to her admission to the facility (11/20/24) from a fall at home. The note indicated the resident was not able to tell staff what happened other than she fell. Factors of the fall were identified as poor lighting and confusion. The 11/26/24 interdisciplinary team (IDT) meeting note identified Resident #2 was last toileted at 4:00 a.m. and checked at 4:45 a.m. The call light was in reach, her bed was in a low position, her wall light was on, she was incontinent at the time of the fall and was wearing socks. According to the note, the resident complained of shoulder and head pain. No other injuries were noted at the time of the incident. The nursing recommendation was to place the resident in a recliner in the line of sight.-The note did not identify if the socks the resident was wearing were non-skid or not. -The IDT note did not identify if the bump on her head occurred at the time of the 11/21/24 fall or if she had the bump from her last fall at home.-The review of the care plan did not identify new interventions were updated on the fall care plan until 12/12/24, three weeks after the 11/21/24 fall. 2. Fall on 11/29/24 - witnessedThe 11/29/24 fall occurrence note identified Resident #2 had a fall. According to the note, a CNA observed Resident #2 attempting to transfer herself from her wheelchair to the recliner in the living room and she sat on the floor between two recliners. The resident had non-slip shoes on and her wheelchair was in front of her. The note indicated there were no injuries and she was placed in a recliner near the nurse's station. -The fall occurrence note identified Resident #2 was not placed in a recliner by staff as recommended in the 11/21/24 IDT note. The 12/3/24 IDT meeting note identified the recommendation after the fall was to implement a restorative program.-The restorative program for Resident #1 was not implemented until 12/13/24, two weeks after the fall (see interview below).-The review of the care plan did not identify that the restorative program was implemented as recommended on 12/3/24 by the IDT. 3. Fall on 1/4/25 - witnessedThe 1/4/25 fall occurrence note identified Resident #2 was observed sliding from the recliner, down to the floor before staff could intervene. There were no injuries identified. According to the note, the resident stated she was going to the restroom. The 1/7/25 IDT note documented a video surveillance recording identified Resident #2 scooted herself over the edge of the recliner, walked around the foot rest, lost her balance and landed on her buttocks on the recliner foot rest which caused the recliner to tip forward. The resident slid down the foot rest and landed on the left side of her body. According to the note, there were no injuries and she deniedany new or increased pain. The note indicated the resident did not ask to go to the restroom or was able to remember to ask for help. The nursing recommendations were to place the resident on a bowel and bladder toileting program. 4. Fall on 1/23/25 - unwitnessedThe 1/23/25 fall occurrence note identified Resident #2 was found in a shower room on the floor at 7:45 a.m. The shower room door was propped open by a stool and unlocked. Resident #2 was laying on the floor on her right side with her pants pulled down below her knees. Her wheelchair was to the left of the resident and the brakes were unlocked. She was wearing non-slip shoes at the time of the fall. According to the note, during the nurse's physical assessment, the resident grabbed her right lower extremity in pain. Resident #2 had redness and light colored bruising to her right hip and a skin tear measuring 3 centimeters (cm) by 3 cm on her right knee. The note indicated the resident was sent to the hospital for an evaluation and treatment. The note documented the resident was last checked on at 7:40 a.m. Resident #2 was forgetful and overestimated her limitations. The bathing rooms were immediately locked. The 1/23/25 change in condition note identified Resident #2 returned to the facility with a diagnosis of a right femoral head fracture. Her family declined surgery. The note indicated the resident was on comfort-focused care. The note indicated the resident was attempting to crawl out of bed after returning from the hospital. The resident was placed in a recliner in view of the nurse's station due to her high fall risk. The 1/28/25 IDT meeting note identified staff were educated to keep doors locked for safety concerns as the nursing recommendation. -The fall care plan did not identify new care plan interventions were added after Resident #2 had another fall during a self-transfer that resulted in a broken hip (see care plan above). C. EducationThe 1/23/25 staff education sheet was provided by the NHA on 3/6/25 at 6:17 p.m. The education sheet identified 75 staff members were educated to keep all of the doors in the hallways locked, except for the resident's rooms. It indicated doors could not be propped open or left unlocked for staff convenience. According to the provided education, leaving the doors open was extremely dangerous. Staff was expected to frequently check all the doors on the hallways to ensure the hallway doors were properly closed and locked. The education indicated that disciplinary action would be taken if the doors were not secured. The 1/28/25 staff education participation record on reporting was provided by the NHA on 3/6/25 at 6:02 p.m. According to the education record, 71 staff members were informed/reminded to report changes, loss of balance (without a fall), falls, slips, trips, physical contact, choking, behaviors or any change of condition in a resident to the nurse. The education record documented it was the nurse's responsibility to document and assess once it was reported to the nurse. III. Staff interviewsThe DON was interviewed on 3/6/25 at 4:14 p.m. The DON said after a fall she conducted a fall investigation. She said during a fall investigation, she would look for any injuries/skin issues and review prior skin checks. She said if there were new injuries, she would look at the resident's environment to see if there was anything that the resident could have bumped into. The DON said staff documented the details of each fall in the risk management incident report and a fall occurrence note. She said she and the IDT reviewed who found the resident and at what time, how the resident was found, including the position of the resident, what the resident was wearing on their feet at the time of the fall, what was the lighting in the fall location, when was the resident last checked on and last toileted, was the resident continent at the time of the