Based on record review and interview, the facility failed to ensure an initial facility reported incident regarding an allegation of abuse was sent within two hours to the state agency for 3 (#1, 2, and #4) of 6 sampled residents reviewed for abuse. The BOM identified 78 residents resided in the facility. Findings: An abuse, neglect, exploitation or misappropriation policy, revised 04/2021, read in part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management.If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.Immediately is defined as .within two hours of an allegation involving abuse. An admission resident assessment, dated 06/04/25, showed Resident #2's cognition was intact (BIMS 15). The assessment showed the resident exhibited verbal behavioral symptoms directed toward others that significantly disrupted care or the living environment. The assessment showed the resident required supervision or touching assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfer. An annual resident assessment, dated 06/16/25, showed Resident #1's cognitive skills for daily decision making were severely impaired per staff assessment for mental status. The assessment showed the resident required substantial/maximum assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff for chair to bed transfers. A quarterly resident assessment, dated 06/29/25, showed Resident #4's cognition was severely impaired (BIMS 04). The assessment showed the resident was independent for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. A nurse progress note, dated 07/25/25 at 3:30 a.m., showed at approximately 3:25 a.m. RN #1 was alerted by another resident (Resident #4) to a situation occurring in their room. Upon entering the room, RN #1 observed concerning behavior between (Resident #1 and Resident #2). RN #1 instructed Resident #2 to stop and leave the area. A CNA (CNA #1) was directed to supervise and escort Resident #2 out of the room while RN #1 contacted the DON for further guidance. The note showed Resident #1 was briefly assessed with no visible injuries noted at the time. The note showed Resident #2 was placed on 1:1 supervision for close monitoring. The note showed the provider on call and facility administration were notified and appropriate reporting procedures were initiated per protocol. An initial facility reported incident, dated 07/25/25, showed the DON and administrator were notified Resident #2 was in Resident #1's room. The reported incident showed the residents were immediately separated and Resident #2 left the property. The reported incident showed Resident #1 was sent to the emergency room for precautionary evaluation. The reported incident showed the police, family, physician, resident's legal representative, and APS were notified. The initial report was received by the state agency on 07/25/25 at 7:14 a.m. Resident #1's hospital records, dated 07/25/25, showed final diagnoses of sexual assault of adult, initial encounter. The hospital records showed a staff member had gone into Resident #1's room on 07/25/25 and found another resident (Resident #2) vaginally penetrating Resident #1. The hospital records showed Resident #1 was nonverbal. The hospital records showed Resident #1 had diagnoses which included anxiety, brain tumor, dementia with behavioral disturbance, and traumatic brain injury. On 07/30/25 at 10:34 a.m., Resident #4 stated they reported, [Resident #2's] laying on top of [Resident #1]. Resident #4 stated when they saw the two residents, Resident #2 told Resident #4 to shut the door, so they did. Resident #4 stated Resident #1 had to be sexually assaulted because [Resident #2] was on top of [Resident #1]. On 07/30/25 at 2:33 p.m., family member #4 stated the first call they received from the facility was on 07/25/25 at 5:57 a.m. Family member #4 stated the regional director of operations informed family member #4 Resident #1 had been sexually assaulted. Family member #4 stated no details were provided from the facility at the time. Family member #4 stated the next call they received was from the hospital to obtain consent for a rape kit. On 07/30/25 at 4:41 p.m., an attempt was made to call and speak with RN #1. RN #1's phone was not accepting calls at the time and did not return the state agency's call. On 07/31/25 at 12:00 a.m., CNA #1 stated if they saw any abuse or neglect, they would report it. They stated they would reach out to the administrator. On 07/31/25 at 12:01 a.m., CNA #1 stated they believed the administrator and DON were responsible for investigating abuse. On 07/31/25 at 12:16 a.m., CNA #1 stated they had gone down to Resident #4's room to get clothes for the resident to put on 07/25/25. They stated when they walked in the room they saw Resident #2 in Resident #1's bed. They stated Resident #1 was in the bed too. They stated no one else was in the room at the time. They stated it had to be around 3:00 a.m. to 3:30 a.m. CNA #1 stated Resident #1's brief was ripped off and their gown was off. They stated Resident #2 was in the bed with their shorts pulled down to their knees. CNA #1 reported saying What are you doing? CNA #1 reported saying Did you just rape [Resident #1]? CNA #1 stated Resident #2 said, No, [Resident #1] invited me in. CNA #1 told Resident #2 that Resident #1 could not have invited them in the room because the resident was unable to speak like that. CNA #1 stated, You need to get out of her bed. CNA #1 stated they were so upset when they saw what happened. They stated they observed a wet towel next to Resident #1 in the bed. They stated Resident #2 was prepared to wipe themselves off afterwards. CNA #1 stated there was nothing in the bed besides the blankets and the resident when they previously left Resident #1's room after providing care. On 07/31/25 at 12:21 a.m., CNA #1 stated Resident #2 started to get out of Resident #1's bed and sat in their wheelchair. They stated Resident #2 transferred themselves to their electric wheelchair and started rubbing Resident #1's leg saying, I saw your [family member] at the store. CNA #1 told Resident #2 You don't even know [Resident #1's] family. CNA #1 told Resident #2 stop rubbing on [Resident #1's] leg. CNA #1 stated if they did not take Resident #2 to jail, they were not going to work for the facility anymore. They stated, I'm not working at a place that allows someone to rape a resident. CNA #1 stated after Resident #2 left the room, CNA #1 proceeded to get clothes and dress Resident #4. They stated Resident #4 stated [Resident #2] had told [them] when [they] walked out the room to close the door. CNA #1 stated that was the point when police, the DON, and everyone came to the facility. On 07/31/25 at 12:45 a.m., LPN #1 stated if abuse was observed or reported to them, they were to report it immediately. They stated they would call the abuse hotline number and call the administrator right away. On 07/31/25 at 12:46 a.m., LPN #1 stated the administrator was responsible for investigating abuse. On 07/31/25 at 12:47 a.m., LPN #1 stated Resident #1 did not talk. They stated the resident speaks very minimal words. On 07/31/25 at 12:49 a.m., LPN #1 stated Resident #1 was unable to make decisions on their own. LPN #1 stated they did not witness anything regarding the abuse allegation on 07/25/25 for Resident #1 and #2. LPN #1 stated they saw Resident #4 speaking to RN #1 on the night shift that morning. They stated Resident #4 was wearing a Sleep jacket with no other clothes on. They stated they did not know the reason Resident #4 was talking to RN #1 that day, but LPN #1 had Resident #4 sit in the television room on hall 300 and instructed CNA #1 to get the resident dressed. On 07/31/25 at 12:52 a.m., LPN #1 stated RN #1 came to them and said they had CNA #1 in Resident #1's room (who shares a room with Resident #4) and reported [Resident #2] was in [Resident #1's] room. They stated RN #1 had to call the DON because they saw Resident #2 in the room with Resident #1. They stated RN #1 was visibly upset saying [Explicit], [explicit] and banging on the nurses' station. LPN #1 stated they later saw the DON fly in the facility with the police. On 07/31/25 at 12:57 a.m., LPN #1 stated they asked what was going on and RN #1 said Resident #2 was in bed with Resident #1. On 07/31/25 at 12:58 a.m., LPN #1 stated the ADON, the DON, the administrator, and the cops came to the facility. LPN #1 stated they started interviewing RN #1 with the door closed. On 07/31/25 at 5:50 a.m., the DON stated if staff reported abuse, they would investigate it. They stated they would send a report to the state agency, APS, notify police, complete an investigation, and have it finalized in five days. They stated the initial reporting for abuse had to be completed within two hours. They stated the timeline for reported a criminal act was also two hours. On 07/31/25 at 5:52 a.m., the DON stated the administrator and DON were responsible for investigating abuse. On 07/31/25 at 6:02 a.m., the DON stated they had received a call from RN #1 on 07/25/25 around 3:40 to 3:45 a.m. who reported Resident #2 was found in Resident #1's room and both residents' clothes were off. The DON instructed RN #1 to separate the residents, monitor them, put Resident #2 on 1:1, and call the police. On 07/31/25 at 6:04 a.m., the DON stated they were who called the police because when they were in route to the facility, RN #1 still had not called the police. They stated RN #1 was instructed to call EMSA. The DON stated they pulled up to the facility at the same time the police arrived. They stated the police informed them it was a crime scene and they could not touch anything. They stated law enforcement took all of the bedding and the gown Resident #1 was wearing. They stated Resident #1 was sent to the hospital for a SANE rape kit. The DON stated Resident #1 received a prophylactic antibiotic for STDs at the hospital. On 07/31/25 at 6:07 a.m., the DON stated the facility was able to review video footage and identified Resident #2 entered Resident #1's room at 2:49 a.m. and Resident #4 came out of the room and told CNA #1 there was a person (Resident #2) in their room who got RN #1. They stated at 3:09 a.m., RN #1 entered Resident #1's room and saw Resident #2 with their pants down. They stated RN #1 called them at 3:34 a.m. because that was when they could no longer see them on the video footage. On 07/31/25 at 6:15 a.m., the DON stated once they arrived to the facility, they started the investigation. The DON reviewed the initial state reportable sent on 07/25/25 at 7:14 a.m. and stated they thought it was sent before then.On 07/31/25 at 8:22 a.m., the COO was identified as the person who would answer questions for the administrator who was on vacation. The COO stated the facility operated on state and federal regulations and met the abuse and neglect training requirements for new hires as well as ongoing education throughout the year. On 07/31/25 at 8:24 a.m., the COO stated the facility abuse and neglect policy met the state and federal guidelines. On 07/31/25 at 8:25 a.m., the COO stated they could not tell the surveyor what they did if they witnessed abuse or neglect because they had not witnessed it and it would be speculation. They stated they could tell the surveyor speculation was they would protect the residents. They stated if it was reported to them, they would need to follow state and federal regulation and follow policy and regulation. On 07/31/25 at 8:26 a.m., the COO stated the administrator was the abuse coordinator and responsible for investigating abuse. They stated in their absence, the DON, COO or regional nursing staff would be responsible. On 07/31/25 at 8:33 a.m., the COO stated they received a call there was an incident between Resident #1 and Resident #2 on 07/25/25. They stated by the time the COO was notified, the administration, DON, and leadership were aware and the police were on site. They stated they were aware one resident was detained by police, and one resident was sent to the hospital for evaluation. They stated at the time of the initial call they did not know the reason for the detainment. On 07/31/25 at 8:34 a.m., the COO stated they had seen online Resident #2 had been charged for first degree rape after further investigation on Friday (07/25/25) because those details began to come to light pretty quickly. On 07/31/25 at 8:57 a.m., the COO stated the facility had a two-hour timeline to submit the initial allegation of abuse to the state agency. They stated the initial report to the state agency for a criminal act was two hours. The COO stated the first note from RN #1 regarding this incident of abuse was dated 07/25/25 at 3:30 a.m. The COO stated 07/25/25 at 7:14 a.m. was when the state agency received the initial allegation of abuse.

Based on observation, record review, and interview, the facility failed to implement their abuse policy for 3 (#1, 2, and #4) of 6 sampled residents reviewed for abuse. The BOM identified 78 residents resided in the facility.Findings: On 07/30/25 at 9:13 a.m., Resident #4 was observed seated on the bed in their room with family member #1 present in the room. On 07/30/25 at 9:28 a.m., the room with Resident #2's name on it was observed. Resident #2's side of the room was free from any personal items from a resident and did not have a resident on that side of the room. On 07/30/25 at 10:10 a.m., Resident #1's name was observed outside the fourth room down from the nurse's station on the right side of hall 300. Resident #1 was not observed inside the room. On 07/30/25 at 10:14 a.m., Resident #1 was observed seated in a standard wheelchair at the beginning of hall 300. Resident #1 was observed wearing a light green shirt with a flower on it, blue/grey pants, and tan skid proof socks on. Resident #1 was able to identify their first name, but was unable to provide any additional information to the surveyor. An abuse, neglect, exploitation or misappropriation policy, revised 04/2021, read in part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator.Witness statements are obtained in writing, signed, and dated.A significant change resident assessment, dated 04/28/25, showed Resident #7's cognition was intact (BIMS 13).An abuse and neglect policy, dated 05/02/25, read in part, It is the Policy of any [name withheld] Long Term Care managed facility that no resident shall be subject to abuse and/or neglect.All incidents to include suspected resident abuse will be reported to the Administrator and Director of Nursing.Any occurrence of abuse/neglect will be evaluated at the time for removal of a resident to a more appropriate facility.Following the initial verbal investigation, the Administrator will take written statements from all employees, residents, any witness if any, and will determine action to be taken.Administration will evaluate and analyze any occurrence and make any necessary changes that would prevent the situation from recurring in the future. An admission resident assessment, dated 06/04/25, showed Resident #2's cognition was intact (BIMS 15). The assessment showed the resident exhibited verbal behavioral symptoms directed toward others that significantly disrupted care or the living environment. The assessment showed the resident required supervision or touching assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfer. An annual resident assessment, dated 06/16/25, showed Resident #1's cognitive skills for daily decision making were severely impaired per staff assessment for mental status. The assessment showed the resident required substantial/maximum assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff for chair to bed transfers. A quarterly resident assessment, dated 06/29/25, showed Resident #4's cognition was severely impaired (BIMS 04). The assessment showed the resident was independent for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. A nurse progress note, dated 07/25/25 at 3:30 a.m., showed at approximately 3:25 a.m., RN #1 was alerted by another resident (Resident #4) to a situation occurring in their room. Upon entering the room, RN #1 observed concerning behavior between (Resident #1 and Resident #2). RN #1 instructed Resident #2 to stop and leave the area. A CNA (CNA #1) was directed to supervise and escort Resident #2 out of the room while RN #1 contacted the DON for further guidance. The note showed Resident #1 was briefly assessed with no visible injuries noted at the time. The note showed Resident #2 was placed on 1:1 supervision for close monitoring. The note showed the provider on call and facility administration were notified and appropriate reporting procedures were initiated per protocol. An initial facility reported incident, dated 07/25/25, showed the DON and administrator were notified Resident #2 was in Resident #1's room. The initial report showed the residents were immediately separated and Resident #2 left the property. The initial report showed Resident #1 was sent to the emergency room for precautionary evaluation. The initial report showed the police, family, physician, resident's legal representative, and APS were notified. The initial report was received by the state agency on 07/25/25 at 7:14 a.m. The final facility reported incident, dated 07/25/25, was received by the state agency on 07/30/25 at 12:12 p.m. The final report contained additional information in the description of the incident. The final report showed at 3:42 a.m., (RN #1) contacted the DON regarding (Resident #2) in (Resident #1's) room and in (Resident #1's) bed. The final report showed staff reported (Resident #2) was in (Resident #1's) room with (Resident #2's) pants halfway pulled down. The final report showed (Resident #2) was on the bed with (Resident #1). The DON notified (RN #1) to immediately separate the residents. (Resident #2) was to be placed on 1:1. (Resident #2) then exited the facility while staff was attempting to talk with them. Police were notified and (Resident #1) was sent to the emergency room for precautionary evaluation. The final report showed staff stayed with (Resident #1) until they left to the emergency room. The final report showed (Resident #1) was transported via ambulance and report was given. When police arrived, (Resident #2) was taken into custody by the police department. The DON notified the administrator at 3:48 a.m. The final report showed (Resident #1's) most recent BIMS was 0/15, required total assistance with ADLs, and had diagnoses which included dementia. The final report showed investigation of the incident revealed staff was present on the hall at 2:42 a.m. giving medication to (Resident #2). At 2:49 a.m., (Resident #2) entered (Resident #1's) room. At 2:52 a.m., (Resident #2) shut (Resident #1's) door. At 3:06 a.m. (Resident #4) heard (Resident #2) enter, got up, and reported to staff (name not provided) that (Resident #2) was in their room. At 3:09 a.m., (RN #1) went down to the room and when they entered, (RN #1) saw (Resident #2) in the bed with (Resident #1) appearing to be engaged in sex. (RN #1) reported they told (Resident #2) to stop and exit the room and (Resident #2) was getting up and attempting to explain what (Resident #2) was doing when (RN #1) exited the room to call the DON. At 3:12 a.m., (CNA #1) walked into (Resident #1's) room and (Resident #2) was still in the bed with (Resident #1). (CNA #1) separated (Resident #2 and #1) and (Resident #2) was placed on 1:1. The police department was contacted by the DON along with the facility administrator. (Resident #2) exited the building while staff was attempting 1:1 supervision with (Resident #2) until the police arrived. The police department escorted (Resident #2) back into the building and took them into custody. (Resident #1's) family was notified of the incident and of the resident being transported to the emergency room. (Resident #1) was sent to the emergency room for evaluation and treatment. A SANE exam was completed. (Resident #1) returned to the facility and was moved to a room closer to the nurse's station for family comfort. Psych NP to see (Resident #1) upon return from the hospital to evaluate and treat as needed. Safe surveys for all resident's completed with each resident. No concerns for safety or incidents of abuse reported. In-service with staff completed, small roundtables completed with staff over abuse types, appropriate interventions related and who to report abuse to. In house counselor made available for staff and residents as needed. Immediate QAPI completed and ongoing QAPI review. (RN #1) suspended indefinitely. The immediate QAPI provided for this abuse investigation, dated 07/25/25, showed the COO was called, the administrator was notified, and the DON, ADON, and the SSD were present for the QAPI. The immediate QAPI showed Resident #1 and #2 were placed on 1:1 on 07/25/25 and an in-service was held for all types of abuse. The immediate QAPI showed the physician, nursing board, police, OSDH, and APS were notified of the event and Resident #1 was went to the emergency room for an evaluation. There was no documentation of the 1:1 for the residents provided to the surveyors. There was no documentation of any monitoring component the facility completed to ensure the ongoing safety of the residents in the facility for this immediate QAPI. There was documentation the facility had interviewed Resident #4 and obtained a statement for this abuse investigation. Resident #1's hospital records, dated 07/25/25, showed final diagnosis of sexual assault of adult, initial encounter. The hospital records showed a staff member had gone into Resident #1's room on 07/25/25 and found another resident (Resident #2) vaginally penetrating Resident #1. The hospital records showed Resident #1 was nonverbal. The hospital records showed Resident #1 had diagnoses which included anxiety, brain tumor, dementia with behavioral disturbance, and traumatic brain injury. On 07/30/25 at 9:24 a.m., Resident #7 (who was Resident #2's roommate the day of the incident) stated they had not been a roommate with (Resident #2) for long. Resident #7 stated Resident #2 Went to jail. Resident #7 stated the reason Resident #2 went to jail was because they were a sexual predator. Resident #7 stated Resident #2 had shared stories with them parenting children at the age of eight. On 07/30/25 at 10:10 a.m., CNA #8 stated Resident #1 had just moved to hall 300 because there was an incident on hall 100. CNA #8 stated they did not know the details of the incident, but if something traumatic did occur, [they] wouldn't want [Resident #1] returned to the same room. On 07/30/25 at 10:34 a.m., Resident #4 stated they reported, [Resident #2's] laying on top of [Resident #1]. Family Member #1 stated (Resident #1) had been moved out of Resident #4's room. Family Member #1 stated the incident was on the news on 07/29/25. Resident #4 stated when they saw the two residents, Resident #2 told Resident #4 to shut the door, so they did. Resident #4 stated Resident #1 had to be sexually assaulted because [Resident #2] was on top of [Resident #1]. Resident #4 stated once facility staff came in to get Resident #1 and #2, Resident #4 walked out because they did not want any part of it. On 07/30/25 at 10:46 a.m., family member #1 stated family member #2 (who could be reached by phone) would be the best person to talk to about the incident. Family Member #1 stated they only knew what was on the news and what was in the police report. Family Member #1 stated they were alarmed by the information and came up to the facility. Resident #4 stated, It was very scary. On 07/30/25 at 10:52 a.m., Resident #4 stated, Yeah, it was very scary. Resident #4 stated they reported it when they heard someone coming. Resident #4 reported seeing a firetruck at the facility. On 07/30/25 at 1:19 p.m., family member #2 and family member #3 reported there was a rape that occurred in Resident #4's room on 07/25/25. Family Member #2 stated Resident #4 was woke up and went to the door to their room that was closed. Family Member #2 stated as Resident #4 was going to open the door, they noticed (Resident #2) in bed on top of (Resident #1). Family Member #2 stated Resident #4 left to go to the nurse's station and report (Resident #2) in the room. Family Member #2 stated the facility would not give family member #2 any information on anything and family member #2 was Resident #4's legal representative. On 07/30/25 at 1:28 p.m., family member #2 stated they still had not received any phone calls from the facility about the incident. On 07/30/25 at 1:30 p.m., family member #3 stated all the facility would tell them was there was an incident. Family Member #3 stated, If [Resident #4] was in the room where the incident started, don't you think we should have been notified? They stated the facility went into HIPAA. Family Member #3 stated they were not asking about the other resident, they wanted to know the incident that involved Resident #4 and (an opposite sex individual) being in their room. On 07/30/25 at 1:32 p.m., family member #3 stated, But is [Resident #4] safe? On 07/30/25 at 1:43 p.m., family member #2 stated after 5:00 p.m. that day (07/25/25), they spoke with the regional director of operations. Family Member #2 stated that was when the regional director of operations informed them a criminal act had occurred and a police report was made. They stated the regional director of operations told them you need to know the person who committed the crime was no longer in the facility. Family Member #2 stated at 7 o'clock at night [07/25/25], that's the first time we were told [Resident #2] was gone. They stated the only reason the regional director of operations was answering them was because they were asking the questions and the regional director of operations started covering it up. They stated that was the first time the facility staff had told family member #2 the police were involved. Family Member #2 stated they already knew the police were involved because they talked with the police already. On 07/30/25 at 1:45 p.m., family member #3 stated the lieutenant called and spoke with them about the event. They told family member #2 there was a person arrested at the facility for an alleged assault in the first degree, rape. Family Member #3 stated what the lieutenant did not know was Resident #4 was in the room when it happened. Family Member #3 stated the facility never told the police that Resident #4 was in the room. They stated the facility was acting like their staff was who discovered the incident. On 07/30/25 at 1:52 p.m., family member #3 stated the detective only told them it was first degree rape. They stated no one from the facility would talk to them or give them information for three days which was why they went to the news station. They stated they believed the facility was trying to cover it up and it needed to be investigated. They stated on 07/29/25, a reporter from the news station came to them and read them the police report. They stated that was the only way they knew exactly what occurred because the facility still had not communicated the information to them. On 07/30/25 at 1:58 p.m., family member #3 stated when they found out (Resident #2) was in the room raping (Resident #1), (Resident #4) was also in the room, and went and got staff, and the police report omits that (Resident #4) was who discovered it because they were not told was concerning. Family Member #3 stated, then (Resident #2) got into a wheelchair, unassisted from the bed of (Resident #1), left the room, and told staff (Resident #2) was going to go outside and smoke while they were giving aide to (Resident #1). Meanwhile the police came to the facility and (Resident #2) was nowhere to be found. The police located (Resident #2) two blocks away from the facility and arrested them in a mobile wheelchair. Family Member #3 stated the facility can't detain someone who committed rape? Family Member #3 stated, Where's the protection for the residents in the facility? Family Member #3 stated, Where's the accountability for this place? Family Member #2 stated, They need to be shut down. On 07/30/25 at 2:03 p.m., family member #2 stated, At night [Resident #4] can't sleep. Family Member #2 stated Resident #4 was scared and their eyes were black from lack of sleep. Family Member #2 stated Resident #4 reported they were going to climb out the window today. Family Member #2 stated, [Resident #4] is just scared! On 07/30/25 at 2:04 p.m., family member #2 stated the facility had not addressed their concerns at all. Family Member #2 stated no one had come back to talk to Resident #4 or family member #2. Family Member #2 stated Resident #4 reported They are all scared in there. Family Member #2 stated (Surveyor 1) was the only person who had come into Resident #4's room to talk with the resident. On 07/30/25 at 2:33 p.m., family member #4 stated the first call they received from the facility was on 07/25/25 at 5:57 a.m. Family Member #4 stated the regional director of operations informed family member #4 Resident #1 had been sexually assaulted. Family Member #4 stated no details were provided from the facility at the time. Family Member #4 stated the next call they received was from the hospital to obtain consent for a rape kit. Family Member #4 stated they were with Resident #1 at the hospital all day and returned with the resident to the facility around 3:00 p.m. Family Member #4 stated the facility informed them (Resident #2) was found in (Resident #1's) room and they did not have pants on. Family Member #4 stated they did not know the details until they saw the story come across their social media page. On 07/30/25 at 2:36 p.m., family member #4 stated, at this time, Resident #1 does not even know who family member #4 was when they visit. Family Member #4 stated Resident #1 could not consent for anything. Family Member #4 stated Resident #1 was able to speak, but just can't speak up for [themselves]. On 07/30/25 at 2:42 p.m., family member #4 stated staff had reported they were going to move Resident #1 by the nurses' station, but they did not. Family Member #4 stated Resident #1's room was halfway down the hallway. Family Member #4 stated they informed the facility of the concern with the new room and they responded It might not be today, but [Resident #1] would be moved closer. Family Member #4 stated the regional director of operations told family member #4 We can't protect the residents from everything that is going to happen to them. The regional director of operations reported the facility was making new trainings and strategies to make it not happen again. On 07/30/25 at 2:44 p.m., family member #4 stated the facility mentioned trying to get Resident #1 a (same sex) therapist, but other than that and training the staff, there is nothing else they are doing. Family Member #4 stated they did not feel Resident #1 was safe in the facility. Family Member #4 stated, If [Resident #1] was safe, it wouldn't have happened. On 07/30/25 at 3:52 p.m., CNA #2 stated if they saw abuse, they would tell the administrator and DON right away. They stated the administrator was responsible for investigating abuse. On 07/30/25 at 3:55 p.m. CNA #2 stated they did not know the details about the abuse allegation between Resident #1 and Resident #2. They stated on 07/25/25, they had asked CNA #1 (who was working another hall) to assist with a two person transfer on their hall. They stated this was during the time the alleged incident occurred. CNA #1 had left the hall the incident occurred on to help CNA #2 on their hall. CNA #2 stated they were informed by staff that while CNA #1 was assisting them, (Resident #2) had raped (Resident #1). They stated they believed the supervisor (RN #1) went in the room to separate the residents and called the administrator. CNA #2 stated the DON, administrator, and people higher up in the company came in. They stated a police report was filed, and Resident #1 went to the hospital during their shift. CNA #2 stated Resident #2 somehow ended up leaving the building, and the police found Resident #2 outside. CNA #2 stated they did not know where Resident #2 had gone. CNA #2 stated when the police arrived at the facility, Resident #2 was not around the building, but the police ended up finding them. CNA #2 stated they believed the police took Resident #2 away before their shift ended. On 07/30/25 at 4:04 p.m., CNA #2 stated in response to the event, the facility just made sure everyone was on the hall. If someone had to leave the hall, they were to make sure another staff member was on the hall. On 07/30/25 at 4:41 p.m., an attempt was made to call and speak with RN #1. RN #1's phone was not accepting calls at the time and did not return the state agency's call. On 07/31/25 at 12:00 a.m., CNA #1 stated if they saw any abuse or neglect, they would report it. They stated they would reach out to the administrator. On 07/31/25 at 12:01 a.m., CNA #1 stated they believed the administrator and DON were responsible for investigating abuse. On 07/31/25 at 12:05 a.m., CNA #1 stated on 07/25/25 when the allegation between Resident #1 and Resident #2 occurred, they were assisting CNA #2 with a resident on another hall. CNA #2 stated they saw Resident #4 come out of their room and go to the nurses' station. CNA #1 stated, [Resident #4] was never up that early in the morning. CNA #1 stated it was between 3:00 a.m. and 3:30 a.m. They stated Resident #4 was with RN #1 wearing a knit sweater type covering. CNA #1 stated they asked RN #1 to check Resident #4 because they usually slept with no clothes on. On 07/31/25 at 12:14 a.m., CNA #1 stated when they finished helping CNA #2, LPN #1 was sitting in the hall at a bedside table, and wanted CNA #1 to get Resident #4 (who was sitting in the living room on hall 300) dressed. CNA #1 stated Resident #4 also requested to have their purse. On 07/31/25 at 12:16 a.m., CNA #1 stated they had gone down to Resident #4's room to get clothes for the resident to put on 07/25/25. They stated when they walked in the room they saw Resident #2 in Resident #1's bed. They stated Resident #1 was in the bed too. They stated no one else was in the room at the time. They stated it had to be around 3:00 a.m. to 3:30 a.m. CNA #1 stated Resident #1's brief was ripped off and their gown was off. They stated Resident #2 was in the bed with their shorts pulled down to their knees. CNA #1 reported saying What are you doing? CNA #1 reported saying Did you just rape [Resident #1]? CNA #1 stated Resident #2 said, No, [Resident #1] invited me in. CNA #1 told Resident #2 that Resident #1 could not have invited them in the room because the resident was unable to speak like that. CNA #1 stated, You need to get out of her bed. CNA #1 stated they were so upset when they saw what happened. They stated they observed a wet towel next to Resident #1 in the bed. They stated Resident #2 was prepared to wipe themselves off afterwards. CNA #1 stated there was nothing in the bed besides the blankets and the resident when they previously left Resident #1's room after providing care. On 07/31/25 at 12:21 a.m., CNA #1 stated Resident #2 started to get out of Resident #1's bed and sat in their wheelchair. They stated Resident #2 transferred themselves to their electric wheelchair and started rubbing Resident #1's leg saying, I saw your [family member] at the store. CNA #1 told Resident #2 You don't even know [Resident #1's] family. CNA #1 told Resident #2 stop rubbing on [Resident #1's] leg. CNA #1 stated if they did not take Resident #2 to jail, they were not going to work for the facility anymore. They stated, I'm not working at a place that allows someone to rape a resident. CNA #1 stated after Resident #2 left the room, CNA #1 proceeded to get clothes and dress Resident #4. They stated Resident #4 stated [Resident #2] had told [them] when [they] walked out the room to close the door. CNA #1 stated that was the point when police, the DON, and everyone came to the facility. On 07/31/25 at 12:24 a.m., CNA #1 stated before the police arrived at the facility, Resident #2 told CNA #1 and RN #1 they were going to smoke outside. CNA #1 stated from what they understood when the police arrived, Resident #2 was not outside the facility. CNA #1 stated the police did find Resident #2 and took them to jail. CNA #1 stated before they had left Resident #1's room to assist in dressing Resident #4, [Resident #1] was just laying there lifeless. CNA #1 stated, [Resident #1] couldn't defend [themselves]. On 07/31/25 at 12:29 a.m., CNA #1 stated Resident #1 was pretty much mute. They stated the resident would sometimes say thank you after care. CNA #1 stated when they returned to work the 11:00 p.m. to 7:00 a.m. shift (07/25/25 into the morning of 07/26/25), they went and checked on Resident #1 who had been moved to a different hall. CNA #1 stated Resident #1 was usually asleep during their whole shift, but the night following the rape incident, Resident #1 was awake. CNA #1 also checked on Resident #4 who was asleep with a gown on. On 07/31/25 at 12:32 a.m., CNA #1 stated they were not aware of anything the facility did in response to the abuse allegation. On 07/31/25 at 12:33 a.m., CNA #1 stated they reported the abuse to the DON and administrator who came up to the facility that night. CNA #1 stated they had not received any new instructions related to the plan of care of Resident #1 or Resident #4 since the abuse incident. On 07/31/25 at 12:36 a.m., CNA #1 stated no additional staff came to work when the abuse occurred on 07/25/25. CNA #1 stated no 1:1 supervision was provided to any resident during the night shift on the day the abuse occurred (07/25/25). CNA #1 stated when Resident #2 went down to their room after the rape occurred, no staff went with the resident. CNA #1 stated RN #1 did not come to them at all regarding the incident. CNA #1 stated they did not know about the rape incident until they walked into Resident #1 and Resident #4's room and discovered Resident #2 in the room with their pants down with Resident #1 completely naked. CNA #1 began to cry while recalling the events. On 07/31/25 at 12:45 a.m., LPN #1 stated if abuse was observed or reported to them, they were to report it immediately. They stated they would call the abuse hotline number and call the administrator right away. On 07/31/25 at 12:46 a.m., LPN #1 stated the administrator was responsible for investigating abuse. On 07/31/25 at 12:47 a.m., LPN #1 stated Resident #1 did not talk. They stated the resident speaks very minimal words. On 07/31/25 at 12:49 a.m., LPN #1 stated Resident #1 was unable to make decisions on their own. LPN #1 stated they did not witness anything regarding the abuse allegation on 07/25/25 for Resident #1 and #2. LPN #1 stated they saw Resident #4 speaking to RN #1 on the night shift that morning. They stated Resident #4 was wearing a Sleep jacket with no other clothes on. They stated they did not know the reason Resident #4 was talking to RN #1 that day, but LPN #1 had Resident #4 sit in the television room on hall 300 and instructed CNA #1 to get the resident dressed. On 07/31/25 at 12:52 a.m., LPN #1 stated RN #1 came to them and said they had CNA #1 in Resident #1's room (who shares a room with Resident #4) and reported [Resident #2] was in [Resident #1's] room. They stated RN #1 had to call the DON because they saw Resident #2 in the room with Resident #1. They stated RN #1 was visibly upset saying [Explicit], [explicit] and banging on the nurses' station. LPN #1 stated they later saw the DON fly in the facility with the police. On 07/31/25 at 12:57 a.m., LPN #1 stated they asked what was going on and RN #1 stated Resident #2 was in bed with Resident #1. On 07/31/25 at 1:00 a.m., LPN #1 stated they received an in-service that night informing staff if they saw any resident in another resident's room in an inappropriate way, staff were to stay and not leave the resident. LPN #1 stated staff were to make sure the residents were safe. On 07/31/25 at 1:04 a.m., LPN #1 stated Resident #1 was moved to LPN #1's hall after the event. LPN #1 stated they were not instructed on any new interventions for the care of Resident #1 since the abuse allegation. LPN #1 stated they just would just go in Resident #1's room during their shift and Makes sure [they] are fine. On 07/31/25 at 5:50 a.m., the DON stated if staff reported abuse, they would investigate it. They stated they would send a report to the state agency, APS, notify police, complete an investigation, and have it finalized in five days. On 07/31/25 at 5:52 a.m., the DON stated the administrator and DON were responsible for investigating abuse. They stated if there was a resident to resident abuse, they would make sure the abuser had no contact with the other residents and would try to get the abuser out of the facility. On 07/31/25 at 6:01 a.m., the DON stated Resident #1 was a total assist with all ADLs. They stated the resident could not engage in conversation, but could say yes. They stated the resident was incontinent of bowel and bladder. The DON stated Resident #1's cognition was impaired and they did not have the ability to consent. On 07/31/25 at 6:02 a.m., the DON stated they had received a call from RN #1 on 07/25/25 around 3:40 to 3:45 a.m. who reported Resident #2 was found in Resident #1's room and both residents' clothes were off. The DON stated Resident #2's cognition was very much intact. The DON instructed RN #1 to separate the residents, monitor them, put Resident #2 on 1:1, and call the police. On 07/31/25 at 6:04 a.m., the DON stated they were who called the police because when they were in route to the facility, RN #1 still had not called the police. They stated RN #1 was instructed to call EMSA. The DON stated they pulled up to the facility at the same time the police arrived. They stated the police informed them the room was a crime scene and they could not touch anything. They stated law enforcement took all of the bedding and the gown Resident #1 was wearing. They stated Resident #1 was sent to the hospital for a SANE rape kit. The DON stated Resident #1 received a prophylactic antibiotic for STDs at the hospital. The DON stated Resident #2 was arrested. On 07/31/25 at 6:07 a.m., the DON stated the facility was able to review video footage and identified Resident #2 entered Resident #1's room at 2:49 a.m. and Resident #4 came out of the room and told CNA #1 there was a person (Resident #2) in their room who got RN #1. They stated at 3:09 a.m., RN #1 entered Resident #1's room and saw Resident #2 with their pants down. They stated RN #1 called them at 3:34 a.m. because that was when they could no longer see them on the video footage. The DON stated RN #1 leaving the room did not follow the facility abuse policy. The DON stated the policy showed once residents were observed in abusive behavior, staff were supposed to separate the residents. The DON stated RN #1 missed separating the residents. The DON stated the abuse policy was not followed. The DON stated when CNA #1 entered the room, Resident #2 was still in bed with Resident #1. The DON stated CNA #1 separated the residents and stayed in the room with Resident #1. The DON stated when Resident #2 came out of Resident #1's room, RN #1 and Resident #2 were observed on the video footage in the hallway together by Resident #2's room. On 07/31/25 at 6:09 a.m., The DON stated MDS coordinator #1 spoke with Resident #4 and wrote down their statement after the abuse allegation on 07/25/25. On 07/31/25 at 6:54 a.m., the DON stated CNA #1 was the staff member who completed1:1 supervision with Resident #1 after the incident until Resident #1 left for the hospital. The DON stated RN #1 completed 1:1 supervision with Resident #2 until the resident left the building. The DON stated there were no other staff members called in to help when the 1:1 was in place because it was only an hour and a half before they left. The DON stated CNA #1 did not document the 1:1 and just stayed with Resident #1. The DON stated there was no documentation to put in the chart. On 07/31/25 at 7:04 a.m., the DON asked MDS coordinator #1 where the statement from Resident #4 was (for the allegation of abuse investigation). MDS Coordinator #1 stated, I didn't write anything down on it. On 07/31/25 at 8:22 a.m., the COO was identified as the person who would answer questions for the administrator who was on vacation. The COO