fall, was the resident wearing oxygen if they had a physician's order, was the call light in reach at the time of the fall, was it witnessed, was there a head injury and who was notified after the fall. The DON said Resident #2's fall on 11/29/24 was witnessed by a CNA. The resident was self transferring to a recliner in the living room. When Resident #2 was last checked on, she was continent. She was wearing non-skid shoes and the lighting was dim. The DON said the intervention was to continue to work with restorative nursing. She said Resident #2 started on a restorative nursing program on 12/13/24 after her November 2024 falls. The DON said the fall on 1/4/25 happened at the nurse's station. The resident landed on her left side of her body. The DON said the nurse was alerted when she heard a noise. The DON said it was not documented if Resident #2 was continent at the time of the fall, when she was last toileted or when she was last checked on. She said it was not documented what the resident was wearing on her feet at the time of the fall. The DON said the resident was able to say she was trying to go to the bathroom at the time of the fall. She said a bowel and bladder program was added to Resident #2's care plan and the CNA communication sheet/Kardex on 1/7/25. The DON said Resident #2's fall on 1/23/25 resulted in a hip fracture. She said the resident was found in the shower room lying on her right side. The DON said it was not documented what time the resident was last toileted other than it was on the night shift. She said the resident was last checked on at 7:40 a.m. She said she did not check if the resident was asked to use the toilet at 7:40 a.m. The DON said the resident normally needed assistance to use the toilet. She said she did not know who last checked on the resident before she fell. The DON said the resident was not able to say what happened or why she was in the shower/tub room but she assumed the resident was attempting to use the toilet because her pants were down and she was near the toilet. The DON said the door to the shower/tub room was propped open, allowing Resident #2 to enter the room. The DON said she did not know why the door was propped open and the light was on. The DON said the day staff said it was open when they arrived on shift. The DON said she questioned the night staff but no one could tell her why the door was left open. The DON said after reviewing the fall investigations, she felt she needed to ask more questions to get a better idea of all the fall details and what all happened. She said she saw areas where she could work on improving with her fall investigations. The NHA was interviewed again on 3/6/25 at 5:28 p.m. The NHA said Resident #2's fall on 1/23/25, which resulted in a hip fracture was because she self transferred herself to the toilet in the shower room. The NHA said Resident #2 used the toilet and then fell. The NHA said the door to the shower room should not have been left open for her to be able to enter. The NHA said the staff were educated to close and lock the doors. The NHA said falls were reviewed with the IDT and the new fall interventions were updated by the DON in the care plan within a week of the fall. CNA #4 was interviewed on 3/6/25 at 6:49 p.m. She said she worked with Resident #2 at night and would help other CNAs toilet her. She said she was not aware of a bowel and bladder toileting schedule for her, but she said Resident #2 was toileted every two hours, which was standard for any resident who needed assistance. The DON was interviewed again on 3/6/25 at 6:55 p.m. The DON said Resident #2 would try to get up and go to the bathroom by herself and not tell anyone. She said the care planned intervention bowel and bladder program for Resident #2 after her 1/4/25 fall meant she would be toileted every two hours. The DON said all residents were checked on every two hours.

A survey prompted by Incident #39322 was conducted 3/5/25-3/6/25. Three deficiencies were cited.

Based on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for one (#1) of two residents out of three sample residents. Specifically, the facility failed to timely report an injury of unknown origin for Resident #1 to the State Agency. Findings include: A. Facility policy and procedureThe Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, "All accidents or incidents involving residents, employees, visitors, vendors, occurring on premises shall be investigated and reported to the administrator."The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing services within 24 hours of the incident or accident."The Unusual Occurrence Reporting policy, revised December 2007, was provided by the NHA on 3/6/25 at 6:02 p.m. The policy read in pertinent part, "As required by the federal or state regulations, our facility reports unusual currencies or other reportable events which affect the health, safety, or welfare of residents, employees or visitors."According to the policy, unusual occurrences would be reported to the appropriate agencies as required by current law and or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event would be sent or delivered to the State Agency within 48 hours of reporting the event as required. The policy identified allegations of abuse, neglect and misappropriation of resident property and any other occurrences that interfered with facility operations and had effects on the welfare, safety, or health of residents, employees and visitors would be reported to the appropriate agency. B. Resident status Resident #1, age greater than 65, was admitted on 12/15/23 and discharged to the hospital on 12/29/24. According to the December 2024 computerized physician orders (CPO), diagnoses included unspecified osteoarthritis, edema, pain in the and left knee, history of falling, type 2 diabetes without complications, muscle weakness, acute embolism and thrombosis of unspecified deep vein of left lower extremity, unspecified dementia on specificity with psychotic disturbance, anxiety disorder and chronic pain syndrome. The 12/16/24 minimum data set (MDS) assessment documented Resident #1 had severe cognitive impairments per staff assessment for mental status and presented with long term and short term memory loss. The resident required partial to moderate assistance with most of her activities of daily living (ADL). She used a walker for mobility. According to the MDS assessment, Resident #1 had hallucinations and delusions. The MDS assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The MDS assessment did not identify the resident had a fall at the facility since her admission to the facility. C. Facility reported incidentThe State Agency reporting portal identified an allegation of neglect was reported for Resident #1 on 1/23/25, regarding an incident that occurred on 12/29/24.