Based on observation, record review, and interview, the facility failed to complete a thorough investigation after an allegation of abuse for 3 (#1, 2, and #4) of 6 sampled residents reviewed for abuse. The BOM identified 78 residents resided in the facility.Findings: On 07/30/25 at 9:13 a.m., Resident #4 was observed seated on the bed in their room with family member #1 present in the room. On 07/30/25 at 9:28 a.m., the room with Resident #2's name on it was observed. Resident #2's side of the room was free from any personal items from a resident and did not have a resident on that side of the room. On 07/30/25 at 10:10 a.m., Resident #1's name was observed outside the fourth room down from the nurse's station on the right side of hall 300. Resident #1 was not observed inside the room. On 07/30/25 at 10:14 a.m., Resident #1 was observed seated in a standard wheelchair at the beginning of hall 300. Resident #1 was observed wearing a light green shirt with a flower on it, blue/grey pants, and tan skid proof socks on. Resident #1 was able to identify their first name, but was unable to provide any additional information to the surveyor. An abuse, neglect, exploitation or misappropriation policy, revised 04/2021, read in part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator.Witness statements are obtained in writing, signed, and dated.A significant change resident assessment, dated 04/28/25, showed Resident #7's cognition was intact (BIMS 13).An abuse and neglect policy, dated 05/02/25, read in part, It is the Policy of any [name withheld] Long Term Care managed facility that no resident shall be subject to abuse and/or neglect.All incidents to include suspected resident abuse will be reported to the Administrator and Director of Nursing.Any occurrence of abuse/neglect will be evaluated at the time for removal of a resident to a more appropriate facility.Following the initial verbal investigation, the Administrator will take written statements from all employees, residents, any witness if any, and will determine action to be taken.Administration will evaluate and analyze any occurrence and make any necessary changes that would prevent the situation from recurring in the future. An admission resident assessment, dated 06/04/25, showed Resident #2's cognition was intact (BIMS 15). The assessment showed the resident exhibited verbal behavioral symptoms directed toward others that significantly disrupted care or the living environment. The assessment showed the resident required supervision or touching assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfer. An annual resident assessment, dated 06/16/25, showed Resident #1's cognitive skills for daily decision making were severely impaired per staff assessment for mental status. The assessment showed the resident required substantial/maximum assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, and was dependent on staff for chair to bed transfers. A quarterly resident assessment, dated 06/29/25, showed Resident #4's cognition was severely impaired (BIMS 04). The assessment showed the resident was independent for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. A nurse progress note, dated 07/25/25 at 3:30 a.m., showed at approximately 3:25 a.m., RN #1 was alerted by another resident (Resident #4) to a situation occurring in their room. Upon entering the room, RN #1 observed concerning behavior between (Resident #1 and Resident #2). RN #1 instructed Resident #2 to stop and leave the area. A CNA (CNA #1) was directed to supervise and escort Resident #2 out of the room while RN #1 contacted the DON for further guidance. The note showed Resident #1 was briefly assessed with no visible injuries noted at the time. The note showed Resident #2 was placed on 1:1 supervision for close monitoring. The note showed the provider on call and facility administration were notified and appropriate reporting procedures were initiated per protocol. An initial facility reported incident, dated 07/25/25, showed the DON and administrator were notified Resident #2 was in Resident #1's room. The initial report showed the residents were immediately separated and Resident #2 left the property. The initial report showed Resident #1 was sent to the emergency room for precautionary evaluation. The initial report showed the police, family, physician, resident's legal representative, and APS were notified. The initial report was received by the state agency on 07/25/25 at 7:14 a.m. The final facility reported incident, dated 07/25/25, was received by the state agency on 07/30/25 at 12:12 p.m. The final report contained additional information in the description of the incident. The final report showed at 3:42 a.m., (RN #1) contacted the DON regarding (Resident #2) in (Resident #1's) room and in (Resident #1's) bed. The final report showed staff reported (Resident #2) was in (Resident #1's) room with (Resident #2's) pants halfway pulled down. The final report showed (Resident #2) was on the bed with (Resident #1). The DON notified (RN #1) to immediately separate the residents. (Resident #2) was to be placed on 1:1. (Resident #2) then exited the facility while staff was attempting to talk with them. Police were notified and (Resident #1) was sent to the emergency room for precautionary evaluation. The final report showed staff stayed with (Resident #1) until they left to the emergency room. The final report showed (Resident #1) was transported via ambulance and report was given. When police arrived, (Resident #2) was taken into custody by the police department. The DON notified the administrator at 3:48 a.m. The final report showed (Resident #1's) most recent BIMS was 0/15, required total assistance with ADLs, and had diagnoses which included dementia. The final report showed investigation of the incident revealed staff was present on the hall at 2:42 a.m. giving medication to (Resident #2). At 2:49 a.m., (Resident #2) entered (Resident #1's) room. At 2:52 a.m., (Resident #2) shut (Resident #1's) door. At 3:06 a.m. (Resident #4) heard (Resident #2) enter, got up, and reported to staff (name not provided) that (Resident #2) was in their room. At 3:09 a.m., (RN #1) went down to the room and when they entered, (RN #1) saw (Resident #2) in the bed with (Resident #1) appearing to be engaged in sex. (RN #1) reported they told (Resident #2) to stop and exit the room and (Resident #2) was getting up and attempting to explain what (Resident #2) was doing when (RN #1) exited the room to call the DON. At 3:12 a.m., (CNA #1) walked into (Resident #1's) room and (Resident #2) was still in the bed with (Resident #1). (CNA #1) separated (Resident #2 and #1) and (Resident #2) was placed on 1:1. The police department was contacted by the DON along with the facility administrator. (Resident #2) exited the building while staff was attempting 1:1 supervision with (Resident #2) until the police arrived. The police department escorted (Resident #2) back into the building and took them into custody. (Resident #1's) family was notified of the incident and of the resident being transported to the emergency room. (Resident #1) was sent to the emergency room for evaluation and treatment. A SANE exam was completed. (Resident #1) returned to the facility and was moved to a room closer to the nurse's station for family comfort. Psych NP to see (Resident #1) upon return from the hospital to evaluate and treat as needed. Safe surveys for all resident's completed with each resident. No concerns for safety or incidents of abuse reported. In-service with staff completed, small roundtables completed with staff over abuse types, appropriate interventions related and who to report abuse to. In house counselor made available for staff and residents as needed. Immediate QAPI completed and ongoing QAPI review. (RN #1) suspended indefinitely. The immediate QAPI provided for this abuse investigation, dated 07/25/25, showed the COO was called, the administrator was notified, and the DON, ADON, and the SSD were present for the QAPI. The immediate QAPI showed Resident #1 and #2 were placed on 1:1 on 07/25/25 and an in-service was held for all types of abuse. The immediate QAPI showed the physician, nursing board, police, OSDH, and APS were notified of the event and Resident #1 was went to the emergency room for an evaluation. There was no documentation of the 1:1 for the residents provided to the surveyors. There was no documentation of any monitoring component the facility completed to ensure the ongoing safety of the residents in the facility for this immediate QAPI. There was documentation the facility had interviewed Resident #4 and obtained a statement for this abuse investigation. Resident #1's hospital records, dated 07/25/25, showed final diagnosis of sexual assault of adult, initial encounter. The hospital records showed a staff member had gone into Resident #1's room on 07/25/25 and found another resident (Resident #2) vaginally penetrating Resident #1. The hospital records showed Resident #1 was nonverbal. The hospital records showed Resident #1 had diagnoses which included anxiety, brain tumor, dementia with behavioral disturbance, and traumatic brain injury. On 07/30/25 at 9:24 a.m., Resident #7 (who was Resident #2's roommate the day of the incident) stated they had not been a roommate with (Resident #2) for long. Resident #7 stated Resident #2 Went to jail. Resident #7 stated the reason Resident #2 went to jail was because they were a sexual predator. Resident #7 stated Resident #2 had shared stories with them parenting children at the age of eight. On 07/30/25 at 10:10 a.m., CNA #8 stated Resident #1 had just moved to hall 300 because there was an incident on hall 100. CNA #8 stated they did not know the details of the incident, but if something traumatic did occur, [they] wouldn't want [Resident #1] returned to the same room. On 07/30/25 at 10:34 a.m., Resident #4 stated they reported, [Resident #2's] laying on top of [Resident #1]. Family Member #1 stated (Resident #1) had been moved out of Resident #4's room. Family Member #1 stated the incident was on the news on 07/29/25. Resident #4 stated when they saw the two residents, Resident #2 told Resident #4 to shut the door, so they did. Resident #4 stated Resident #1 had to be sexually assaulted because [Resident #2] was on top of [Resident #1]. Resident #4 stated once facility staff came in to get Resident #1 and #2, Resident #4 walked out because they did not want any part of it. On 07/30/25 at 10:46 a.m., family member #1 stated family member #2 (who could be reached by phone) would be the best person to talk to about the incident. Family Member #1 stated they only knew what was on the news and what was in the police report. Family Member #1 stated they were alarmed by the information and came up to the facility. Resident #4 stated, It was very scary. On 07/30/25 at 10:52 a.m., Resident #4 stated, Yeah, it was very scary. Resident #4 stated they reported it when they heard someone coming. Resident #4 reported seeing a firetruck at the facility. On 07/30/25 at 1:19 p.m., family member #2 and family member #3 reported there was a rape that occurred in Resident #4's room on 07/25/25. Family Member #2 stated Resident #4 was woke up and went to the door to their room that was closed. Family Member #2 stated as Resident #4 was going to open the door, they noticed (Resident #2) in bed on top of (Resident #1). Family Member #2 stated Resident #4 left to go to the nurse's station and report (Resident #2) in the room. Family Member #2 stated the facility would not give family member #2 any information on anything and family member #2 was Resident #4's legal representative. On 07/30/25 at 1:28 p.m., family member #2 stated they still had not received any phone calls from the facility about the incident. On 07/30/25 at 1:30 p.m., family member #3 stated all the facility would tell them was there was an incident. Family Member #3 stated, If [Resident #4] was in the room where the incident started, don't you think we should have been notified? They stated the facility went into HIPAA. Family Member #3 stated they were not asking about the other resident, they wanted to know the incident that involved Resident #4 and (an opposite sex individual) being in their room. On 07/30/25 at 1:32 p.m., family member #3 stated, But is [Resident #4] safe? On 07/30/25 at 1:43 p.m., family member #2 stated after 5:00 p.m. that day (07/25/25), they spoke with the regional director of operations. Family Member #2 stated that was when the regional director of operations informed them a criminal act had occurred and a police report was made. They stated the regional director of operations told them you need to know the person who committed the crime was no longer in the facility. Family Member #2 stated at 7 o'clock at night [07/25/25], that's the first time we were told [Resident #2] was gone. They stated the only reason the regional director of operations was answering them was because they were asking the questions and the regional director of operations started covering it up. They stated that was the first time the facility staff had told family member #2 the police were involved. Family Member #2 stated they already knew the police were involved because they talked with the police already. On 07/30/25 at 1:45 p.m., family member #3 stated the lieutenant called and spoke with them about the event. They told family member #2 there was a person arrested at the facility for an alleged assault in the first degree, rape. Family Member #3 stated what the lieutenant did not know was Resident #4 was in the room when it happened. Family Member #3 stated the facility never told the police that Resident #4 was in the room. They stated the facility was acting like their staff was who discovered the incident. On 07/30/25 at 1:52 p.m., family member #3 stated the detective only told them it was first degree rape. They stated no one from the facility would talk to them or give them information for three days which was why they went to the news station. They stated they believed the facility was trying to cover it up and it needed to be investigated. They stated on 07/29/25, a reporter from the news station came to them and read them the police report. They stated that was the only way they knew exactly what occurred because the facility still had not communicated the information to them. On 07/30/25 at 1:58 p.m., family member #3 stated when they found out (Resident #2) was in the room raping (Resident #1), (Resident #4) was also in the room, and went and got staff, and the police report omits that (Resident #4) was who discovered it because they were not told was concerning. Family Member #3 stated, then (Resident #2) got into a wheelchair, unassisted from the bed of (Resident #1), left the room, and told staff (Resident #2) was going to go outside and smoke while they were giving aide to (Resident #1). Meanwhile the police came to the facility and (Resident #2) was nowhere to be found. The police located (Resident #2) two blocks away from the facility and arrested them in a mobile wheelchair. Family Member #3 stated the facility can't detain someone who committed rape? Family Member #3 stated, Where's the protection for the residents in the facility? Family Member #3 stated, Where's the accountability for this place? Family Member #2 stated, They need to be shut down. On 07/30/25 at 2:03 p.m., family member #2 stated, At night [Resident #4] can't sleep. Family Member #2 stated Resident #4 was scared and their eyes were black from lack of sleep. Family Member #2 stated Resident #4 reported they were going to climb out the window today. Family Member #2 stated, [Resident #4] is just scared! On 07/30/25 at 2:04 p.m., family member #2 stated the facility had not addressed their concerns at all. Family Member #2 stated no one had come back to talk to Resident #4 or family member #2. Family Member #2 stated Resident #4 reported They are all scared in there. Family Member #2 stated (Surveyor 1) was the only person who had come into Resident #4's room to talk with the resident. On 07/30/25 at 2:33 p.m., family member #4 stated the first call they received from the facility was on 07/25/25 at 5:57 a.m. Family Member #4 stated the regional director of operations informed family member #4 Resident #1 had been sexually assaulted. Family Member #4 stated no details were provided from the facility at the time. Family Member #4 stated the next call they received was from the hospital to obtain consent for a rape kit. Family Member #4 stated they were with Resident #1 at the hospital all day and returned with the resident to the facility around 3:00 p.m. Family Member #4 stated the facility informed them (Resident #2) was found in (Resident #1's) room and they did not have pants on. Family Member #4 stated they did not know the details until they saw the story come across their social media page. On 07/30/25 at 2:36 p.m., family member #4 stated, at this time, Resident #1 does not even know who family member #4 was when they visit. Family Member #4 stated Resident #1 could not consent for anything. Family Member #4 stated Resident #1 was able to speak, but just can't speak up for [themselves]. On 07/30/25 at 2:42 p.m., family member #4 stated staff had reported they were going to move Resident #1 by the nurses' station, but they did not. Family Member #4 stated Resident #1's room was halfway down the hallway. Family Member #4 stated they informed the facility of the concern with the new room and they responded It might not be today, but [Resident #1] would be moved closer. Family Member #4 stated the regional director of operations told family member #4 We can't protect the residents from everything that is going to happen to them. The regional director of operations reported the facility was making new trainings and strategies to make it not happen again. On 07/30/25 at 2:44 p.m., family member #4 stated the facility mentioned trying to get Resident #1 a (same sex) therapist, but other than that and training the staff, there is nothing else they are doing. Family Member #4 stated they did not feel Resident #1 was safe in the facility. Family Member #4 stated, If [Resident #1] was safe, it wouldn't have happened. On 07/30/25 at 3:52 p.m., CNA #2 stated if they saw abuse, they would tell the administrator and DON right away. They stated the administrator was responsible for investigating abuse. On 07/30/25 at 3:55 p.m. CNA #2 stated they did not know the details about the abuse allegation between Resident #1 and Resident #2. They stated on 07/25/25, they had asked CNA #1 (who was working another hall) to assist with a two person transfer on their hall. They stated this was during the time the alleged incident occurred. CNA #1 had left the hall the incident occurred on to help CNA #2 on their hall. CNA #2 stated they were informed by staff that while CNA #1 was assisting them, (Resident #2) had raped (Resident #1). They stated they believed the supervisor (RN #1) went in the room to separate the residents and called the administrator. CNA #2 stated the DON, administrator, and people higher up in the company came in. They stated a police report was filed, and Resident #1 went to the hospital during their shift. CNA #2 stated Resident #2 somehow ended up leaving the building, and the police found Resident #2 outside. CNA #2 stated they did not know where Resident #2 had gone. CNA #2 stated when the police arrived at the facility, Resident #2 was not around the building, but the police ended up finding them. CNA #2 stated they believed the police took Resident #2 away before their shift ended. On 07/30/25 at 4:04 p.m., CNA #2 stated in response to the event, the facility just made sure everyone was on the hall. If someone had to leave the hall, they were to make sure another staff member was on the hall. On 07/30/25 at 4:41 p.m., an attempt was made to call and speak with RN #1. RN #1's phone was not accepting calls at the time and did not return the state agency's call. On 07/31/25 at 12:00 a.m., CNA #1 stated if they saw any abuse or neglect, they would report it. They stated they would reach out to the administrator. On 07/31/25 at 12:01 a.m., CNA #1 stated they believed the administrator and DON were responsible for investigating abuse. On 07/31/25 at 12:05 a.m., CNA #1 stated on 07/25/25 when the allegation between Resident #1 and Resident #2 occurred, they were assisting CNA #2 with a resident on another hall. CNA #2 stated they saw Resident #4 come out of their room and go to the nurses' station. CNA #1 stated, [Resident #4] was never up that early in the morning. CNA #1 stated it was between 3:00 a.m. and 3:30 a.m. They stated Resident #4 was with RN #1 wearing a knit sweater type covering. CNA #1 stated they asked RN #1 to check Resident #4 because they usually slept with no clothes on. On 07/31/25 at 12:14 a.m., CNA #1 stated when they finished helping CNA #2, LPN #1 was sitting in the hall at a bedside table, and wanted CNA #1 to get Resident #4 (who was sitting in the living room on hall 300) dressed. CNA #1 stated Resident #4 also requested to have their purse. On 07/31/25 at 12:16 a.m., CNA #1 stated they had gone down to Resident #4's room to get clothes for the resident to put on 07/25/25. They stated when they walked in the room they saw Resident #2 in Resident #1's bed. They stated Resident #1 was in the bed too. They stated no one else was in the room at the time. They stated it had to be around 3:00 a.m. to 3:30 a.m. CNA #1 stated Resident #1's brief was ripped off and their gown was off. They stated Resident #2 was in the bed with their shorts pulled down to their knees. CNA #1 reported saying What are you doing? CNA #1 reported saying Did you just rape [Resident #1]? CNA #1 stated Resident #2 said, No, [Resident #1] invited me in. CNA #1 told Resident #2 that Resident #1 could not have invited them in the room because the resident was unable to speak like that. CNA #1 stated, You need to get out of her bed. CNA #1 stated they were so upset when they saw what happened. They stated they observed a wet towel next to Resident #1 in the bed. They stated Resident #2 was prepared to wipe themselves off afterwards. CNA #1 stated there was nothing in the bed besides the blankets and the resident when they previously left Resident #1's room after providing care. On 07/31/25 at 12:21 a.m., CNA #1 stated Resident #2 started to get out of Resident #1's bed and sat in their wheelchair. They stated Resident #2 transferred themselves to their electric wheelchair and started rubbing Resident #1's leg saying, I saw your [family member] at the store. CNA #1 told Resident #2 You don't even know [Resident #1's] family. CNA #1 told Resident #2 stop rubbing on [Resident #1's] leg. CNA #1 stated if they did not take Resident #2 to jail, they were not going to work for the facility anymore. They stated, I'm not working at a place that allows someone to rape a resident. CNA #1 stated after Resident #2 left the room, CNA #1 proceeded to get clothes and dress Resident #4. They stated Resident #4 stated [Resident #2] had told [them] when [they] walked out the room to close the door. CNA #1 stated that was the point when police, the DON, and everyone came to the facility. On 07/31/25 at 12:24 a.m., CNA #1 stated before the police arrived at the facility, Resident #2 told CNA #1 and RN #1 they were going to smoke outside. CNA #1 stated from what they understood when the police arrived, Resident #2 was not outside the facility. CNA #1 stated the police did find Resident #2 and took them to jail. CNA #1 stated before they had left Resident #1's room to assist in dressing Resident #4, [Resident #1] was just laying there lifeless. CNA #1 stated, [Resident #1] couldn't defend [themselves]. On 07/31/25 at 12:29 a.m., CNA #1 stated Resident #1 was pretty much mute. They stated the resident would sometimes say thank you after care. CNA #1 stated when they returned to work the 11:00 p.m. to 7:00 a.m. shift (07/25/25 into the morning of 07/26/25), they went and checked on Resident #1 who had been moved to a different hall. CNA #1 stated Resident #1 was usually asleep during their whole shift, but the night following the rape incident, Resident #1 was awake. CNA #1 also checked on Resident #4 who was asleep with a gown on. On 07/31/25 at 12:32 a.m., CNA #1 stated they were not aware of anything the facility did in response to the abuse allegation. On 07/31/25 at 12:33 a.m., CNA #1 stated they reported the abuse to the DON and administrator who came up to the facility that night. CNA #1 stated they had not received any new instructions related to the plan of care of Resident #1 or Resident #4 since the abuse incident. On 07/31/25 at 12:36 a.m., CNA #1 stated no additional staff came to work when the abuse occurred on 07/25/25. CNA #1 stated no 1:1 supervision was provided to any resident during the night shift on the day the abuse occurred (07/25/25). CNA #1 stated when Resident #2 went down to their room after the rape occurred, no staff went with the resident. CNA #1 stated RN #1 did not come to them at all regarding the incident. CNA #1 stated they did not know about the rape incident until they walked into Resident #1 and Resident #4's room and discovered Resident #2 in the room with their pants down with Resident #1 completely naked. CNA #1 began to cry while recalling the events. On 07/31/25 at 12:45 a.m., LPN #1 stated if abuse was observed or reported to them, they were to report it immediately. They stated they would call the abuse hotline number and call the administrator right away. On 07/31/25 at 12:46 a.m., LPN #1 stated the administrator was responsible for investigating abuse. On 07/31/25 at 12:47 a.m., LPN #1 stated Resident #1 did not talk. They stated the resident speaks very minimal words. On 07/31/25 at 12:49 a.m., LPN #1 stated Resident #1 was unable to make decisions on their own. LPN #1 stated they did not witness anything regarding the abuse allegation on 07/25/25 for Resident #1 and #2. LPN #1 stated they saw Resident #4 speaking to RN #1 on the night shift that morning. They stated Resident #4 was wearing a Sleep jacket with no other clothes on. They stated they did not know the reason Resident #4 was talking to RN #1 that day, but LPN #1 had Resident #4 sit in the television room on hall 300 and instructed CNA #1 to get the resident dressed. On 07/31/25 at 12:52 a.m., LPN #1 stated RN #1 came to them and said they had CNA #1 in Resident #1's room (who shares a room with Resident #4) and reported [Resident #2] was in [Resident #1's] room. They stated RN #1 had to call the DON because they saw Resident #2 in the room with Resident #1. They stated RN #1 was visibly upset saying [Explicit], [explicit] and banging on the nurses' station. LPN #1 stated they later saw the DON fly in the facility with the police. On 07/31/25 at 12:57 a.m., LPN #1 stated they asked what was going on and RN #1 stated Resident #2 was in bed with Resident #1. On 07/31/25 at 1:00 a.m., LPN #1 stated they received an in-service that night informing staff if they saw any resident in another resident's room in an inappropriate way, staff were to stay and not leave the resident. LPN #1 stated staff were to make sure the residents were safe. On 07/31/25 at 1:04 a.m., LPN #1 stated Resident #1 was moved to LPN #1's hall after the event. LPN #1 stated they were not instructed on any new interventions for the care of Resident #1 since the abuse allegation. LPN #1 stated they just would just go in Resident #1's room during their shift and Makes sure [they] are fine. On 07/31/25 at 5:50 a.m., the DON stated if staff reported abuse, they would investigate it. They stated they would send a report to the state agency, APS, notify police, complete an investigation, and have it finalized in five days. On 07/31/25 at 5:52 a.m., the DON stated the administrator and DON were responsible for investigating abuse. They stated if there was a resident to resident abuse, they would make sure the abuser had no contact with the other residents and would try to get the abuser out of the facility. On 07/31/25 at 6:01 a.m., the DON stated Resident #1 was a total assist with all ADLs. They stated the resident could not engage in conversation, but could say yes. They stated the resident was incontinent of bowel and bladder. The DON stated Resident #1's cognition was impaired and they did not have the ability to consent. On 07/31/25 at 6:02 a.m., the DON stated they had received a call from RN #1 on 07/25/25 around 3:40 to 3:45 a.m. who reported Resident #2 was found in Resident #1's room and both residents' clothes were off. The DON stated Resident #2's cognition was very much intact. The DON instructed RN #1 to separate the residents, monitor them, put Resident #2 on 1:1, and call the police. On 07/31/25 at 6:04 a.m., the DON stated they were who called the police because when they were in route to the facility, RN #1 still had not called the police. They stated RN #1 was instructed to call EMSA. The DON stated they pulled up to the facility at the same time the police arrived. They stated the police informed them the room was a crime scene and they could not touch anything. They stated law enforcement took all of the bedding and the gown Resident #1 was wearing. They stated Resident #1 was sent to the hospital for a SANE rape kit. The DON stated Resident #1 received a prophylactic antibiotic for STDs at the hospital. The DON stated Resident #2 was arrested. On 07/31/25 at 6:07 a.m., the DON stated the facility was able to review video footage and identified Resident #2 entered Resident #1's room at 2:49 a.m. and Resident #4 came out of the room and told CNA #1 there was a person (Resident #2) in their room who got RN #1. They stated at 3:09 a.m., RN #1 entered Resident #1's room and saw Resident #2 with their pants down. They stated RN #1 called them at 3:34 a.m. because that was when they could no longer see them on the video footage. The DON stated RN #1 leaving the room did not follow the facility abuse policy. The DON stated the policy showed once residents were observed in abusive behavior, staff were supposed to separate the residents. The DON stated RN #1 missed separating the residents. The DON stated the abuse policy was not followed. The DON stated when CNA #1 entered the room, Resident #2 was still in bed with Resident #1. The DON stated CNA #1 separated the residents and stayed in the room with Resident #1. The DON stated when Resident #2 came out of Resident #1's room, RN #1 and Resident #2 were observed on the video footage in the hallway together by Resident #2's room. On 07/31/25 at 6:09 a.m., The DON stated MDS coordinator #1 spoke with Resident #4 and wrote down their statement after the abuse allegation on 07/25/25. On 07/31/25 at 6:54 a.m., the DON stated CNA #1 was the staff member who completed1:1 supervision with Resident #1 after the incident until Resident #1 left for the hospital. The DON stated RN #1 completed 1:1 supervision with Resident #2 until the resident left the building. The DON stated there were no other staff members called in to help when the 1:1 was in place because it was only an hour and a half before they left. The DON stated CNA #1 did not document the 1:1 and just stayed with Resident #1. The DON stated there was no documentation to put in the chart. On 07/31/25 at 7:04 a.m., the DON asked MDS coordinator #1 where the statement from Resident #4 was (for the allegation of abuse investigation). MDS Coordinator #1 stated, I didn't write anything down on it. On 07/31/25 at 8:22 a.m., the COO was identified as the person who would answer questions for the admini[TRUNCATED]

Based on record review and interview, the facility failed to complete and submit a final report of findings of an investigation after an allegation of verbal abuse for 1 (#3) of 3 sampled residents reviewed for abuse.Administrator #1 identified 80 residents resided in the facility.Findings:An Abuse Investigation and Reporting policy, revised 07/2017, read in part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse').The administrator. or his/her designee, will provide the appropriate agencies or individuals.a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. An undated care plan for Resident #3's showed the resident had diagnoses which included hypertension and diabetes mellitus type 2.An Initial Incident Report Form, dated 03/06/25, read in part, [Resident #3] was very upset because [they] could not find [their] remote control to [their] TV [television], [CNA #5] (employee) told [Resident #3] that [they] needed to calm down and stop yelling. [CNA #5] spoke to [Resident #3] in a tone/manner that they are used to speaking but [CNA #5] did have to raise [their] volume due to [Resident #3] yelling. The resident did not seem to be offended by [CNA #5] tone/manner and [CNA #5] ordered a replacement remote for the resident.Administrator was notified, [CNA #5] was suspended immediately upon notification.There was no documentation of the results of an abuse/mistreatment investigation or documentation of final results being reported.On 07/23/25 at 3:22 p.m., the DON stated they could not find the follow up and the final 5-day investigation.

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of abuse/mistreatment for 1 (#2) of 3 sampled residents reviewed for abuse.Administrator #1 identified 80 residents resided in the facility.Findings:An Abuse Investigation and Reporting policy, revised 07/2017, read in part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it.An undated facesheet for Resident #2 showed diagnoses of dehiscence of wound of abdominal wall and acute kidney failure.A Final State Reportable Incident form, dated 07/16/25, read in part, [Family member] stated they arrived at the facility at about 2pm on Sunday 07/13/25 and noted [Resident #2] to be throwing up, and they had bowel movement on them. [Family member] said [Resident #2] had IV fluids running. [They] [were] upset that no one had called them to inform them that there had been changes or that [Resident #2] was on IV fluids or new medications. [They] stated they requested the nurse to clean [Resident #2] up and [the nurse] said [they] would get a CNA to assist. [Family member] also stated they asked for the nurse to come and check [Resident #2] and [they] did not come in a timely manner.[They] had waited for about 15 minutes total when they decided they just wanted [Resident #2] sent to the ER [emergency room].There was no documentation of employee witness statements being conducted.On 07/23/25 at 1:48 p.m., the DON stated they had spoken with registered nurse #1, licensed practical nurse #1, and CNA #1.On 07/23/25 at 1:52 p.m., the assistant director of nursing stated they had not been told to do interviews with staff.On 07/23/25 at 1:54 p.m., the DON stated they had spoken with staff, but they had not written it down. The DON stated, I usually just talk with them.

Based on observation, record review, and interview, the facility failed to place a call light within reach of a resident for 1 (#1) of 1 sampled resident who was observed for call lights.Administrator #1 identified 80 residents resided in the facility.Findings:On 07/23/25 at 2:35 p.m., Resident #1's call light was observed nearest the head of bed laying on top of a pillow. Resident #1 was observed in their Geri-chair approximately two feet away from the bed.An Answering the Call Light policy and procedure, revised 03/2021, read in part, The purpose of this procedure is to ensure timely response to the resident's request and needs.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.A quarterly resident assessment, dated 05/17/25, showed Resident #2 was cognitively intact.An undated care plan for Resident #1 showed the resident had diagnoses which included post traumatic disorder and quadriplegia.On 07/23/25 at 2:38 p.m., Resident #1 stated they could use the call light if it was clipped to their shirt and placed under their chin so they could use their chin to activate it.On 07/23/25 at 2:50 p.m., CNA #1 stated the call light was on the bed and yes Resident #1 was able to use it. On 07/23/25 at 2:53 p.m., CNA #1 stated the policy for call lights was it was to be within reach of the resident and to make sure the call light was in working order. On 07/23/25 at 3:02 p.m., the director of clinical services stated the expectation was to have call lights within reach of the residents.

Based on record review and interview, the facility failed to ensure residents who received dialysis had pre and post monitoring for 2 (#1 and #3) of 3 sampled residents reviewed for dialysis. The DON identified four residents who received dialysis services resided in the facility. Findings: An undated facility policy titled Dialysis Care/Arterial-Venous Fistula, read in part, All residents receiving dialysis will have monitoring before and after their dialysis treatment to ensure condition is stable after treatment. 1. Resident #1's physician's order, dated 03/31/25, showed scheduled visits to the dialysis center every Tuesday, Thursday, and Saturdays with a chair time of 6:15 a.m. to 10:15 a.m., but to be present at the site at 6:00 a.m. to coordinate care accordingly. Resident #1's admission resident assessment, dated 04/03/25, showed the resident had moderate cognitive impairment with a brief interview for mental status score of 11. A review of 04/2025 dialysis communication forms showed Resident #1 had one completed pre and post monitoring dialysis communication form dated 04/17/25. A review of 04/2025 dialysis communication forms showed there were no pre and post monitoring dialysis communication forms for the dates of 04/01/25, 04/03/25, 04/05/25, 04/08/25, 04/10/25, 04/12/25, 04/15/25, 04/19/25, 04/22/25, 04/24/25, 04/26/25, and 04/29/25. Resident #1's order summary report, dated 05/2025, showed the resident had a diagnosis of end stage renal disease. On 05/02/25 at 7:58 a.m., Resident #1 stated staff did not assess them before or after dialysis. They stated they went to dialysis on Tuesday, Thursday, and Saturdays. On 05/02/25 at 10:47 a.m., the DON stated they could only locate one pre and post monitoring dialysis communication form for Resident #1. They stated the resident does not bring back the communication form. The DON stated they instructed the nurses to call the dialysis center for the form. On 05/02/25 at 10:50 a.m., the DON stated the process for pre and post dialysis monitoring was for the nurses to fill out the pre dialysis communication form and give the form to the resident to take to the dialysis center. They stated the dialysis center would fill out the form and would include any new orders or changes. The DON stated the nurse at the facility would complete the post dialysis on the form when the resident returned to the facility. 2. Resident #3's physician's order, dated 03/25/25, showed scheduled visits to the dialysis center every Tuesday, Thursday, and Saturdays with a chair time of 12:00 p.m., but to be present at site at 11:40 a.m. to coordinate care accordingly. A review of 04/2025 dialysis communication forms showed there were no post monitoring dialysis communication forms for the dates of 04/08/25, 04/15/25, 04/17/25, 04/22/25, and 04/24/25. Resident #3's order summary report, dated 05/2025, showed the resident had a diagnosis of end stage renal disease. On 05/02/25 at 12:57 p.m., license practical nurse #1 stated the pre and post dialysis monitoring included obtaining vitals, weights, and assessing dialysis site. On 05/02/25 at 2:41 p.m., the DON stated the post dialysis forms were not completed for the dates above.

Based on record review and interview, the facility failed to ensure a resident's legal representative was notified of a resident's refusal to use a c-pap for 1 (#3) of 3 sampled residents reviewed for respiratory care. The administrator identified 72 residents resided in the facility. Findings: Resident #3 had diagnoses which included chronic respiratory failure with hypoxia, bipolar disorder, generalized anxiety, and major depressive disorder. A court ORDER APPOINTING GUARDIAN, dated 04/07/21, showed the Resident #3 had a court appointed guardian. The court appointed guardian was listed on Resident #3's electronic health record as the guardian, power of attorney, and emergency contact. Resident #3's quarterly resident assessment, dated 11/21/24, showed the resident's cognition was intact with a BIMS of 15. A care plan, initiated, 07/12/24, showed Resident #3 often will remove the c-pap once staff has left the room, staff has found it under their bed before where they had tossed/tried to hide it. Staff to encourage them to keep it in place and not remove it. A physician's order, dated 07/19/24, read in part, the resident was to wear c-pap due to sleep apnea. Oxygen to bleed [oxygen going through the tube] in at 3 LPM [liters per minute], c-pap setting: 6 cmH20 to 14 cmH20. The Resident may remove at their discretion every evening and night shift related to chronic respiratory failure with hypoxia. Document when the resident refuses to wear c-pap. The January 2025 TAR showed refused for Resident #3's evening shift c-pap administration on the 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 12th, 13th, 18th, 19th, and 25th. The January 2025 TAR showed refused for Resident #3's night shift c-pap administration on the 1st, 2nd, 3rd, 7th, 8th, 9th, 10th, 11th, 12th, 14th, 15th, 16th, 17th, 20th, 21st, 22nd, and 23rd. A nursing note, dated 01/16/25 at 10:09 a.m., read in part, Resident's representative [name withheld], expressed concerns to me regarding Resident #3's condition reporting they were experiencing low oxygen saturation. Resident was refusing to wear their c-pap at night due to discomfort. I let [name withheld] know we were going to send a new pulmonologist referral and have the c-pap company come evaluate their c-pap and pressure setting. [name withheld] requested to be updated when we have updates. I assured them I would. No additional questions or concerns at this time. There was no documentation prior to 01/16/25 Resident #3's legal guardian was aware of their refusal to use the c-pap. On 03/19/25 at 4:14 p.m., CNA #4 stated Resident #3 was non-compliant with care and diet including the use of the c-pap machine. They stated the resident's memory was intact. On 03/19/25 at 4:16 p.m., CNA #4 stated Resident #3 mostly needed assistance with transfers. On 03/19/25 at 4:21 p.m., LPN #3 stated they were familiar with Resident #3. They stated the resident was non-complaint with oxygen and c-pap use. On 03/19/25 at 4:25 p.m., LPN #3 stated Resident #3's cognition was intact. On 03/19/25 at 4:27 p.m., LPN #3 stated nurses were responsible for administering c-pap for residents. On 03/19/25 at 4:28 p.m., LPN #3 stated if a resident refuses care, the first emergency contact was notified and if unable to reach, call the second emergency contact, notify the doctor and document notification. On 03/19/25 at 4:30 p.m., LPN #3 stated if there was a pattern of refusal to use a c-pap, they would notify the resident's representative. They stated Resident #3's family had a camera in the resident's room and were able to see everything. On 03/19/25 at 4:32 p.m., LPN #3 stated they did not notify Resident #3's legal guardian of the resident's refusal to use the c-pap. On 03/19/25 at 4:36 p.m., the DON stated staff were to notify the physician and family of refusal of treatment unless the resident is their own representative. They stated when they started working at the facility in January 2025, they identified staff were not notifying family so they did a performance improvement plan and staff in-service. On 03/19/25 at 4:38 p.m., the DON stated refusal to use a c-pap required family/guardian notification. On 03/19/25 at 4:47 p.m., the DON stated there was no documentation Resident #3's legal guardian was notified of refusals to use c-pap prior to 01/16/25.