-The facility reported the incident to the State Agency 24 days after the reporting requirements. D. Record reviewReview of Resident #1's electronic medical record (EMR) revealed Resident #1's last known fall at the facility was on 2/8/24. The 12/26/24 skin assessments did not identify any skin concerns or injuries. The 12/29/24 health status note documented by licensed practical nurse (LPN) #1, identified a CNA attempted to move Resident #1 and she started to complain of severe pain. The CNA reported the pain to LPN #1. The resident cried out in pain when her hips were moved slightly. Resident #1 was diaphoretic, her oxygen saturation levels were at 55% and her blood sugar was at 340 milligrams/deciliter (mg/dl). According to the note, the resident's oxygen was set at 2 lpm (liters per minute) with a face mask. Her oxygen was increased to 3 lpm and her saturation levels rose to 77%. Resident #1 was full code and 911 was called. The note identified the resident in pain and cried out when paramedics transferred her from the bed to a gurney. The note identified Resident #1 was her own responsible party and she was aware she was going to the hospital. The note indicated the medical director (MD) was notified. The pain log identified Resident #1 last pain level check was on 12/29/24 at 12:10 a.m. The resident's documented pain level was at zero out of 10. The facility investigation summary was provided by the NHA on 3/4/25 at approximately 4:30 p.m. The summary identified the facility was notified that Resident #1 had right and left hip fractures. The hospital contacted registered nurse (RN) #1 on 12/29/24 and notified the RN of a bruise/hematoma on her left proximal thigh. The summary indicated the facility staff was asked about the bruise and none of the staff saw a bruise. -However, the facility failed to report the fractures, which were of unknown origin, until 1/23/25. The 12/29/24 hospital #1 emergency department physician note documented Resident #1 was in significant pain and a computed tomography (CT) scan identified bilateral fractures and an ortho-surgeon was contacted. The resident had a large left-sided proximal thigh hematoma with a suspicion of compartment syndrome. According to the note, Resident #1 was transferred to hospital #2 for higher level care. The 12/29/24 hospital #1 radiology report documented Resident #1 had intra-articular subcapital impacted right hip fracture, probably subacute and a subacute intertrochanteric left hip fracture, pathological fracture based on the CT scan. The resident had osteoarthritis, osteopenia and degenerative changes in the lower spine with multiple wedge deformitiesThe 12/29/24 hospital #2 emergency department (ED) records documented Resident #1 was transported to hospital #2 for multiple concerns including bilateral femur fractures. She was admitted to hospital #2 for possible surgical repair of her fractures. The ED notes identified Resident #1 was not able to move her hips due to the broken femurs. She had a left hip hematoma that was determined not to be compartment syndrome. She had T-spine fractures and sepsis related to a urinary tract infection (UTI). According to the notes the resident would have a right hemiarthroplasty (a half joint hip replacement procedure). The resident had a fracture of her left femur, right femur and a fracture of multiple thoracic vertebrae E. EducationThe 1/28/25 staff education participation record on reporting was provided by the NHA on 3/6/24 at 6:02 p.m. According to the 1/28/25 education record, 71 staff were informed/reminded to report changes, loss of balance (without a fall), falls slips, trips, physical contact, choking, behaviors or any change of condition in a resident to the nurse. The education record documented it was the nurse's responsibility to document and assess once it was reported to the nurse. F. Staff interviewsThe NHA was interviewed on 3/5/25 at 4:05 p.m. She said after the 12/29/24 incident with Resident #1, she started an investigation by reviewing the hallway video and interviewing staff. She said she did not save the interview notes and the video only saved for two weeks. She said she reported the injury of unknown origin late on 1/23/25 because she did not know it was reportable. Cross-reference F610, failure to thoroughly investigate an injury of unknown origin. The NHA said on 12/30/24 an ED nurse contacted the facility and asked about a bruise on Resident #1's left outer hip. The NHA said the staff did not see the bruise when she was assessed by the RN. She said she did not believe the bruise was caused at the facility. She said the bruise could have occurred at the hospital or when the paramedics put her on a gurney. The NHA said she did not believe Resident #1 could have fallen at the facility to break her hip because she would not have been able to pick herself off the floor with a broken hip and put herself back to bed. The director of nursing (DON) was interviewed on 3/5/25 at 5:45 p.m. The DON said LPN #1 notified her to inform her that Resident #1 was sent to the hospital because she was screaming in pain. The DON said the resident was diagnosed with fractures to both of her hips. The DON said she did not know how the fractures occurred when it was reported to her. LPN #1 was interviewed on 3/6/25 at 10:53 a.m. LPN #1 said Resident #1 was fine on the evening of 12/28/24. She said the resident had no reports of pain and she walked normally down to her room. She said the CNAs checked on her every two hours. She said when the staff went to get her up to get dressed, she started crying in pain. LPN #1 said she tried to get her up to see if she could bear weight but she could not stand. She said she assessed Resident #1 with range of motion and hip palpitations (touch). She said she was able to look at the resident's skin a little bit but did not see any concerns. LPN #1 was interviewed on 3/6/25 again at 11:06 a.m. She said she did not see a bruise on the resident's hip or leg but just remembered she saw a small lump on Resident #1's forehead about nickel-sized with some coloring to the skin. She said she did not think the lump was new because new bruising was usually bright purple. She said she did not document or report the lump on her forehead. The DON was interviewed on 3/6/25 at 4:14 p.m. The DON said unexplained injuries, such as what happened to Resident #1, should have been reported within 24 hours and it was not reported timely.