Based on record review and interview, the facility failed to ensure: a. the results of an abuse/mistreatment investigation were reported to the State Agency within 10 business days for 1 (#2); and b. an allegation of abuse/mistreatment was reported to the appropriate licensing board in a timely manner for 1 (#2) of 3 sampled residents reviewed for timely care and treatment. The administrator identified 72 residents resided in the facility. Findings: The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised 04/2021, read in part, Findings of all investigations are documented and reported. Resident #2 had diagnoses which included altered mental status and quadriplegia. An Initial INCIDENT REPORT FORM, dated 03/03/25, showed an allegation of abuse/mistreatment. The report showed Resident #2 told LPN #1 that they were sick. The report showed Resident #2 vomited on themselves, and LPN #1 refused to clean them up and left them covered in their vomit until the aide on the next shift came in to clean them up. The report showed the appropriate licensing board had been notified. The final investigation report was not sent to the State Agency within 10 business days after the incident on 03/03/25. There was no documentation to show the appropriate licensing board was notified on 03/03/25. On 03/20/25 at 12:34 p.m., the administrator stated the process was to send a final report of an investigation to the State Agency within five days. They stated their fax machine had issues so the final report was sent in today. On 03/20/25 at 12:35 p.m., the administrator stated the report was not successfully sent in a timely manner to the State Agency. On 03/20/25 at 12:44 p.m., the administrator stated they did not notify the appropriate licensing board in a timely manner. They stated they sent the notification today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to add an intervention to a residents care plan to prevent future accidents after a fall for one (#12) of three sampled residents reviewed for accident hazards. The DON identified 76 residents resided in the facility. Findings: The facility's Falls- Clinical Protocol policy, revised 03/2018, read in part, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risk of clinically significance consequences of falling. Resident #12 was admitted [DATE] with diagnoses which included cerebral infarction due to thrombosis of right middle cerebral artery, type two diabetes, unspecified, lack of coordination, muscle, weakness, and contusion of right lower leg. Resident #12's annual assessment, dated 5/31/24, documented the resident's cognition was fully intact and required substantial to maximal assistance for chair to bed transfers. The facility's #1420 Witnessed Fall with Injury report, dated 12/29/24, documented Resident #12 fell from the lift sling during a transfer and received a skin tear to the left toe. Resident #12's care plan, dated 01/04/25, documented the resident required assistance with all ADLs and required two person assistance with the use of a mechanical lift for transfers. The care plan did not document interventions were added to the care plan after the fall on 12/29/24 to prevent future accidents. On 01/08/25 at 2:29 p.m., Resident #12 was asked about the incident on 12/29/24. They stated about three weeks ago, they had a fall when the lift machine failed during a lift. They stated the sling loop tore and they fell to the floor and hit their head. The resident stated EMSA was called and they were transported to the hospital. They stated their hip was bruised and they did not stay overnight. On 01/13/25 at 10:15 a.m., the ADON was asked what was the facility's policy for adding interventions after a fall. They stated after a fall they had a clinical meeting and discussed interventions and then the MDS coordinator would add the interventions during the clinical meeting to the care plan. The ADON was asked what interventions were added after Resident #12's fall on 12/29/24. They reviewed the care plan and stated there were no interventions added to the care plan after the fall. The ADON was asked if their policy was followed. They stated,No. On 01/13/25 at 10:27 a.m., MDS coordinator #1 was asked what interventions were added after Resident #12's fall on 12/29/24. They stated there were no interventions added to the care plan after the fall on 12/29/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide ADL care for a dependent resident for one (#3) of three sampled residents reviewed for ADL care. The DON identified 76 residents resided in the facility. Findings: The facility's Bath, Shower/Tub policy, revised 02/2018, read in part, Documentation 1. The date and time the shower/tub was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data obtained during the bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s). The facility's Activities of Daily Living (ADL), Supporting policy, revised 03/2018, read in part, Appropriate care services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care.) Resident #3 was admitted on [DATE] with diagnoses which included cerebral infarction, contracture of the right hand, conversion disorder, and dysphagia. Resident #3's annual assessment, dated 01/01/25, documented their cognition was impaired and they required substantial/maximal assistance with showers/baths. Resident #3's care plan, dated 01/01/25, documented the resident had an ADL self-care performance deficit. It documented the resident was totally dependent for bathing. Task sheets for bathing, reviewed 11/01/24 through 12/31/24, documented the resident was not bathed 13 out of 26 opportunities on the following dates, a. 11/01/24, b. 11/04/24, c. 11/06/24, d. 11/15/24, e. 11/18/24, f. 11/20/24, g. 11/22/24, h. 12/04/24, i. 12/09/24, j. 12/13/24, k. 12/20/24, l. 12/23/24, and m. 12/27/24. On 01/08/25 at 10:35 a.m., CNA #1 was asked to discuss Resident #3's baths. They stated the resident took showers on the 3-11 shift and had a bath about a month ago and had not been getting showers. The CNA stated they had bath sheets and residents should sign a refusal, but they did not think the resident had refused showers because they did not think the resident was offered a shower. On 01/08/25 at 11:30 a.m., corporate nurse #1 was asked about showers on the above mentioned dates. They stated there was no documented refusal or showers given for the above dates. Corporate Nurse #1 was asked what the policy was for bathing dependent residents. They stated baths were logged in task and if the resident refused, the refusal should be documented. Corporate Nurse #1 was asked if their policies were followed regarding the above dates. They stated,No, they did not document refusals, notify the nurse of the refusal, and did not fill out shower sheets.

Based on record and interview, the facility failed to ensure call lights were accessible for one (#5) of seven sampled residents reviewed for call lights. The DON identified 82 residents resided in the facility. Findings: A Falling Leaves Fall Prevention Program, dated 08/25/23, read in part, 22. Call lights in reach and in good working order. Res #5 had diagnoses which included heart failure, emphysema, paraplegia and quadriplegia. A physician order, dated 05/07/24, documented falling leaves prevention program. On 09/12/24 at 1:54 p.m., Res #5's call light was not accessible while resting in bed. On 09/12/24 at 1:55 p.m., LPN #1 stated Res #5's call light was supposed to be within reach while resting in bed. On 09/17/24 at 4:12 p.m., Res #5's call light was not in accessible while resting in bed. On 09/17/24 at 4:13 p.m., RN #1 stated Res #5's call light was not within reach. They stated their call light was stuck behind their pillow in their bed.

Based on observation and interview, the facility failed to have an effective pest control for one (#9) of nine sampled residents reviewed for pest control. The DON identified 82 residents resided in the facility. On 09/17/24 at 2:50 p.m., Res #9 was observed with eight flies located on different areas of their body. On 09/17/24 at 2:52 p.m., housekeeping #1 stated there were lots of flies, but they sprayed. On 09/17/24 at 2:56 p.m., CMA #1 stated there had always been a lot of flies on hall 400.

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#8) of three sampled residents reviewed for abuse. The Administrator identified 82 residents resided in the facility. Findings: An Abuse and Neglect policy, undated, read in part, .no resident shall be subject to abuse and/or neglect .All incidents to include suspected resident abuse will be reported to the Administrator and Director of Nursing immediately .Any staff member involved in any incident will report it immediately to his/her supervisor, and a written statement would be obtained through interview about the incident. The Administrator will be the person to notify appropriate agencies .the employee will be suspended pending the investigation . Resident #8 had diagnoses which included quadriplegia, post-traumatic stress disorder, and schizoaffective disorder bipolar type. An Initial State Reportable Incident form, dated 06/02/24, documented an allegation of abuse/mistreatment. It documented the family of Resident #8 observed video footage of CNA #3 cursing and arguing with Resident #8. It documented the CNA was suspended pending an investigation. A Final State Reportable Incident form, faxed 06/11/24, documented the allegation of abuse was substantiated and CNA #3 was terminated. The supporting documents attached to the incident form documented CNA #3 was observed on video footage cursing and mocking Resident #8. It documented when Resident #8 asked CNA #3 to get out of their room, the CNA replied make me get out. The facility did not have documentation QAPI was involved. On 08/08/24 at 2:20 p.m., the Administrator stated the allegation of abuse with Resident #8 was substantiated. They stated it Absolutely was abuse. The stated the CNA was cursing the resident and mocking the resident. They stated it was horrible. The Administrator stated the facility completed an investigation, completed an abuse inservice, completed safe surveys, and terminated the employee. They stated, we didn't take anything to QAPI on this particular abuse investigation. They stated they would involve QAPI if they had back to back abuse or a pattern. They stated they go above and beyond the regulatory requirement for in-services on abuse and training. On 08/08/24 at 2:38 p.m., the Administrator stated the facility did go over incident reports in their QAPI meetings. They stated the meetings were a month behind. They stated they did not meet in July because they had an annual survey. They stated the QAPI had not reviewed this incident.

Based on record review and interview, the facility failed to ensure the results of abuse investigations were submitted to the State within five business days for two ( #7 and #8) of three sampled residents reviewed for abuse. The Administrator identified 82 residents resided in the facility. Findings: An Abuse and Neglect policy, undated, read in part, .no resident shall be subject to abuse and/or neglect .All incidents to include suspected resident abuse will be reported to the Administrator and Director of Nursing immediately .Any staff member involved in any incident will report it immediately to his/her supervisor, and a written statement would be obtained through interview about the incident. The Administrator will be the person to notify appropriate agencies .the employee will be suspended pending the investigation . 1. Resident #7 had diagnoses which included Alzheimer's disease, dysphagia, and anxiety disorder. An Initial State Reportable Incident form, faxed 07/08/24 at 2:10 p.m., documented an allegation of abuse/mistreatment. It documented a family member of Resident #7 reported CNA #4 was verbally abusive during care on the 3:00 p.m. to 11:00 p.m. shift on 07/07/24. It documented video surveillance from the resident's camera was reviewed and the physician and police were notified. It documented the resident was assessed for injuries, the staffing agency the CNA worked for was notified, and the CNA would not be working at the facility during the investigation. A Final State Reportable Incident form, faxed 07/16/24 at 10:10 a.m., documented the investigation was complete and the abuse allegation was unsubstantiated. On 08/08/24 at 12:16 p.m., the Administrator stated abuse was to be reported to the DON and the Administrator. They stated it had to be reported within two hours. They stated the timeline for reporting the final to the State Agency was five days. They stated if the investigation took longer, they would send an Addendum. On 08/08/24 at 12:22 p.m., the Administrator stated Resident #7's incident of abuse was initially reported on 07/08/24. They stated the final report was submitted on 07/16/24. They stated they could not get the accused person to come to the facility and view video footage until the afternoon of 07/15/24. The Administrator stated the final was sent in at 10:00 a.m. on the 16th. 2. Resident #8 had diagnoses which included quadriplegia, post-traumatic stress disorder, and schizoaffective disorder bipolar type. An Initial State Reportable Incident form, dated 06/02/24 at 3:20 p.m., documented an allegation of abuse/mistreatment. It documented the family of Resident #8 observed video footage of CNA #3 cursing and arguing with Resident #8. It documented the CNA was suspended pending an investigation. A Final State Reportable Incident form, faxed 06/11/24, documented the allegation of abuse was substantiated and CNA #3 was terminated. The supporting documents attached to the incident form documented CNA #3 was observed on video footage cursing and mocking Resident #8. It documented when Resident #8 asked CNA #3 to get out of their room, the CNA replied make me get out. There were two faxed confirmations for this form with the same date but different times. One documented 11:20 a.m. and one documented 11:28 a.m. On 08/08/24 at 2:15 p.m., the Administrator stated the allegation of abuse for Resident #8 occurred on Sunday June 2nd. They stated the allegation was reported to the facility by a family member who had video surveillance of the event. They stated the original report was sent to OSDH on 06/02/24. They stated the final report was faxed on 06/11/24. They stated, It was late, but it was done.

Based on observation, record review, and interview, the facility failed to utilize a safe transfer technique when transferring a resident who required two-person physical assistance for one (#10) of one sampled resident observed during a transfer. The Administrator identified 82 residents resided in the facility. Findings: A Safe Lifting and Movement of Residents policy, revised 07/17, read in part, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .Manual lifting of residents shall be eliminated when feasible .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices . Resident #10 had diagnoses which included nontraumatic subarachnoid hemorrhage and hemiplegia affecting left nondominant side. Resident #10's Care Plan, initiated on 09/24/23, documented the resident required one to two person assistance with all ADLs due to left sided hemiplegia from a stroke. It documented the intervention for transfers was the resident required a mechanical lift with two staff assistance for transfers. The care plan also documented a focus area for falls. It documented Resident #10 required two person assistance with all transfers with a mechanical lift. An Incident Report, dated 04/10/24, documented Resident #10 had experienced a witnessed fall without injury. It documented Resident #10 stated a CNA was trying to transfer them from the bed to the wheelchair after getting changed. It documented the bed was not low enough, and the resident was lowered to the floor by the CNA. Resident #10's Care plan was updated with interventions which included 04/10/24 actual fall noted educate staff on proper transfer technique, make sure bed is in proper position before transfers. An Incident Report, dated 05/02/24, documented Resident #10 had experienced a witnessed fall without injury. It documented the CNA had notified the nurse the resident had falled on the floor during a transfer from the wheelchair to the bed. Resident #10 reported their bad foot got caught and they ended up on the floor. Resident #10's Care Plan was updated with interventions which included 05/02/24 actual fall no injuries intervention educate staff on proper transfer technique. A Quarterly Resident Assessment, dated 05/15/24, documented Resident #10's cognition was intact, and they had an impairment on one side in the upper and lower extremity. It documented the resident required substantial/maximum assistance for toilet hygiene, shower/bath, upper body dressing, lower body dressing and putting on/taking off footwear. It documented Resident #10 was dependent for a chair/bed-to-chair transfer. An Incident Report, dated 08/02/24, documented Resident #10 had experienced a witnessed fall without injury. It documented Resident #10 stated the CNA was transferring them to the bed and the resident got weak in their good leg. It documented both the resident and the CNA went to the floor. Resident #10's Care Plan was updated with interventions which included 08/02/24 actual fall no injuries intervention staff education to use two person assistance with all transfers. On 08/07/24 at 9:41 a.m., CNA #1 and CNA #2 were observed transferring Resident #10 from their wheelchair to the bed. The CNAs placed one arm under each of the resident's arms and hoisted her onto the bed. No gait belt was utilized. On 08/08/24 at 9:50 a.m., CNA #1 stated they should have used the gait belt. On 08/07/24 at 9:53 a.m., CNA #2 stated, The policy is for safety transfers. They stated they would use a gait belt on limited assist residents and sometimes extensive. On 08/07/24 at 10:48 a.m., the Administrator stated the facility trained on use of gait belts, but staff were not required to use them during a transfer. They stated the only policy was to use a lift if it was required. They stated the care plan would document what was required for transfers. On 08/07/24 at 11:55 a.m., Resident #10 stated they were unable to stand on their own because they were paralyzed on their left side. They stated, I've been dropped five times in the last three weeks. They stated The last time was two to three days ago. They stated on the last fall, they were being transferred by one staff member from their bed to the chair. They stated their one leg got weak and they started shaking and the staff member dropped them. Resident #10 stated they did not have a gait belt on when they fell. On 08/07/24 at 12:45 p.m., CNA #1 stated they had heard Resident #10 had experienced falls. They stated the resident had informed them they experienced falls but never involving CNA #1. They stated the resident was a two person assist for transfers. On 08/07/24 at 12:50 p.m., LPN #1 stated Resident #10 was maximum assistance for transfers and toileting. They stated more than one person should assist them with transfers and it could be up to total assist with a lift. LPN #1 stated they were not aware of any falls experienced by the resident. They stated Resident #10 was very alert and oriented, knew what they can and can't do, and would ask for help. On 08/07/24 at 1:33 p.m., the Regional Nurse stated Resident #10 was a two person assist with transfers with a gait belt because the resident could bear weight. On 08/07/24 at 1:36 p.m., the Regional Nurse and DON stated the resident had experienced a fall on 08/02. The Regional nurse stated the resident had also experienced a fall in April and May of 2024. On 08/07/24 at 1:37 p.m., the Regional Nurse stated on 04/10/24 Resident #10 stated the CNA was trying to transfer the resident from the bed to the wheelchair after getting changed. They stated they did not know if the resident was a two person assist during this timeframe. On 08/07/24 at 1:40 p.m., the Regional Nurse stated on 05/02/24 Resident #10 fell during a transfer from the wheelchair to the bed. They stated by reading the report, it was unclear how many staff members were present during the transfer. The Regional Nurse stated the report documented it was CNA #5 who no longer worked for the facility. On 08/07/24 at 1:43 p.m., the Regional Nurse stated on 08/02/24 Resident #10 was transferred by a CNA to bed, got weak, and both the resident and CNA went to the floor. They stated it was a transfer with only one CNA. On 08/07/24 at 1:45 p.m., the Regional Nurse Reviewed Resident #10's care plan and stated it had been updated today by the Regional Nurse. They stated they were informed the resident was a two person assist. They stated before today, the care plan documented the resident required a two person assist with use of mechanical lift for transfers. They stated they did not know the reason the care plan documented mechanical lift. They stated the resident was care planned for a two person assist for transfers since 09/24/23.

Based on record review and interview, the facility failed to monitor nutritional intake for two (#1 and #2) of three sampled residents reviewed for nutrition. The Administrator identified 82 residents resided in the facility. Findings: A Snacks policy, revised 09/10, read in part, .The purpose of this procedure is to provide the resident with adequate nutrition .Supplements to be offered if meal consumption is less than 50 [percent] .To document supplement - Y - for yes supplement given N .supplement not given .record the following information in the resident's medical record .date and time the snack was served .The amount of snack eaten by resident . 1. Resident #1 had diagnoses which included senile degeneration of the brain, dementia, and Parkinson's disease. Resident #1's Care Plan, revised 03/29/24, documented provide regular diet, document how much is eaten after each meal. A Physician Order, dated 05/20/24, documented Resident #10 had a regular diet regular texture, regular thin consistency. A Quarterly Resident Assessment, dated 06/09/24, documented Resident #1's cognition was moderately impaired and required setup or clean up assistance for the task of eating. Resident #1's July 2024 Nutrition Amount Eaten record documented 59 blanks out of 93 opportunities. Resident #1's July 2024 snack pass record documented 57 blanks out of 86 opportunities. Resident #1's July 2024 supplement offer mighty shake if eats less than 50 percent documented 57 blanks out of 86 opportunities. 2. Resident #2 had diagnoses which included hypoxemia and personal history of traumatic brain injury. Resident #2's Care Plan, revised 06/06/24, documented regular no added salt diet, regular texture, regular/thin consistency liquids. It documented serve diet as order and monitor intake and record every meal. Resident #2's Quarterly Resident Assessment, date 07/17/24, documented the resident's cognition was intact and they required setup or clean up assistance for the task of eating. Resident #2's July 2024 Nutrition Amount Eaten record documented 28 blanks out of 93 opportunities. Resident #2's July 2024 snack pass record documented 31 blanks out of 86 opportunities. Resident #2's July 2024 supplement offer might shake if eats less than 50 percent documented 30 blanks out of 86 opportunities. On 08/08/24 at 11:15 a.m., CNA #6 stated if they assisted a resident on the hall with eating, they would document what they ate. They stated if the resident ate in the dining room, then the staff in there would write down what they ate. They stated it was documented in the computer. They stated if there were blanks, it meant Someone didn't do them. On 08/08/24 at 11:20 a.m., CNA #7 stated staff would feed residents and mark the amount consumed on the meal percentages. They stated if the area was blank, They didn't chart it. On 08/08/24 at 11:30 a.m., the DON stated either the nurse or the CNA would document residents' meal intake after they were finished eating. They stated blanks meant It wasn't charted. On 08/08/24 at 11:37 a.m., the DON stated they did not have an explanation for the blanks, and staff wouldn't know whether or not to give a mighty shake if there was nothing documented.