Based on record review and interviews, the facility failed to thoroughly investigate an allegation of abuse and neglect for one (#1) of one resident out of three sample residents. Specifically, the facility failed to complete a thorough investigation when Resident #1 sustained an injury of unknown origin. Findings include:I. Facility policy and procedureThe Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, "All accidents or incidents involving residents, employees, visitors, and vendors occurring on premises shall be investigated and reported to the administrator."The nurse supervisor/charge nurse and or the department director or supervisor shall promptly initiate a document investigation of the accident or incident."The policy identified the following data should be reported on a report of incident/accident form: "The date and the time the accident or incident took place; the nature of the injury/illness; the circumstances surrounding the accident or incident; where the accident or incident took place; the names of witnesses and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured persons attending physician was notified, as well as the time of the physician's response and his or her instructions; the date and time the injured person's family was notified and by whom; the condition of the injured person including his or her vital signs; the disposition of the injured; any corrective actions taken; follow up information; other pertinent data is necessary or required; and the signature and title the person completing the report. The policy identified the following steps that should be taken after the initial data was collected: "The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. "The director of nursing (DON) shall ensure that the administrator receives a copy of the incident/accident form on each occurrence."The incident/accident reports will be reviewed by the safety committee for trends related to the accident or safety hazards in the facility and to analyze any individual resident vulnerabilities."II. Resident #1 A. Resident statusResident #1, age greater than 65, was admitted on 12/15/23 and discharged to the hospital on 12/29/24. According to the December 2024 computerized physician orders (CPO), diagnoses included unspecified osteoarthritis, edema, pain in the left knee, history of falling, type 2 diabetes without complications, muscle weakness, acute embolism and thrombosis of unspecified deep vein of left lower extremity, unspecified dementia on specificity with psychotic disturbance, anxiety disorder and chronic pain syndrome. The 12/16/24 minimum data set (MDS) assessment documented Resident #1 had severe cognitive impairments, per staff assessment, for mental status and presented with long term and short term memory loss. The resident required partial to moderate assistance with most of her activities of daily living (ADL). She used a walker for mobility. The MDS assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The MDS assessment did not identify the resident had a fall at the facility since her admission to the facility. B. Facility investigation An investigation packet for Resident #1 was provided by the NHA on 3/4/25 at approximately 4:30 p.m. The packet included a summary of the events that occurred on 12/29/24, a police report, an emergency department physician report from hospital #1, a radiology report from hospital #1 and progress notes from the facility. The 12/29/24 summary of events documented on the night of 12/28/24, Resident #1 was sitting in the recliner in the common area, she was then toileted in the shower room by certified nursing assistant (CNA) #1 and CNA #2. The resident was then assisted to her room and to bed. The resident was sleeping and her brief was dry until 12/29/24 at 4:30 a.m. According to the summary, Resident #1 was incontinent of bowel, which was unusual for her, and she was soaking wet with sweat. The CNAs began to turn her on her side and she started to scream and scratch at them. The resident was diaphoretic (sweating) and licensed practical nurse (LPN) #1 was notified. LPN #1 assessed the resident and she hollered out when her hips were palpated (touched). The resident was hypoxic (low oxygen). The staff finished cleaning her up and the paramedics were called to transport the resident to the hospital. The summary identified the facility was notified that Resident #1 had right and left hip fractures. The hospital contacted registered nurse (RN) #1 on 12/29/24 and notified the RN of a bruise/hematoma on her left proximal thigh. The summary indicated the facility staff was asked about the bruise and none of the staff saw a bruise. The skin assessments on 12/5/24, 12/12/24, 12/19/24 and 12/26/24 did not identify a bruise. The 12/29/24 hospital #1 emergency department physician note documented Resident #1 was in significant pain and a computed tomography (CT) scan identified bilateral hip fractures and an orthopedic-surgeon was contacted. The resident had a large left-sided proximal thigh hematoma with a suspicion of compartment syndrome (build up of pressure in the body). According to the note, Resident #1 would be transferred to hospital #2 for higher level care. The 12/29/24 hospital #1 radiology report documented Resident #1 had an intra-articular subcapital impacted right hip fracture, probably subacute and a subacute intertrochanteric left hip fracture, pathological fracture based on the CT scan. The resident had osteoarthritis, osteopenia and degenerative changes in the lower spine with multiple wedge deformities. A 1/25/25 police report documented hospital #1 identified Resident #1 had hip and spinal fractures. The resident had both old and new fractures. According to the report, the medical team at hospital #2 was suspicious that Resident #1 went to bed and woke up with hip fractures without a fall. The report identified the resident's hospice nurse reported Resident #1 passed away on 1/23/25. The report documented the hospice nurse felt the injuries were suspicious because no one knew what happened to cause the injuries. A 1/30/25 police report documented the coroners office was contacted on 1/28/25 and Resident #1's death was ruled an accident. According to the police report, the coroner felt there were no signs of a fall. The fractures to her bones were from use and not injury.-The review of the provided facility investigation did not include staff or resident interviews after the 12/29/24 incident. C. Record reviewReview of Resident #1's electronic medical record (EMR) revealed Resident #1's last known fall at the facility was on 2/8/24. The 12/29/24 health status note documented by licensed practical nurse (LPN) #1, identified a CNA attempted to move Resident #1 and she started to complain of severe pain. The CNA reported the pain to LPN #1. The resident cried out in pain when her hips were moved slightly. Resident #1 was diaphoretic, her oxygen saturation levels were at 55% and her blood sugar was at 340 milligrams/deciliter (mg/dl). According to the note, the resident's oxygen was set at 2 lpm (liters per minute) and was applied with a face mask. Her oxygen was increased to 3 lpm and her saturation levels rose to 77%. Resident #1 was a full code and 911 was called. The note identified the resident was in pain and cried out when paramedics transferred her from the bed to the gurney. The note identified Resident #1 was her own responsible party and she was aware she was going to the hospital. The note indicated the medical director (MD) was notified. The pain log identified Resident #1 last pain level check was on 12/29/24 at 12:10 a.m. The resident's documented pain level was at zero out of 10. The 12/29/24 hospital #2 emergency department (ED) notes documented Resident #1 was transported to hospital #2 for multiple concerns, including bilateral femur fractures. She was admitted to hospital #2 for possible surgical repair of her (femur) fractures. The ED notes identified Resident #1 was not able to move her hips due to the broken femurs. She had a left hip hematoma that was determined not to be compartment syndrome. She had T-spine (thoracic spine) fractures and sepsis (infection of the blood) related to a urinary tract infection (UTI). According to the notes, the resident would have a right hemiarthroplasty (a half joint hip replacement procedure). The resident had a fracture of her left and right femur and multiple thoracic vertebrae fractures. According to the ED notes, the fractures were chronic, identifying the bone fractures were not healed properly. IV. Staff interviewsThe NHA was interviewed on 3/5/25 at 4:05 p.m. The NHA said after the 12/29/24 incident with Resident #1, she started an investigation by reviewing the hallway video and interviewing staff. She said she did not save the interview notes and the video only saved for two weeks. The NHA said on 12/30/24, the video surveillance revealed the resident was assisted back to her room by CNA #1 and CNA #2 between 6:15 p.m. and 6:30 p.m. Resident #1 did not have visitors or other residents enter her room after she went to bed. She said the resident reported pain while laying in bed when the staff tried to change her on the overnight shift. LPN #1 assessed the resident and sent her to the ED related to pain with movement and low oxygen saturation levels. The NHA said an ED nurse contacted the facility and asked about a bruise on the resident's left outer hip. The NHA said the staff did not see the bruise when she was assessed by LPN #1. She said she did not believe the bruise was caused at the facility. She said the bruise could have occurred at the hospital or when the paramedics put her on a gurney. The NHA said she did not believe Resident #1 fell at the facility to break her hip because she would not have been able to get off of the floor with a broken hip and put herself back to bed. The director of nursing (DON) was interviewed on 3/5/25 at 5:45 p.m. The DON said LPN #1 notified her to inform her that Resident #1 was sent to the hospital because she was screaming in pain. The resident was diagnosed with fractures to both of her hips. The DON said CNA #1 and CNA #2 were her CNAs at the time of the incident. CNA #2 was shadowing CNA #1 at the time because she only worked periodically and needed to learn the residents on the hall. The DON said she was told by the staff that Resident #1 had no indications of pain or concerns the day before the incident. She said the resident mostly sat in the lounge in the living room all day and told jokes. The DON said she interviewed all the day shift staff. She said she did not remember when Resident #1 was last toileted or if she had asked staff when the resident was last toileted. She said she hand wrote all her notes and had given them to the NHA. She said in the report, it was noted the resident was toileted every two hours, so she would have been checked on every two hours. Resident #1 was dry the last time they checked on her before the incident. The DON said Resident #1 would usually take her own brief off and throw it on the floor if it was wet. She said the next time she was checked on, she had a bowel movement. The DON said staff tried to change the resident but that was when she started to scream in severe pain. She said the resident's vital signs were taken and Resident #1's blood sugar level was 340 mg/dl, which was high for her. She said her oxygen saturation levels were at 55%,which could be life threatening. Resident #1 did not normally need to wear oxygen. She said LPN #1 placed 3 liters per minute (lpm) of oxygen via nasal cannula on the resident and her saturation levels went up to 77%. The DON said by the time the paramedics arrived, she was at 80%. The DON said the resident went to the ED around 4:45 a.m. on 12/29/24. She said the physician was contacted and he gave consent for the surgery. The DON said the police were contacted because adult protective services (APS) was notified of the incident. She said a son the facility was not aware of was also asking questions about the incident. CNA #3 was interviewed on 3/5/25 at 6:05 p.m. CNA #3 said she was working on a different hall than Resident #1 resided on, on the night of 12/29/24. She said CNA #1 told her she was checking on Resident #1's roommate when she identified a bowel movement odor from Resident #1 which was not normal because Resident #1 would take herself to the bathroom when she needed to use the toilet and she would also change her own brief if it was soiled. CNA #3 said CNA #1 asked her for her assistance because she was not able to get Resident #1 up from the bed. CNA #3 said CNA #1, CNA #2 and RN #1 were already with the resident and trying to change her when she entered Resident #1's room. She said the resident would moan when they tried to turn her, but she was not yelling. CNA #3 said the biggest concern she saw was the resident was sweating profusely and was very out of breath. She said Resident #1 was not screaming out when they rolled her to change her brief. She said the resident just got very tense when she was moved. CNA #3 said Resident #1 was normally able to talk and say what she needed. CNA #3 said the NHA asked her some questions a week after the incident. She said after the resident was taken to the hospital, the four of them (CNA #1, CNA #2, LPN #1 and CNA #3) just spoke to each other about what happened. CNA #3 said Resident #1 took herself to bed that night.-However, according to the facility's 12/29/24 summary of events (see above), Resident #1 was toileted in the shower room by CNA #1 and CNA #2 and then assisted to her room and to bed on the evening of 12/28/24. The NHA was interviewed on 3/5/25 at 6:44 p.m. The NHA said CNA #1 had her competency training completed to include transfer training on 11/21/24. The NHA said CNA #2 did not have her competencies completed because she worked at the facility sporadically. CNA #1 was interviewed on 3/6/25 at 10:22 a.m. CNA #1 said Resident #1 took herself to the bathroom but she would sometimes need reminders. She said on the evening of 12/28/24 she walked Resident #1 to her room to go to bed. She said she noticed it took Resident #1 a little longer to walk than usual. She said the resident complained of some leg and hip pain. CNA #1 said Resident #1 was toileted around 8:00 p.m. She said at 10:00 p.m., she checked on her and reminded her to try to go to sleep. She said on 12/29/24 at 12:00 a.m. Resident #1 was sound asleep and her brief was dry. She said at 2:00 a.m the resident was making some noise so the CNAs encouraged her to get up to use the bathroom. CNA #1 said on 12/29/24 at 4:00 a.m. she entered the room to check on Resident #1's roommate and noticed Resident #1 needed to be changed. She said CNA #2 tried to move Resident #1's legs so she could to get up to use the bathroom but the resident screamed, which was not normal for Resident #1, so she went to get LPN #1. CNA #1 