Based on observation, record review, and interview, the facility failed to ensure medication was swallowed by the resident for one (#1) of one sampled resident observed with a medication on their shirt. The Administrator identified 82 residents resided in the facility. Findings: An Administering Medications policy, revised 04/19, read in part, .Medications are administered in a safe and timely manner, and as prescribed .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones . Resident #1 had diagnoses which included senile degeneration of the brain, dementia, constipation, and Parkinson's disease. A Physician Order, dated 05/21/24, documented Colace 100mg give one capsule by mouth one time a day related to constipation. A Quarterly Resident Assessment, dated 06/09/24, documented Resident #1's cognition was moderately impaired. On 08/07/24 at 12:10 p.m., Resident #1 was observed to have a red circular pill on the top of their blue shirt. On 08/07/24 at 12:15 p.m., LPN #1 stated It looks like a pill. They stated maybe it had dropped when the staff gave the resident their pills. On 08/07/24 at 12:16 p.m., CMA #1 stated it was the resident's Colace. They stated the resident spit it out on me. CMA #1 stated they had administered the resident's medication that morning. They stated they were to stand there and make sure [the Resident] swallowed. They stated they did not leave medications in resident rooms. They stated Resident #1 cheeked them. They stated that was the first time the resident had done that. The CMA stated they administered the medication around 10:00 a.m. that morning. On 08/07/24 at 2:00 p.m., the Regional Nurse stated the facility used the punch initial give method for medication administration. They stated staff would verify it was the right medication, right resident, right dose, right time, and right route before administering the medication. They stated staff would sign off on the electronic medical record once the medication was administered.

Based on record review and interview, the facility failed to ensure an accurate PASARR screening was completed for one (#9) of four sampled residents reviewed for PASARR screenings. The Administrator identified 82 residents resided in the facility. Findings: A level 1 PASARR, dated 11/04/21, documented Res #9 had a diagnosis of a serious mental illness and a recent history of mental illness or was prescribed a psychotropic medication. There was no documentation in the resident's chart or on the form indicating a determination for level 2 PASARR was made. On 07/09/24 at 1:25 p.m., the MDS coordinator stated there should have been documentation on the form with the determination for a level 2. They stated the facility was likely told a level 2 was not necessary but did not document it on the form or in the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure CPR was administered in accordance with standards of practice and facility policy. The Administrator identified 82 residents resided in the facility. Findings: A facility policy documented a rate of 30 compressions to two rescue breaths during the administration of CPR. On [DATE] at 12:58 p.m., a staff member retrieved LPN #1 to assist with an unresponsive resident. On [DATE] at 1:04 p.m., CPR was initiated. On [DATE] at 1:09 p.m., the Ambu-bag was observed squeezed five times. On [DATE] at 1:11 p.m., the Ambu-bag was observed squeezed four times, 30 compressions were administered, and a single rescue breath was given and compressions were re-started during the administration of the second rescue breath. On [DATE] at 2:10 p.m., the DON stated they observed compressions and rescue breaths were alternated until EMS responded to the scene. They stated they had corrected the issue with the rescue breaths immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide treatment and services to treat a contracture for one (#22) of one sampled residents reviewed for range of motion. The DON identified three residents with contractures. Findings: 1. Res #22 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction. A physician order, dated 05/17/24, documented Res #22 was to have a hand roll to the left hand at all times except when showering. A quarterly MDS, dated [DATE], documented Res #22 was severely cognitively impaired and had impairment to range of motion on one side. A care plan, revised 07/09/24, documented Res #22 had a contracture to their left hand due to a cerebral vascular accident. The care plan documented the resident was to have a hand roll in their left hand at all times except when showering. On 07/09/24 at 9:32 a.m., Res #22 was observed in their geri-chair being pushed by a staff member. No hand roll was observed in their left hand. The hand was observed to be contracted inward with the pointer finger extended. On 07/11/24 at 8:28 a.m., Res #22 was observed in the dining room seated at a table in their geri-chair. Their left hand was observed contracted with the pointer finger slightly extended. A hand roll was not present in their hand. On 07/11/24 at 8:40 a.m., the restorative aide stated they were not providing any services for Res #22. On 07/11/24 at 8:50 a.m., CNA #3 stated the contracture had been present for a while. They stated they do not do anything for the resident. They stated they would rely on core staff to provide information on resident's care needs. On 07/11/24 at 8:57 a.m., CNA #4 stated the resident's contracture was not new. They stated a rag can be placed in the residents hand. They stated they were unsure if an order to place a hand roll was in place, and no one had communicated that to them. They stated they would have to check with the nurse. On 07/11/24 at 9:03 a.m., LPN #3 stated they were supposed to place a wash cloth and check the hand and nails every shift for changes.

Based on observation, record review, and interview, the facility failed to ensure O2 was administered as ordered by the physician for one ( #85) of three sampled residents reviewed for respiratory therapy. The ADON identified 12 residents who received O2. Findings: Res #85 had diagnoses which included SOB and failure to thrive. A physician order, dated 06/27/24, documented O2 via NC 3 liters continuously. On 07/12/24 at 9:50 a.m., the resident was observed with their O2 tubing not in place. The tubing was on the floor. The O2 concentrator was set at 1.5 LPM. On 07/12/24 at 10:06 a.m., the resident was observed with O2 in place. The O2 concentrator was set at 1.5 LPM. On 07/12/24 at 10:16 a.m., LPN #3 was asked what was the resident's O2 supposed to be set at. They stated they thought they saw it set at 2 LPM, but did not know what the physician ordered. They reviewed the order in the EHR and stated it was supposed to be set at 3 LPM. LPN #3 was asked to verify what the resident's O2 concentrator was set at. They stated 1.5 and it should be 3. They stated that is the reason for the resident's O2 saturation had been 93.

Based on observation and interview, the facility failed to ensure expired supplies were disposed, narcotic medications were kept behind two locks, refrigerator temperatures were checked daily, and multi-use vials were dated when opened. The Administrator identified 82 residents resided in the facility. Findings: On 07/10/24 at 10:29 a.m., the medication room was observed with LPN #2. On 07/10/24 at 10:35 a.m., the white refrigerator was observed containing an undated opened vial of TB skin test, an unopened vial of lorazepam concentrate, not in the clear locked narcotic box, and a bottle of vancomycin solution prepared for enteral administration that was frozen. The temperature log on the front of the refrigerator did not document the month, and had no temperatures documented for the sixth and seventh day. On 07/10/24 at 10:37 a.m., LPN #2 stated they were unable to determine when the TB skin test vial was opened. They stated the narcotic should have been behind two locks. They stated they were unsure how often the med aides were supposed to check the medication room for expired medications. On 07/10/24 at 10:39 a.m., an opened hypodermoclysis kit, five CADD high volume administration sets expired 06/15/23, and 10 CADD high volume administration sets expired 07/18/23 were observed. On 07/10/24 at 10:45 a.m., the DON stated the med aides should check the medication room at least once per week for expired medications and supplies. They stated the TB skin test solution should have been dated when opened. They stated the lorazepam should have been locked behind two locks. On 07/10/24 at 12:09 p.m., the DON stated the night nurse was responsible for obtaining and documented the temperatures of the refrigerator in the medication storage room every shift.

Based on record review and interview, the facility failed to ensure laboratory tests were obtained per physician's orders for one (#67) of five sampled residents reviewed for laboratory testing. The Administrator identified 82 residents resided in the facility. Findings: A Lab Policy & Procedure, undated, documented all laboratory tests will be done as ordered by the physician in a timely manner and the results reported to the physician. Resident #67 had diagnoses which included bipolar, major depression, Diabetes Mellitus, and CHF. A physician's order, dated 06/11/24, documented to obtain a CBC and CMP weekly times two. A laboratory test, dated 06/12/24, documented a CBC and CMP had been collected. There was no documentation the second test had been collected. On 07/12/24 at 4:02 p.m., LPN #4 was asked where Resident #67's second CBC and CMP would be located. LPN #4 looked in Resident #67's EMR and stated they only saw the 06/12/24 lab. LPN #4 then looked in the facilities lab online and stated, I'm not pulling up anything. On 07/12/24 4:21 p.m., the ADON stated, We are missing the second weeks.

Based on observation, record review, and interview, the facility failed to ensure meals were served as scheduled. The Administrator identified 79 residents received services from the kitchen. Three residents received nutrition and hydration solely through a feeding tube. Findings: An undated schedule of meal times, documented breakfast was to be served at 7:30 a.m. On 07/08/24 at 8:31 a.m., food trays were observed being delivered to residents in the dining room. 1. A quarterly assessment, dated 06/20/24, documented Res #52's cognition was intact. On 07/08/24 at 7:45 a.m., the resident was asked about the food. They stated the meals were not always on time. 2. A annual assessment, dated 04/20/24, documented Res #55's cognition was intact. On 07/08/24 at 8:37 a.m., the resident was asked how was the food. They stated the meals were usually late. 3. A quarterly assessment, dated 06/21/24, documented Res #56's cognition was moderately impaired. On 07/08/24 at 8:41 a.m., the resident was asked how was the food. They stated the meals were served late. 4. A quarterly assessment, dated 03/29/24, documented Res #38's cognition was intact. On 07/08/24 at 8:43 a.m., the resident was asked how was the food. They stated meals were not served on time. On 07/10/24 at 2:44 p.m., the DM was asked about meal times. They stated residents who eat in their rooms were served first and then the dining room was served. They stated they tried to get to the dining room within 45 minutes for the scheduled meal time. They were made aware of the above findings.

Based on observation, record review, and interview, the facility failed to promote resident dignity by during dining for two (#6 and #21) of four sampled residents reviewed for dignity. The Administrator identified 82 residents resided in the facility. Findings: 1. An admission assessment, dated 05/10/24, documented Res #6's cognition was intact. It was documented the resident had impairment of their upper extremities and required partial to moderate assistance with eating. 2. A quarterly assessment, dated 05/08/24, documented Res #21's cognition was severly impaired. It was documented the resident was understood, was able to understand, and had adequate vision. It was documented the resident required partial to moderate assistance with eating. On 07/08/24 at 8:43 a.m., CNA #1 was observed standing over Res #6 while assisting them with their breakfast meal. On 07/08/24 at 8:47 a.m., Res #21 was observed with their breakfast plate on the table in front of them. They were placed at the same table as Res #6. Res #21 was observed watching CNA #1 assist Res #6 with their breakfast. On 07/08/24 at 8:55 a.m. CNA #1 was observed assisting Res #21 with their breakfast meal. On 07/09/24 at 8:53 a.m., CNA #1 was asked what was the protocol for assisting residents with their meals. They stated they were instructed not to assist two residents at the same time. They stated they were not trained on if they should sit or stand while assisting a resident. They were made aware of the above observations.

2. A level 1 PASARR screening, dated 09/20/2019, documented Res #8 had no diagnosis of a serious mental illness. A diagnosis, dated 01/15/2020, documented Res #8 had disorganized schizophrenia. On 07/10/24 at 10:08 a.m., the MDS coordinator stated they were unaware a new level 1 PASARR needed to be completed with a new diagnosis of a serious mental illness. 3. A level 1 PASARR screening, dated 02/04/2016, documented Res #22 had no diagnosis of a serious mental illness. A diagnosis, dated 08/20/2016, documented Res #22 had bipolar disorder. A diagnosis, dated 01/01/2018, documented Res #22 had unspecified psychosis not due to a substance or known physiological condition. On 07/10/24 at 10:08 a.m., the MDS coordinator stated they were unaware a new level 1 PASARR needed to be completed with a new diagnosis of serious mental illness. Based on record review and interview, the facility failed to refer residents with newly evident or possible serious mental illnesses to the OHCA for a level II PASARR evaluation for three (#22, 71 and #8) of four sampled residents reviewed for PASARR's. The Administrator identified 82 residents resided in the facility. Findings: 1. A level I PASARR, dated 12/08/23, documented Res #71 did not have evidence or diagnosis of a serious mental illness. The resident's primary diagnosis was documented as CVA and their secondary diagnosis was documented as dementia. On 04/23/24, the resident had a new diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms. There was no documentation the resident had been referred to the OHCA for a level II PASARR evaluation. On 07/10/24 at 11:31 a.m., MDS Coordinator #1 was made aware the resident had a negative level I pre-screen and was later identified with newly evident of possible serious mental illness. They were asked if the resident was referred to the OHCA for a level II PASARR evaluation. They stated they did not contact the OHCA due to the resident having a diagnosis of dementia.

Based on observation, record review, and interview, the facility failed to provide ADL care to dependent residents for two (#26 and #85) of three sampled residents reviewed for ADLs. The Administrator identified 82 residents resided in the facility. Findings: 1. Res #26 had diagnoses which included aphasia, need for assistance with personal care, and flaccid hemiplegia affecting the left dominant side. An annual assessment, dated 05/30/24, documented the resident's speech was not clear, sometimes understood, and usually understands. It was documented the resident required substantial/maximal assistance with personal hygiene. The June 2024 survey report for personal hygiene documented personal hygiene to include combing the resident's hair was not completed six out of 30 opportunities. On 07/08/24 at 7:49 a.m., the resident was observed with a bonnet on their head. On 07/08/24 at 9:31 a.m., the resident was observed without a bonnet on their head. Their hair was not combed. 07/11/23 at 8:56 a.m., the resident was observed without a bonnet on their head. The hair on the back of their head was flattened to their head and their hair was not combed. They were asked if their hair was combed daily. They shook their head no. They stated their hair had been matted. They gestured with their hands their hair was much longer than what it was now. They were asked who cut their hair. They stated staff. They were asked if they wanted their hair combed daily. They shook their head yes. On 07/11/24 at 9:06 a.m., CNA #2 was asked how often the resident's hair was combed. They stated when they got the resident up they combed their hair. They stated they documented completion of personal hygiene in the EHR. They stated the resident wore a bonnet while in bed to prevent their hair from becoming matted. They stated not too long ago the resident's hair had to be cut due to being matted. On 07/11/24 at 9:51 a.m., LPN #2 was asked how often the resident's hair was combed. They stated their hair was combed all of the time. They stated if the resident stayed in bed their hair got tangled. They stated staff did not always know how to manage the resident's hair and it got matted. They stated they were not aware of the resident's hair being cut due to being matted. On 07/11/24 at 10:20 a.m., the DON was asked about the resident's hair having to be cut due to matting. They stated they knew the resident's hair had to be cut due to being matted. They stated staff who had experience dealing with ethnic hair cut it. They were shown on the survey report where it was not documented personal hygiene was being completed. 2. Res #85 had diagnoses which included cerebrovascular disease, dementia, and failure to thrive. A care plan, dated 06/17/24, documented the resident was incontinent of bowel and bladder. It was documented the resident used a brief and to change frequently and as needed. A significant change assessment, dated 06/28/24, documented the resident's cognition was severly impaired. It was documented the resident was dependent on staff for toileting, hygiene, and was always incontinent of bowel and bladder. On 07/12/23 at 10:26 a.m., Resident #60 was observed in bed positioned to their left side. Resident #60's incontinent brief was observed to be saturated with urine. LPN #3 stated Resident #60 had not been changed this shift. On 10:30 a.m., the DON and CNA #7 were observed to provide incontinent care for Resident #60. Resident #60's incontinent brief was observed to be saturated with urine.

Based on record review and interview, the facility failed to monitor and document blood pressures as ordered by physician for two (#60 and #189) of 22 sampled residents reviewed for following physician's orders. The Administrator identified 82 residents resided in the facility. Findings: 1. Resident #189 had diagnoses which included anoxic brain damage. A physician order, initiated on 03/21/24, documented the resident was to receive amlodipine 10 mg daily via peg tube. Hold if blood pressure is less than 110/65. March, April, May, June, and July 2024 MARs/TARs were reviewed for blood pressure monitoring. There was no documentation blood pressures had been monitored. On 07/12/24 at 9:45 a.m., the DON stated the medication order initiated 3/21/24 was to be held if BP was less than 110/65. There was no documentation blood pressure had been monitored from 03/21/24 through 04/25/24. There were 34 missing blood pressure entries to ensure blood pressure had been monitored. The DON stated the nurses would be unable to hold the medications appropriately if the blood pressures were not monitored. The DON stated staff were not following the physician's orders. 2. Resident #60 had diagnoses which included hypertension. A Physician's Order, dated 05/08/24, documented to administer Clonidine Oral Tablet 0.1 mg every eight hours as needed for SBP 160 or greater. May, June, and July 2024 MARs/TARs were reviewed for blood pressure monitoring. There was no documentation blood pressures had been monitored every eight hours. On 07/12/24 at 2:13 p.m., the corporate nurse was asked how frequently staff should monitor a resident's blood pressure if they had an order for Clonidine as needed every eight hours for SBP of 160 or greater. They stated it should be monitored every eight hours.

Based on observation, record review, and interview, the facility failed to ensure food was palatable and served at appetizing temperatures during meals. The Administrator identified 79 residents received services from the kitchen. Three residents received nutrition and hydration solely through a feeding tube. Findings: 1. A quarterly assessment, dated 04/11/24, documented Res #1's cognition was intact. On 07/08/24 at 6:09 a.m., the resident was asked how was the food. They stated the food was not warm. 2. A quarterly assessment, dated 06/20/24, documented Res #52's cognition was intact. On 07/08/24 at 7:45 a.m., the resident was asked how was the food. They stated the food was cold. 3. A quarterly assessment, dated 05/15/24, documented the Res #28's cognition was moderately impaired. On 07/08/24 at 8:22 a.m., the resident was asked how was the food. They stated the food was not great. They stated they received a mechanical soft diet and the meat was like mush. 4. A annual assessment, dated 04/20/24, documented Res #55's cognition was intact. On 07/08/24 at 8:37 a.m., the resident was asked how was the food. They stated the eggs were always cold. 5. A quarterly assessment, dated 06/21/24, documented Res #56's cognition was moderately impaired. On 07/08/24 at 8:41 a.m., the resident was asked how was the food. They stated the food was always cold. 6. A quarterly assessment, dated 03/29/24, documented Res #38's cognition was intact. On 07/08/24 at 8:43 a.m., the resident was asked how was the food. They stated the French toast was soggy, the bacon was hard to chew, and the food was cold. A weekly menu, dated week three, documented at lunch on 07/10/24 residents were to receive crab cakes, macaroni and cheese, vegetable blend, dinner roll, coconut cake, beverage of choice, and butter. On 07/10/24 at 12:12 p.m., the lunch cart for hall 100 was delivered to the hall from the kitchen. On 07/10/24 at 12:24 p.m., one tray was remaining on hall 100 cart. The tray was removed for testing. The food was luke warm. The crab cake was 112 degrees F, macaroni and cheese was 113 degrees F, and the vegetable blend was 115 degrees F. The crab cake was not palatable. On 07/10/24 at 12:29 p.m., the lunch cart for hall 400 was delivered to the hall from the kitchen. On 07/10/24 at 12:53 p.m., two trays were remaining on the hall 400 lunch cart. A tray for testing was removed from the cart. The food was luke warm. The temperature of the grilled cheese sandwich was 104 degrees F, macaroni and cheese was 118 degrees F, and the vegetable blend was 121 degrees F. On 07/10/24 at 2:44 p.m., the DM was asked how staff ensured the food was palatable and served at appetizing temperatures. They stated they took food temperatures and tasted the food they made. They stated once the hall cart left the kitchen they had no control. They were asked if they tasted the crab cake. They stated they did not. They were made aware of the above observations.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The Administrator identified 79 residents received services from the kitchen. Three residents received nutrition and hydration solely through a feeding tube. Findings: On 07/09/24 at 11:20 a.m., a tour of the kitchen was conducted. The following observations were made. a. There was a hole in the wall below the two compartment sink, b. There was black and white residue on the floor and the wall below the dish washer area c. There was a gap between the floor and the wall below the dish washer area, d. Two of two door gaskets were torn on the True two door reach in cooler, e. One of two door gaskets were torn on the True three door reach in freezer, f. Base boards were missing near the microwave rack, g. Grout was missing between the counter tiles on the serve out window, h. Black and white residue was on the floor under the ice machine, i. One of two oven hood lights were burned out and/or not working, j. Plastic lids on bulk dry ingredient containers of oatmeal, sugar, and flour were cracked, k. Base boards were missing behind the dry ingredient table, l. Material was peeling off of the wall behind the dry ingredient table, m. There was black residue on the floor and the wall under and behind the stove, n. Water was leaking from the neck of the faucet on the one compartment sink, o. There was a crack in the ceiling near the ice machine, p. Material was peeling off of the ceiling around the fire sprinkler above the steam table, q. There was brown residue on the shelf below the food preparation table across from the cook line, r. There was a gap between the wall and the floor behind the one compartment sink. Floor tiles were missing and there was black residue. s. The sides of the hand sink cabinet was warped, t. Material was peeling off of the ceiling and the heat/air unit in the dry storage room; and u. Base boards and Formica were cracked and/or missing on the bottom shelving in the dry storage room. On 07/10/24 at 11:48 a.m., the DM was asked how staff ensured the kitchen was kept clean and maintained in good repair. They stated they cleaned daily and reported maintenance concerns to the maintenance department. They were shown the above findings.

Based on observation, interview, and record review, the facility failed to: a) Place dirty linens in a plastic bag before removing from the res room for 1 (#22) of who were dependent on staff for ADL care, b) Provide environmental cleaning, disinfection, and reprocessing of reusable resident medical equipment for wrist blood pressure cuff (CNA #1) between residents, and proper hand hygiene breaks in infection control (CNA #2) wiping sanitized hands on front of their top and pant legs without re-cleaning hands, c) Replace O2 tubing after the NC touched the floor and was placed back into the res nose for 1 (#85) of 12 residents who were O2 dependent; and d) Maintain an infection control program for enhanced barrier precautions by donning gowns prior to wound care for 2 (#60 and #40) of who received wound care at the facility. The Administrator identified 82 residents residing at the facility. Findings: An Enhanced Barrier Precautions policy, dated 04/01/24, read in part, .an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities .High-contact resident care activities include .Wound care .such as pressure ulcers . 1. On 07/08/24 at 5:21 a.m., CNA #5 applied gloves in hallway and entered Resident #22's room to assist them out of bed to go to the bathroom. CNA #5 removed wet sheets from the bed and carried them out to the linen bin at the other end of the hallway. The soiled linens were not placed in a bag. On 07/08/24 at 5:25 a.m., CNA #5 applied clean gloves and then assisted Resident #22 to find clean clothes to wear after redressing the bed. They did not sanitize or wash their hands between applying new gloves either time. On 07/08/24 at 05:54 a.m. CNA #5 stated they should have washed their hands between every room. They stated they should have taken the dirty linen bin to the room with them. On 07/12/24 at 10:03 a.m., the ADON stated direct care staff are to sanitize or wash hands before entering a resident's room. They are to wear gloves when providing care and sanitize and change gloves when going from dirty task to a clean task. Staff are to remove soiled linens from rooms in plastic bags. 2. On 07/10/24 at 8:29 a.m., CMA #1 was observed obtaining a blood pressure from a resident using a wrist cuff. On 07/10/24 at 8:35 a.m., CMA #1 was observed placing a spoon onto the mouse pad on the medication cart and then using it to stir a medication in water for a resident. On 07/10/24 at 8:42 a.m., CMA #1 was observed using the same blood pressure wrist cuff to obtain a blood pressure reading from a different resident. The CMA was not observed cleaning the blood pressure cuff prior to placing it on the resident. On 07/10/24 at 8:50 a.m., CMA #1 stated they should not have placed the spoon onto the mouse pad. On 07/10/24 at 9:13 a.m., CMA #2 was observed using hand sanitizer and wiping their hands onto the front of their top and legs of their pants. The CMA was not observed re-cleaning their hands. 4. Resident #60 had diagnoses which included stage 3 pressure ulcer to the left outer ankle. A physician's order, dated 05/23/24, Enhanced Barrier Precautions every shift. A physician's order, dated 07/11/24, documented to clean the left lateral ankle with normal saline, pat dry, apply Santyl ointment to wound bed, apply calcium alginate, and cover with a dry dressing on Mondays, Wednesdays, and Saturdays. On 07/12/24, at 9:20 a.m., Enhanced barrier precaution signage was observed on Resident #60's door. It documented to wear gloves and gowns for wound care. LPN #3 was observed to enter Resident #60's room and perform wound care to the left outer ankle pressure ulcer. LPN #3 did not wear a gown during the wound care. 5. Resident #40 had diagnoses which included sacral pressure ulcer. A physician's order, dated 07/09/24, documented to cleanse sacrum with NS, pat dry- soak gauze with Dakins (wring out gauze) then pack in wound and cover with dry dressing daily and PRN soiled/dislodged. On 07/12/24 at 10:13 a.m., Resident #40 was observed sitting in a wheelchair in their room. Enhanced barrier precaution signage was observed on Resident #40's door. It documented to wear gloves and gowns for wound care. On 07/12/24 at 12:21 p.m., LPN #3 was observed to enter Resident #40's room and perform wound care to Resident #40's the sacral area. CNA #7 came in to assist with positioning the resident. LPN #3 was observed to clean the coccyx area with normal saline, apply Dakins soaked gauze to sacral area, and had placed a dry dressing to the pressure ulcer. LPN #3 and CNA #7 did not wear gowns during the wound care. On 07/12/24 at 12:27 p.m., the IP nurse entered Resident #40's room and told LPN #3 they had to stop wound care, wash their hands, and put a gown on in order to follow enhanced barrier precautions. LPN #3 stated, What's the point? The IP nurse told her she had to stop with wound care. LPN #3 and CNA #7 stopped, removed their gloves, washed their hand, and donned gowns and gloves. LPN #3 resumed securing the dry dressing to the sacral area. On 07/12/25 at 12:33 p.m., the IP was asked what the protocol was for enhanced barrier precautions. They stated staff should put a gown on at the resident's door, wash their hands, and put gloves on. The IP was informed LPN #3 had not followed enhanced barrier precautions with Residents #40 and #60. 3. Res #85 had diagnoses which included SOB and failure to thrive. A physician order, dated 06/27/24, documented O2 via NC 3 liters continuously. On 07/12/24 at 9:50 a.m., the resident was observed with their O2 tubing not in place. The tubing was on the floor. On 07/12/24 at 10:06 a.m., the resident was observed with O2 in place. On 07/12/24 at 10:08 a.m., RN #1 was asked if the resident's O2 had been on the floor. They stated it had. They stated they were in training, but wiped off the tubing with an alcohol wipe before they placed it back on the resident. On 07/12/24 at 10:16 a.m., LPN #3 was asked what was the protocol if a residents O2 tubing was observed on the floor. They stated it should be replaced. They stated the floor was dirty. On 07/12/24 at 10:31 a.m., the DON was asked what was the protocol if a residents O2 tubing was observed on the floor. They stated the tubing should be replaced. They were made aware of the above observations.

Based on record review and interview, the facility failed to provide medical record to a resident's representative upon request for one (#3) of one sampled resident reviewed for medical records. The Administrator identified 80 residents resided in the facility. Findings: An Access to Personal and Medical Records policy, revised 05/17, read in part, .Access to the resident's personal and medical records will be provided to the resident within 1 week .of his or her request .The resident .may grant others the right to access the resident's records if such request is made in writing and identifies the information that is to be released and to whom the information is to be released . Resident #3 had diagnoses which included bipolar and schizophrenia. An AUTHORIZATION FOR ACCESS BY PATIENT OR DISCLOSURE OF PROTECTED HEALTH INFORMATION form, dated 02/20/24, documented Resident #3 signed the release of their medical records to their representative. On 03/06/24 at 12:58 p.m., the Administrator stated they were not aware Resident #3's family had requested medical records. They stated it takes a week for the release of medical records. On 03/06/24 at 1:04 p.m., the Medical Records stated Resident and the Resident's representative requested medical records during their care plan meeting on 02/20/24. They stated they compiled the medical records and sent them to legal the next day. On 03/06/24 at 1:10 p.m., the Administrator stated corporate informed them they released the medical records to the Resident's representative on the request form. On 03/06/24 at 1:50 p.m., the Administrator provided an email correspondence dated 03/06/24. It documented unsuccessful attempts to contact the person on the request form regarding the medical record pick up. They were unable to provide documentation on the release of the medical records prior to 03/06/24.

Based on record review and interview, the facility failed to ensure a resident was not involuntarily discharged for one (#2) of three sampled residents reviewed for involuntary discharge. The Administrator identified 80 residents resided in the facility. Findings: A Transfer or Discharge Documentation policy, revised 12/16, read in part, .Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by a physician .The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The following information will be communicated to the receiving facility or provider .Resident representative information including contact information . A Transfer or Discharge, Emergency policy, revised 08/18, read in part, .Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures .Notify the representative (sponsor) or other family member . Resident #2 had diagnoses which included dementia, schizoaffective disorder, and bipolar. A progress note, dated 12/01/23, read in part, Resident experiencing increased delusions religious in nature .received order to transfer to geri psych for further eval, treatment, and stabilization. Resident #2's discharge assessment return anticipated, dated 12/01/23, documented the Resident had an unplanned discharge to an inpatient psychiatric facility. Resident #2's medical record was reviewed for documentation regarding their transfer on 12/01/23 and the reason the Resident did not return to the facility. No such documentation was found. On 03/05/24 at 1:30 p.m., the Administrator stated Resident #2 was transferred to [hospital name withheld] on 12/01/23 due to behaviors. They stated Resident #2 went to a sister facility on 12/15/23 upon discharge from the hospital. On 03/05/24 at 1:41 p.m., the Administrator stated Resident #2 did not return to the facility because the Resident was a danger to self and others due to their behaviors. They stated they could not meet the Resident's needs at the facility. On 03/05/24 at 1:48 p.m., the Administrator stated there was no contact information in Resident #2's medical record for a DPOA to notify them about the transfer to the hospital that occurred on 12/01/23. On 03/05/24 at 3:52 p.m., the Administrator stated they did not know if Resident #2 or their DPOA were given a notice of the Resident's discharged from the hospital to the sister facility. On 03/05/24 at 3:53 p.m., the Administrator stated there was no physician documentation in Resident #2's medical record for the reasons the Resident could not return to the facility.

Based on observation, record review, and interview, the facility failed to provide a homelike environment for one (#51) of 24 sampled residents reviewed for homelike environment. The Resident Census and Conditions of Residents report, dated 07/05/23, documented 81 residents resided in the facility. Findings: A Homelike Environment policy, revised 02/21, read in parts, .Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible .clean, sanitary and orderly environment .clean bed and bath linens that are in good condition . On 07/05/23 at 9:46 a.m., Resident #51 was observed lying in bed with a pillow under their head. The pillow did not have a pillow case on it. The pillow was observed to have a large purple/black colored area measuring approximately 12 inches in length by approximately 2 1/2 inches in width on the bottom right side of the pillow (orientation facing the resident). The resident was unable to answer questions about the pillow. On 07/05/23 at 9:48 a.m., RN #1 was asked the reason Resident #51 did not have a pillowcase on their pillow. They stated the resident moved around a lot and it slides off. RN #1 was asked if they could locate a pillow case on Resident #51's bed. They observed the resident's bed and stated, No. On 07/05/23 at 9:49 a.m., RN #1 was asked to explain the large purple/black area on Resident #51's pillow. They stated they were not sure, but it could have been marker from writing their name on the pillow. On 07/05/23 at 10:01 a.m., the DON and CNO were asked the policy for providing a clean homelike environment. The CNO stated housekeeping was supposed to clean and dust. On 07/05/23 at 10:02 a.m., the DON and CNO were asked the policy for resident linens. The CNO stated laundry kept resident linens and watched for stains. They stated the laundry would let the administration know if new linens needed to be ordered. The DON and CNO were asked the policy for providing residents with pillow cases. The CNO stated the facility had pillow cases and should replace them when needed. On 07/05/23 at 10:04 a.m., the CNO and DON were asked to observe Resident #51's pillow and identify if there was a pillow case present and if the pillow was clean and in good repair. The DON shook their head no. The CNO stated, Well it does need a pillowcase. The CNO stated they did not know if that was a facility pillow. On 07/05/23 at 10:17 a.m., the DON stated someone had written Resident #51's name on the pillow, and when it was washed, it smeared the name. They stated the pillow still should have had a pillowcase on it.

Based on record review and interview, the facility failed to ensure a resident received a diagnostic test for one (#41) of one sampled resident reviewed for diagnostic tests. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 81 residents resided in the facility. Findings: Resident #41 had diagnoses which included cerebral infarction and seizures. An After Visit hospital summary, dated 05/26/23, documented an appointment for a CT angiogram of the heart and an echo cardiogram to be conducted on 06/22/23 at the hospital. It documented the following medications to take prior to the CT angiogram: a. prednisone 50 mg, 13 hours, seven hours, and one hour prior to test; b. benadryl 50 mg, one hour prior; c. metoprolol 50 mg, 12 hours prior, and 50-100 mg one hour prior; d. valium 5-10 mg, one hour prior; and e. diltiazem if patient has COPD or asthma. On 07/10/23 1:37 p.m., the DON was asked about Resident #41's diagnostic tests. They stated the pharmacy didn't send all of the medication protocol, so the tests had to be rescheduled. On 07/10/23 at 2:11 p.m., the CNO stated the orders for the diagnostic tests were very confusing. They stated they were unsure if staff had put the orders in correctly and there were questions as to what medications Resident #41 was supposed to take the day of the tests.

Based on record review and interview, the facility failed to ensure residents were offered the opportunity to formulate an Advance Directive for three (#23, 27, and #63) of 24 sampled residents reviewed for Advance Directives. The Resident Census and Conditions of Residents report, dated 07/05/23, documented 81 residents resided in the facility. Findings: 1. Resident #27 had an initial admission date of 07/13/18 and a current admission date of 03/30/23. There was no documentation Resident #27 had been given the opportunity to formulate an Advance Directive. 2. Resident #63 had an initial admission date of 02/01/23. There was no documentation Resident #63 had been given the opportunity to formulate an Advance Directive. 3. Resident #23 had an initial admission date of 06/12/13 and a current admission date of 08/19/22. There was no documentation Resident #23 had been given the opportunity to formulate an Advance Directive. On 07/06/23 at 1:42 p.m., the CNO stated they were unable to locate the Advance Directive acknowledgement form for Resident #27 and Resident #63. The CNO was asked the policy for offering residents the right to execute an Advance Directive. They stated, It's supposed to be completed on admission with their contract. On 07/06/23 at 2:42 p.m., the Social Services staff stated Resident #23 was missing the admission paperwork and had no admission form regarding Advance Directives.