said she tried to swing the resident's legs off the bed and tried to stand her but she was dead weight so they laid her back down. She said Resident #1 started screaming again when they changed her brief in bed. She said the resident was drenched in sweat and her oxygen saturation levels were low. She said CNA #3 brought in the oxygen and a second nurse, LPN #2 also came in to the room to help them with Resident #1. CNA #1 said she gave a verbal report of what happened to the NHA on the 12/29/24 night shift. She said she asked LPN #1 if there were any bruises she saw and she said no. CNA #1 said the staff was in shock because they never had seen Resident #1 in that condition. LPN #1 was interviewed on 3/6/25 at 10:53 a.m. LPN #1 said Resident #1 was fine on the evening of 12/28/24. LPN #1 said there were no reports of pain and she walked normally down to her room. She said the CNAs checked on her every two hours. She said when the staff went to get her up to get dressed, she started crying in pain. LPN #1 said she tried to get her up to see if she could bear weight but she could not stand. She said she assessed Resident #1 with range of motion and hip palpitations. She said she was able to look at the resident's skin a little bit but did not see any concerns. LPN #1 was interviewed again on 3/6/25 at 11:06 a.m. She said she did not see a bruise on her hip or leg but just remembered she saw a small lump on Resident #1's forehead that was about the size of a nickel with some bruise that was similar in coloring to her skin. She said she did not think the lump was new because a new bruise was usually bright purple. She said she did not document the lump on her forehead. RN #1 was interviewed on 3/6/25 at 1:42 p.m. She said the hospital ED called her and asked about a bruise on Resident #1 but she said she did not know anything about a bruise. She said she asked LPN #1 about the bruise and if anything happened before Resident #1 was sent to the hospital. RN #1 said nothing happened to cause the injuries that she was aware of. RN #1 said all the staff were surprised that Resident #1 had fractures and a bruise. RN #1 said Resident #1 would spend most of the day in a recliner in the living room or walk to her room or shower room to use the bathroom. She said no staff or residents reported any concerns to her. The NHA was interviewed again on 3/6/25 at 1:58 p.m. The NHA said she still thought Resident #1 did not fall and she ruled out abuse, because she watched the hall surveillance video and talked to staff. She said she did not interview other residents. Medical director (MD) #1 was interviewed on 3/6/25 at 3:47 p.m. MD #1 said the staff notified him that Resident #1 was sent to the hospital because she was in pain. MD #1 said the ED determined Resident #1 had bilateral hip fractures. MD #1 said he did not recall if Resident #1 had bruising along with the fractures but with that type of her injury, he would not be surprised if she had bruising. He said if one of the fractures was identified as a subacute fracture, it could indicate a fracture was potentially in the healing process. He said fractures could have easily occurred at Resident #1's age. The DON was interviewed on 3/6/25 at 4:14 p.m. The DON said she learned of the bruise on Resident #1's leg on the following morning (12/29/24) after the ED contacted the facility. She said she did not know which leg the bruise was found on or the size of the bruise. She said she was not aware of a lump on Resident #1's head or any other incidents that would have caused a lump on her head. The DON said she and the interdisciplinary (IDT) reviewed a resident when they sustained a change of condition, such as weight loss, falls and skin concerns. The DON said she did not conduct a fall investigation after Resident #1's 12/29/24 incident. She said she did not feel Resident #1 fell but she did not know what happened to cause the injuries. She said she did not think Resident #1 could have fallen because she was found in bed and did not think she would have been able to get up and in bed after a fall. She said she did not know how or when the resident acquired the bruise. She said normally when there was a bruise of unknown origin, she would conduct an investigation. She said for bruise investigations she would look how the resident transferred, check if the resident was on blood thinners, look at furniture or equipment that could have caused the bruise and check past skin assessments. The DON said the staff were good about documenting and they did not see or document a bruise for Resident #1 before she was sent to the hospital so she was not aware of the bruise to the leg until the ED notified the facility. She said she did not conduct a bruise of unknown origin investigation after she was notified of the bruise on her thigh from the ED. The DON said a bruise may not always show up right away after a resident was injured. She said that was why they continued to monitor the resident and check for skin injuries 24 hours after a fall. The DON said she was not aware of a nickel-sized lump on Resident #1's forehead. She said nothing was reported to her or documented. The DON said she reviewed skin assessments prior to 12/29/24 and nothing indicated that the resident had a lump on her head or bruising. She said Resident #1 was sent out to the hospital because of pain, not because of an unknown injury. She said she needed to get more details about the incident by asking more questions and making sure staff documented any skin related concerns. The DON said the resident had weak bones and the fractures could have happened before 12/29/24, according to a coroner report conducted in January 2025. The NHA was interviewed a third time on 3/6/25 at 5:28 p.m. She said a fall investigation was not done after Resident #1's 1/23/25 incident because the facility did not feel there was a fall. She said a bruise of unknown origin was not investigated because the staff did not see the bruise and felt it did not happen at the facility. She said she checked to see if the resident was on blood thinners but she was not. She said she did not do a full abuse investigation because there was no indication of abuse. The NHA said she never figured out why the resident had an oxygen saturation level of 55% because she did not have respiratory problems. The NHA said she was not aware of Resident #1's lump on her forehead with slight coloring until the LPN #1 contacted her today (3/6/25). She said she would have conducted a fall investigation to see what had happened if she would have known about the lump on the forehead earlier. She said the lump could have been caused by a fall, however, she still felt Resident #1 did not fall. She said nothing was documented about the lump on her head. The NHA said a staff education regarding falls was conducted on 1/28/25 and 1/29/25, just in case Resident #1 injuries were a result of an undocumented fall that was not reported.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#2) of three residents reviewed for accidents out of three sample residents. Resident #2 admitted to the facility on 11/20/24 with a history of falls. Resident #2 sustained a fall on 11/21/24, 11/29/24, 1/4/25 and 1/23/25. After the resident sustained falls, the facility failed to implement timely interventions. On 1/23/25 the resident attempted to self transfer in the shower room where she fell and sustained a hip fracture. Review of Resident #1's electronic medical record (EMR) identified the facility failed to implement timely and effective interventions and ensure environmental hazards did not contribute to Resident #1's falls. Findings include:I. Facility policy and procedureThe Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, "All accidents or incidents involving residents, employees, visitors, vendors, occurring on premises shall be investigated and reported to the administrator. The policy identified the following steps that should be taken after the initial data was collected: "The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing (DON) services within 24 hours of the incident or accident. "The DON shall ensure that the administrator receives a copy of the incident/accident form on each occurrence."The incident/accident reports will be reviewed by the safety committee for trends related to the accident or safety hazards in the facility and to analyze any individual resident vulnerabilities."II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 11/20/24. According to the March 2025 computerized physician's orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia, history of falling, generalized muscle weakness, abnormalities of the gate and mobility, need for assistance with personal care, cognitive communication deficit, difficulty walking and unspecified dementia, severe, without behavioral disturbance. The 2/19/25 minimum data set (MDS) assessment documented Resident #2 had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. Resident #2 required substantial/maximal assistance from a sit to stand position and was dependent on staff for a toilet transfer. She used a wheelchair for mobility. The MDS assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The MDS assessment identified Resident #2 had a history of falls. According to the MDS assessment, Resident #2 had two falls without injury and one fall with a major injury since her admission or in the past six months and one fall without injury since her last assessment. B. Record reviewThe fall care plan, initiated 11/20/24 and revised 12/10/24, identified Resident #2 was at risk for falls related to bladder and/or bowel incontinence, generalized weakness, history of falls and needing assistance with activities of daily (ADL). The fall interventions, initiated on 11/20/24, directed staff to implement preventative fall interventions/devices, ensure call light was in reach and needed items were within reach, educate the resident how to use the call light and monitor her for changes in mobility. The fall interventions, initiated on 12/10/24, directed staff to provide Resident #2 with non-skid footwear, conduct physical therapy (PT)/occupational therapy (OT) and speech therapy evaluations, educate the resident and her family to call for assistance before transferring and provide food and drinks within reach. The fall interventions, initiated on 12/12/24, indicated Resident #2 was impulsive, over estimated her abilities and needed to be kept within line of sight. The 12/12/24 fall intervention directed staff to place her in a recliner. The 12/12/24 fall intervention, revised on 1/22/25, directed staff to place anti-roll backs on her wheelchair. The fall intervention, initiated on 1/7/25, identified Resident #2 was placed on a toileting program.-The facility failed to implement timely interventions after Resident #2 sustained a fall on 11/21/24, 11/29/24 and 1/23/25.1. Fall on 11/21/24 - unwitnessedThe fall occurrence note, dated 11/21/24, identified Resident #2 was found on the floor in her room by a certified nurse aide (CNA). According to the note, Resident #2 was found on her back between the foot of the bed and the bathroom. The resident was toileted and brought to the nurse's station to keep within sight. The note documented the nurse completed a physical assessment to include range of motion. The resident was not able to move her right arm related to the presence of a right arm sling after a fall prior to her admission. The note documented the resident had a bump on the crown of her head but it was not known if the bump occurred at the time of the 11/21/24 fall or if the resident had the bump prior to her admission to the facility (11/20/24) from a fall at home. The note indicated the resident was not able to tell staff what happened other than she fell. Factors of the fall were identified as poor lighting and confusion. The 11/26/24 interdisciplinary team (IDT) meeting note identified Resident #2 was last toileted at 4:00 a.m. and checked at 4:45 a.m. The call light was in reach, her bed was in a low position, her wall light was on, she was incontinent at the time of the fall and was wearing socks. According to the note, the resident complained of shoulder and head pain. No other injuries were noted at the time of the incident. The nursing recommendation was to place the resident in a recliner in the line of sight.-The note did not identify if the socks the resident was wearing were non-skid or not. -The IDT note did not identify if the bump on her head occurred at the time of the 11/21/24 fall or if she had the bump from her last fall at home.-The review of the care plan did not identify new interventions were updated on the fall care plan until 12/12/24, three weeks after the 11/21/24 fall. 2. Fall on 11/29/24 - witnessedThe 11/29/24 fall occurrence note identified Resident #2 had a fall. According to the note, a CNA observed Resident #2 attempting to transfer herself from her wheelchair to the recliner in the living room and she sat on the floor between two recliners. The resident had non-slip shoes on and her wheelchair was in front of her. The note indicated there were no injuries and she was placed in a recliner near the nurse's station. -The fall occurrence note identified Resident #2 was not placed in a recliner by staff as recommended in the 11/21/24 IDT note. The 12/3/24 IDT meeting note identified the recommendation after the fall was to implement a restorative program.-The restorative program for Resident #1 was not implemented until 12/13/24, two weeks after the fall (see interview below).-The review of the care plan did not identify that the restorative program was implemented as recommended on 12/3/24 by the IDT. 3. Fall on 1/4/25 - witnessedThe 1/4/25 fall occurrence note identified Resident #2 was observed sliding from the recliner, down to the floor before staff could intervene. There were no injuries identified. According to the note, the resident stated she was going to the restroom. The 1/7/25 IDT note documented a video surveillance recording identified Resident #2 scooted herself over the edge of the recliner, walked around the foot rest, lost her balance and landed on her buttocks on the recliner foot rest which caused the recliner to tip forward. The resident slid down the foot rest and landed on the left side ofher body. According to the note, there were no injuries and she denied any new or increased pain. The note indicated the resident did not ask to go to the restroom or was able to remember to ask for help. The nursing recommendations were to place the resident on a bowel and bladder toileting program. 4. Fall on 1/23/25 - unwitnessedThe 1/23/25 fall occurrence note identified Resident #2 was found in a shower room on the floor at 7:45 a.m. The shower room door was propped open by a stool and unlocked. Resident #2 was laying on the floor on her right side with her pants pulled down below her knees. Her wheelchair was to the left of the resident and the brakes were unlocked. She was wearing non-slip shoes at the time of the fall. According to the note, during the nurse's physical assessment, the resident grabbed her right lower extremity in pain. Resident #2 had redness and light colored bruising to her right hip and a skin tear measuring 3 centimeters (cm) by 3 cm on her right knee. The note indicated the resident was sent to the hospital for an evaluation and treatment. The note documented the resident was last checked on at 7:40 a.m. Resident #2 was forgetful and overestimated her limitations. The bathing rooms were immediately locked. The 1/23/25 change in condition note identified Resident #2 returned to the facility with a diagnosis of a right femoral head fracture. Her family declined surgery. The note indicated the resident was on comfort-focused care. The note indicated the resident was attempting to crawl out of bed after returning from the hospital. The resident was placed in a recliner in view of the nurse's station due to her high fall risk. The 1/28/25 IDT meeting note identified staff were educated to keep doors locked for safety concerns as the nursing recommendation. -The fall care plan did not identify new care plan interventions were added after Resident #2 had another fall during a self-transfer that resulted in a broken hip (see care plan above). C. EducationThe 1/23/25 staff education sheet was provided by the NHA on 3/6/25 at 6:17 p.m. The education sheet identified 75 staff members were educated to keep all of the doors in the hallways locked, except for the resident's rooms. It indicated doors could not be propped open or left unlocked for staff convenience. According to the provided education, leaving the doors open was extremely dangerous. Staff was expected to frequently check all the doors on the hallways to ensure the hallway doors were properly closed and locked. The education indicated that disciplinary action would be taken if the doors were not secured. The 1/28/25 staff education participation record on reporting was provided by the NHA on 3/6/25 at 6:02 p.m. According to the education record, 71 staff members were informed/reminded to report changes, loss of balance (without a fall), falls, slips, trips, physical contact, choking, behaviors or any change of condition in a resident to the nurse. The education record documented it was the nurse's responsibility to document and assess once it was reported to the nurse. III. Staff interviewsThe DON was interviewed on 3/6/25 at 4:14 p.m. The DON said after a fall she conducted a fall investigation. She said during a fall investigation, she would look for any injuries/skin issues and review prior skin checks. She said if there were new injuries, she would look at the resident's environment to see if there was anything that the resident could have bumped into. The DON said staff documented the details of each fall in the risk management incident report and a fall occurrence note. She said she and the IDT reviewed who found the resident and at what time, how the resident was found, including the position of the resident, what the resident was wearing on their feet at the time of the fall, what was the lighting in the fall location, when was the resident last checked on and last toileted, was the resident continent at the time of the fall, was the residentwearing oxygen if they had a physician's order, was the call light in reach at the time of the fall, was it witnessed, was there a head injury and who was notified after the fall. The DON said Resident #2's fall on 11/29/24 was witnessed by a CNA. The resident was self transferring to a recliner in the living room. When Resident #2 was last checked on, she was continent. She was wearing non-skid shoes and the lighting was dim. The DON said the intervention was to continue to work with restorative nursing. She said Resident #2 started on a restorative nursing program on 12/13/24 after her November 2024 falls. The DON said the fall on 1/4/25 happened at the nurse's station. The resident landed on her left side of her body. The DON said the nurse was alerted when she heard a noise. The DON said it was not documented if Resident #2 was continent at the time of the fall, when she was last toileted or when she was last checked on. She said it was not documented what the resident was wearing on her feet at the time of the fall. The DON said the resident was able to say she was trying to go to the bathroom at the time of the fall. She said a bowel and bladder program was added to Resident #2's care plan and the CNA communication sheet/Kardex on 1/7/25. The DON said Resident #2's fall on 1/23/25 resulted in a hip fracture. She said the resident was found in the shower room lying on her right side. The DON said it was not documented what time the resident was last toileted other than it was on the night shift. She said the resident was last checked on at 7:40 a.m. She said she did not check if the resident was asked to use the toilet at 7:40 a.m. The DON said the resident normally needed assistance to use the toilet. She said she did not know who last checked on the resident before she fell. The DON said the resident was not able to say what happened or why she was in the shower/tub room but she assumed the resident was attempting to use the toilet because her pants were down and she was near the toilet. The DON said the door to the shower/tub room was propped open, allowing Resident #2 to enter the room. The DON said she did not know why the door was propped open and the light was on. The DON said the day staff said it was open when they arrived on shift. The DON said she questioned the night staff but no one could tell her why the door was left open. The DON said after reviewing the fall investigations, she felt she needed to ask more questions to get a better idea of all the fall details and what all happened. She said she saw areas where she could work on improving with her fall investigations. The NHA was interviewed again on 3/6/25 at 5:28 p.m. The NHA said Resident #2's fall on 1/23/25, which resulted in a hip fracture was because she self transferred herself to the toilet in the shower room. The NHA said Resident #2 used the toilet and then fell. The NHA said the door to the shower room should not have been left open for her to be able to enter. The NHA said the staff were educated to close and lock the doors. The NHA said falls were reviewed with the IDT and the new fall interventions were updated by the DON in the care plan within a week of the fall. CNA #4 was interviewed on 3/6/25 at 6:49 p.m. She said she worked with Resident #2 at night and would help other CNAs toilet her. She said she was not aware of a bowel and bladder toileting schedule for her, but she said Resident #2 was toileted every two hours, which was standard for any resident who needed assistance. The DON was interviewed again on 3/6/25 at 6:55 p.m. The DON said Resident #2 would try to get up and go to the bathroom by herself and not tell anyone. She said the care planned intervention bowel and bladder program for Resident #2 after her 1/4/25 fall meant she would be toileted every two hours. The DON said all residents were checked on every two hours.

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

A revisit survey was completed on 7/2/24 for all previous deficiencies cited on 5/9/24. The facility is in compliance with all regulations surveyed.