3. Resident #65 had diagnoses which included sacral pressure ulcer. A Wound Assessment, dated 05/03/23, documented a sacral wound measuring 0.5 x 2.0 x 0.2 cm. A Nurse Charting note, dated 05/04/23 at 4:57 p.m., documented the wound care practitioner had been in house. They had given a new order to treat a re-opened wound to the right gluteal/sacral area with normal sterile saline, pat dry, apply triad/nystatin cream/triamcinolone compound and leave open to air. A Wound Assessment, dated 05/10/23, documented a sacral wound measuring 0.5 x 2.0 x 0.2 cm. A Skin/Wound Note, dated 05/18/23 at 12:26 p.m., documented the consultant wound care practitioner had been in house and assessed Resident #65's sacrum wound and to continue the current orders. A Skin Assessment, dated 06/07/23, documented documented the sacral wound was stage IV and measured 0.5 x 0.5 x 0.2 cm. A Skin Assessment, dated 06/14/23, documented documented the sacral wound measured 0.5 cm x 0.2 cm x 0.4 cm A Skin/Wound Note, dated 06/14/2023 at 7:26 p.m., documented the wound practitioner had been to assess Resident #65's sacral wound. They wrote a new order to cleanse the sacral wound with normal saline, pat dry, apply Iodosorb and cover with a dry dressing daily and as needed. A Resident Assessment, dated 06/20/23, documented Resident #65's cognition was intact and they had a stage III pressure ulcer on admit. A Skin Assessment, dated 06/21/23, documented documented the sacral wound measured 0.5 x 0.2 x 0.4 cm. A Skin Assessment, dated 06/28/23, documented documented the sacral wound was unchanged. A Skin Assessment, dated 07/07/23, documented the sacral wound had improved. A Skin/Wound Note, dated 07/08/23, documented the wound care practitioner had been in to assess Resident #65's sacral wound. They wrote new treatment orders to cleanse the wound with cleanser, pat dry, apply collagen to wound bed, cover with an island dressing, and change three times per week and as needed. On 07/11/23 at 1:56 p.m., Resident #65's sacral wound was observed. The wound bed appeared pink, without drainage, and was smaller than pea size. On 07/11/23 02:07 p.m., the CNO was asked to to verify the wound care consultants had not been in the facility to assess wounds the two weeks between 05/18 and 06/07/23. They stated, I know of one, but the DON said it was two. Based on record review and interview, the facility failed to ensure physician ordered weekly skin assessments were completed on residents with pressure ulcers for three (#63, 65, and #182) of four sampled residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 07/05/23, documented nine residents with pressure ulcers greater than a stage I. Findings: A Pressure Ulcers/Skin Breakdown policy, revised 04/18, read in part, .the nurse shall describe and document/report the following .Full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . 1. Resident #63 had diagnoses which included stage III pressure ulcer of the right lateral plantar foot and stage III pressure ulcer of the right calcaneous. A Physician Order, dated 04/19/23, documented weekly skin assessments on Wednesday on night shift. A Wound Assessment, dated 05/17/23, documented Resident #63 had a stage III pressure ulcer of the right lateral plantar foot which measured 1.5 length x 1.5 width x 0.2 cm depth. It documented the wound progress was unchanged. It documented Resident #62 had a stage three pressure ulcer of the right calcaneous which measured 3 x 4 x 0.2 cm. It documented the wound progress was unchanged. A Physician Order, dated 06/06/23, documented weekly skin assessments on Tuesday on evening shift. A Wound Assessment, dated 06/07/23, documented Resident #63 had a stage III pressure ulcer of the right lateral plantar foot which measured 1.5 x 1.5 x 0.2 cm. It documented the wound progress was unchanged. It documented Resident #62 had a stage III pressure ulcer of the right calcaneous which measured 4 x 3.5 x 0.3 cm. It documented the wound progress as worsening. The assessment was signed by APRN #1. There were no wound measurements located in Resident #63's clinical record between the 05/17/23 and 06/07/23 dates. On 07/10/23 at 10:06 a.m., the wound care nurse was observed providing wound care to Resident #63's right lateral plantar foot and right calcaneous. The wound care nurse was observed to use proper technique during the observation, no cross contamination was observed. Neither wound was observed to be actively draining and there was no necrotic tissue observed on either wound. The right lateral plantar foot wound was approximately dime sized with white edges present. The right calcaneous wound was observed to have a deep pink center with white edges present, the wound was a triangular shape. On 07/10/23 at 10:37 a.m., the wound care nurse was asked how often wounds were measured and by whom. They stated wounds were measured weekly by the nurse practitioner. They were asked if Resident #63's wounds were improving. They stated, Yes, very much so. On 07/10/23 at 11:31 a.m., the DON was asked for the policy for measuring pressure wounds. They stated the wound care nurse and provider from the wound care company measured wounds weekly together. On 07/10/23 at 11:32 a.m., the DON was asked who was responsible for measuring pressure wounds. They stated, The nurse practitioner measures. On 07/10/23 at 11:33 a.m. the DON was asked if Resident #63 had pressure wounds. They stated the resident had one on their heel and one on their right lateral plantar foot. On 07/10/23 at 11:37 a.m., the DON was asked to explain the reason for the gap in wound care visits for Resident #63 from 05/17/23 to 06/07/23. The DON reviewed the notes and stated the wound care company was out with the flu and the nurses were doing their own wound care. They stated the ADON was helping with their wound care at the time, but left abruptly one day. On 07/10/23 at 11:39 a.m., the DON was asked if Resident #63's pressure wounds were measured and evaluated during that time. They stated they would have to look into it and get back with an answer. On 07/10/23 at 11:41 a.m., the DON was asked to review Resident #63's wound care notes, dated 05/17/23 and 06/07/23, and identify if either wound had gotten larger or worsened during that time. The DON reviewed the record and stated the right calcaneous wound had changed during that time. On 07/10/23 at 8:52 a.m., the DON stated they could not verify Resident #63's wounds were measured during the missing weeks. They stated the facility did not have measurements of the wounds during that time. 2. Resident #182 had diagnosis which included pressure ulcer of sacral region, diabetes mellitus type two, stage III pressure ulcer of left heel, stage III pressure ulcer of right ankle, osteomyelitis, and paraplegia. A Care Plan, dated 05/17/23, documented Resident #182 had wounds. It documented to provide treatments and dressings as ordered by the physician. A Physician Order, dated 06/29/23, documented weekly skin assessments on Thursday on evening shift. A Weekly Wound Assessment report, dated 05/10/23, documented the resident had multiple wounds to their sacrum, left heel, right lateral ankle, and right lateral heel. It documented the wound to the sacrum was a stage II but now a stage III, measurements: length 115mm x width 40mm x depth 10mm and worsening. Wound to Left Heel measured 30 x 50 x 1mm. Wound to right lateral ankle measured 30 x 50 x 1. Wound to right lateral heel measured 20 x 10 x 3mm. The assessment was signed by APRN #1. A Weekly Wound Assessment report, dated 06/07/23, documented wound to sacrum, stage III had worsened with measurements of 140 x 50 x 25mm. Wound to left heel measured 32 x 40 x 2mm. Wound to right lateral ankle measured 35 x 52 x 7mm. Wound to right lateral heel measured 15 x 6 x 2mm. Wound to left lateral heel measured 10 x 7 x 2mm. Wound to right lateral lower leg measured 15 x 10 x 1mm. A Resident Assessment, dated 06/09/23, documented Resident #182 required extensive assist with bed mobility and transfer, and was frequently incontinent of bowel and bladder. It documented the resident was at risk for pressure ulcers and they had four stage III pressure ulcers. There was no documentation of wound measurements for any wound from 05/17/23 to 06/06/23. On 07/11/23 at 8:25 a.m., the surveyor requested to observe Resident #182's wound care, the resident refused to allow a surveyor to watch the dressings being changed. On 07/11/23 at 10:00 a.m., the wound care nurse was asked to explain if Resident #182's wound to the sacrum has gotten better or worse. They stated the ones on their legs were better and the one on their sacrum they didn't get to see prior to resident going to the hospital in June. The wound care nurse stated the sacral wound looked good after the resident came back from the hospital at the end of June. They were asked if there were any measurements completed on the resident's wounds between the dates of 05/17/23 to 06/07/23. They stated they were not the wound care nurse at the time and were unsure if measurements were completed. On 07/11/23 at 10:53 a.m., the DON was asked to review the weekly assessment for Resident #182's wound care dated 05/10/23 and 06/07/23 and identify if the wounds were getting better or worse. They stated they were worse from the measurements they reviewed. They stated they wondered who completed the measurements. The DON stated that was the time when there was no wound care nurse and the wound care company didn't come to measure. They stated it was probably the nurse practitioner that measured the wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure: a. spare keys to medication and treatment carts were secured and not accessible; b. controlled medications were secured behind two locks; and c. medications were administered as ordered for two (#32 and #34) of five sampled residents reviewed for medication administration. The Resident Census and Conditions of Residents report, dated 07/03/23, documented 81 residents resided in the facility. Findings: A Medication Disposal and Returns policy, dated 05/16/23, read in part, .Full chain of custody should be documented to clearly indicate the removal of the medications from the cart and placed into a secure storage area for destruction . 1. On 07/11/23 at 10:09 a.m., the DON was asked what the policy was for dc'd controlled medications. They stated they were put in a narcotic cabinet and locked. They were asked where the narcotics cabinet was located. The DON stated it was in their office inside a locked closet. They stated the closet was locked and the cabinet was locked and they were the only one with the keys. The DON was asked who had access to medication and treatment carts. They stated the medication aides. The DON was asked if anyone else in the facility had keys to the medication and treatment carts. They stated the pharmacist did. The DON was asked if there were any spare keys to the medication and treatment carts. They stated, No. On 07/11/23 at 10:20 a.m., the closet that contained the discontinued controlled medications was observed. The DON used a key to unlock one of the two locks on door. A file cabinet with three drawers was observed inside the closet. There was a plastic rope like locking mechanism threaded through the handle of the three drawers. Each drawer was able to be partially opened with the controlled medications accessible. The DON stated the rope like lock was not doing any good. On 07/11/23 at 10:50 a.m., the CNO was asked who had keys to medication and treatment carts. They stated the medication aides. The CNO stated they had spare keys to all the carts which the DON kept locked up. They were asked where the DON kept those spare keys. The CNO stated the DON had a lock box and they were usually in the locked destruction closet. The CNO stated they didn't see the box in the closet, so they don't know where it was right now. The CNO was observed to look around the DON's office and stated, I found it. The box which contained the spare keys to all the treatment and medication carts was observed to be unlocked and accessible to anyone in the office. The CNO was asked how they ensured no one had access to those keys. They stated they were kept locked in the closet. The CNO was asked if they had been locked in the closet. They stated, No. The CNO was made aware the DON stated there we no spare keys. 2. Resident #34 had diagnoses which included hypothyroidism. A physician order, dated 07/01/21, documented to administer levothyroxine sodium tablet 150 mcg one daily. The November 2022 MAR, documented blanks for levothyroxine on 11/02, 11/06, 11/18, and on 11/21/22. The December 2022 MAR, documented blanks for levothyroxine on 12/15, 12/19, 12/21, and on 12/23/22. The February 2023 MAR, documented blanks for levothyroxine on 02/09/23. The April 2023 MAR, documented a blank for levothyroxine on 04/15/23. On 07/10/23 at 12:48 p.m., the DON was asked what the blanks on the MARs indicated. They stated, It should say something. It can't say nothing. The DON stated they were going to look in to it. On 07/11/23 at 8:17 a.m., the DON was asked if they were able to verify the levothyroxine had been administered if the MARs had blanks. They stated, I'm not able to verify. 3. Resident #32 had diagnoses which included pain. A Physician's Order, dated 07/01/21, documented to administer Norco 5 mg-325 mg tablet, one every four hours as need for pain. The 2023 March MAR, documented Norco had been administered once on 03/06/23. The Norco Controlled Drug Receipt/Record/Disposition form, documented the Norco had been signed out on 03/05, 03/06, and 03/13/23. The 2023 May MAR, documented Norco had been administered twice on 05/01 and 05/10/23. The Norco Controlled Drug Receipt/Record/Disposition form, documented the Norco had been signed out on 05/01, 05/05, 05/10, 05/11, and on 05/12/23. On 07/11/23 at 2:30 p.m., CMA #5 was asked when staff would sign something out on a controlled count sheet. They stated they would sign it out as it was administered. CMA #5 was shown the March and May 2023 MARs along with the count sheets. They were asked if there were discrepancies in the MAR and count sheets, what did that indicate. CMA #5 stated you can't tell if it's been given because it's not charted. On 07/11/23 at 2:40 p.m., the CNO was shown the above documentation and was asked how they ensured controlled medications were administered if they were not signed out on the MARs. They did not reply. The CNO was asked if the narcotic count sheets were administration logs. They stated, No. [NAME], [NAME] (45583)

Based on observation, record review, and interview, the facility failed to ensure food items were stored and labeled in the refrigerator; and kept at safe temperatures in the freezer. The Resident Census and Conditions of Residents report, dated 07/05/23, documented 81 residents resided in the facility, and three residents received tube feeding. Findings: An undated Receiving Food and Supplies policy, undated, read in part, Food items will be received and handle in accordance with good sanitary practice .All foodstuffs [sic] are to be dated . An undated Purchasing, Receiving and Storage policy, undated, read in part, .Food will be properly stored to preserve flavor, nutritive value, appearance, and safety .The food service director is responsible for inventory control . On 07/05/23 at 8:10 a.m., the initial tour of the kitchen was conducted with the kitchen supervisor as the CDM was not available. Observations of the refrigerator were as follows: a. Beef patties with no label or date, b. Fried okra with no label or date, c. A plastic container of mashed potatoes with no label or date, d. A bag of breadsticks with no label or date, e. A metal container of chicken and beef thawing in separate containers with no label or date, f. A bag of mechanical soft pork with no label or date, g. Eight half sandwiches wrapped in plastic with no label or date, h. Two plastic pitchers of juice with no label or date, i. Three plastic pitchers of water with no label or date, and j. Two trays with 21 cups of juice covered with plastic with no label or date. On 07/05/23 at 8:20 a.m., the freezer was observed to have the following: a. A bag of chicken the supervisor stated had refroze, b. A box of raw biscuits had expanded out of the top of the box and was soft to touch, not frozen, c. A plastic zip bag of french toast sticks, dated 11/25/22, and labeled as pepperoni, and d. A plastic zip bag of eggrolls, not frozen, with no label or date. The kitchen supervisor stated there was a power outage on Monday of that week and the items were not frozen yet. On 07/05/23 at 8:24 a.m., the kitchen supervisor was asked what the policy and procedure was for food storage. They stated, Needs to be labeled and dated with the open date and came in date. The kitchen supervisor was asked if the items identified were labeled and dated. They stated, No. They were asked if the items identified should have been labeled and dated. They stated, Yes, should have been. On 07/05/23 at 1:58 p.m., the kitchen supervisor was asked when was the shipment of biscuits were received. They stated there were already two other boxes of biscuits there when the recent shipment came in on Monday. The kitchen supervisor was asked how long the power was out. They stated they were not present. They stated another staff member stated the power went out at 5:00 p.m. on Monday and had not come back on by the time they had left at 7:45 p.m. On 07/05/23 at 2:05 p.m., the kitchen supervisor was asked if when the freezer items were not frozen to touch, what was the policy. They stated items would be used if they were useable. They stated they would not use if were not under correct temperature, discolored, or dough had risen. They stated they were having problems with the freezer. The kitchen supervisor was asked if maintenance was aware. They stated, they were and that they were told lightening hit the transformer box and could not do anything about it. On 07/06/23 at 8:14 a.m., the CNO provided documentation that the power was not completely out of power and the power was only out for no more than four hours. They stated they kept the freezer closed and that would keep the food frozen if the doors were closed. Other items in the freezer were frozen to touch. Freezer temperatures were acceptable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain an environment free of accident hazards for four (#1, #4, #5, and #6) of four sampled residents who used the facility's smoking patio area. The Resident Census and Conditions of Residents report, dated 03/14/23, documented there were 79 residents residing in the facility. The administrator identified 27 residents in the facility who were smokers. Findings: The ground in the smoking patio area was observed to have three large potholes in the cement and 6 separate areas where the cement was cracked and crumbling. A Grounds policy, revised May 2008, read in parts, .3. Areas around the buildings (i.e., sidewalks, patios .etc.) shall be maintained in a safe and orderly manner at all times. (1) Res #1 had diagnoses that included paraplegia and generalized muscle weakness. Quarterly MDS, dated [DATE], documented Res #1 had BIMS 15, impaired ROM in both lower extremities, was totally dependent for transfers, non-ambulatory, and wheelchair dependent without assistance for mobility. On 03/13/23 at 11:02 a.m., Res #1 was observed on the smoking patio. They were asked if they felt safe navigating the smoking patio area. They stated, No. Somebody is gonna have a bad accident out there. I hope it's not me. (2) Res #6 had diagnoses that included right BK and left AK amputations, muscle wasting, and lack of coordination. admission MDS, dated [DATE], documented Res #6 had BIMS 13, required supervision for transfers, was non-ambulatory, and wheelchair dependent without assistance for mobility. On 03/14/23 at 12:10 p.m., Res #6 was observed on the smoking patio. They were asked if they felt safe navigating the smoking patio area. They stated, No. I am really afraid of that one area over there with the rug on it. It needs to be fixed. (3) Res #4 had diagnoses that included paraplegia, autonomic dysreflexia, and central cord syndrome of cervical spine. admission assessment, dated 03/08/23, documented Res #4 was cognitively intact, non-weight bearing in both legs, required two-person maximum assistance for transfers, was non-ambulatory, and wheelchair dependent without assistance for mobility. On 03/14/23 at 12:12 p.m., Res #4 was observed entering the smoking patio and having the back left wheel of their wheelchair get stuck in a large pothole. Res #4 was assisted by Res #5 to get out of the pothole and maneuver around several areas of cracked and crumbled cement. Res #4 was asked if they felt safe navigating the smoking patio area. They stated, No I don't feel safe out here. The pavement is really uneven. (4) Res # 5 had diagnoses that included depressive disorder and history of suicidal behavior. Quarterly MDS, dated [DATE], documented Res #5 had BIMS 15, was independent for transfers and ambulated independently with a steady gait. On 03/14/23 at 12:15 p.m., Res #5 was asked if they felt safe navigating the smoking patio area. They stated, I'm safer than most of them. I see them struggle lots of times and I help them when I can. On 03/14/23 at 9:06 a.m., the Administrator was asked if they had observed the condition of the grounds in the smoking patio area and they stated no. The Administrator was asked to observe the grounds. On 03/14/23 at 09:28 a.m., the DON was asked if they had observed the condition of the grounds in the smoking patio area and they stated no. The DON was asked to observe the grounds. On 03/14/23 at 11:56 a.m., after the DON had observed the ground in the smoking patio area, they were asked if the condition of the ground was safe and free of accident hazards for residents. They stated, no. On 03/14/23 at 12:10 p.m., after the Administrator had observed the ground in the smoking patio area, they were asked if the condition of the ground was safe and free of accident hazards for residents. They stated, No, we will get that fixed.

Based on record review and interviews, the facility failed to inform residents of the right to participate in care plan meetings for one (#46) of 24 residents reviewed for care plan meetings. Findings: An undated Care Plan Meeting Policy, read in part, Care plan meetings are held quarterly and as needed. Letters are mailed out to families by the Social Services Director prior to the meeting to inform of meeting and invites them to attend . An annual assessment, dated 04/01/21, documented the resident's cognition was intact. The resident was asked during the survey process if he attended his care plan meetings. He stated he did not know anything about them. On 11/17/21 at 10:10 a.m., the social services director (SSD) was asked if the facility had care plan meetings. She stated they did. The SSD was asked to provide documentation care plan meetings had taken place. The SSD stated she did not know what was needed, she stated she sent letters to the families. The SSD was asked for a copy of the letter sent to families and given to residents. The SSD stated she did not have one. The SSD was asked if she retained a copy on the computer or in the resident's chart. The SSD stated she did not know she needed to. The SSD was asked if she had care plan meeting sign in sheets which documented who attended the meetings. She stated, No. She stated we are having meetings. The SSD was asked to provide documentation the meetings were being conducted. The SSD again stated she did not have any.

Based on record review and interview, the facility failed to ensure the facility surety bond covered the daily trust account balances for 43 residents in the resident trust account. The business office manager identified 43 residents in the residents' trust account. Findings: A Surety Bond policy, dated March 2021, read in part, .Our facility has a current surety bond to assure the security of all residents' personal funds deposited with the facility . A Surety Rider dated June, 21, 2021, documented an amount of $110, 000. August, September and October bank statement balances documented the following daily balances: 08/03/21- $123,255.91, 08/05/21- $121,283.91, 08/06/21- $121,343.81, 08/10/21- $121,393.91, 08/11/21- $120,792.91, 09/01/21- $111,709.79, 09/02/21- $110,231.43, 09/03/21- $127,485.73, 09/07/21- $124,912.73, 09/08/21- $130,624.15, 09/09/21- $129,092.37, 09/15/21- $128,343.37, 09/16/21- $128,383.37, 10/01/21- $128,238.18, 10/04/21- $127,468.70, 10/05/21- $125,269.76, 10/06/21- $124,544.66, 10/07/21- $124,394.66. On 11/17/21 at 10:30 a.m., the business office manager was asked if the the daily trust account bank balances exceeded the facilities surety bond. She stated they did and she would need to get the surety bond increased.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a clean, and homelike environment. The assistant director of nursing identified 57 residents resided in the facility. Findings: A Homelike Environment policy, dated 02/2021, read in parts, .Residents are provided with a .clean environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .clean sanitary and orderly environment .pleasant neutral scents . On 11/16/21 at 6:00 a.m., room [ROOM NUMBER] was observed to have a black area on the wall near the towel holder. The housekeeping supervisor stated the black stuff on the wall was dirt from the resident's washcloth. On 11/17/21 at 8:00 a.m., the walls on each hall were observed to have a build up of dirt and debris. Four fluorescent lights on hall 100 were missing covers. The closet doors on hall 100 and 400 had dust and debris build up on the vented area at the bottom of the doors. At 8:03 a.m., housekeeper #1 stated the dirt on the ledge behind the hand rail was supposed to be cleaned daily. She was asked if it had been cleaned. The housekeeper stated the ledge and walls were cleaned if she had time. At 8:19 a.m., room [ROOM NUMBER] had a urine odor. The floor near the bathroom had a darkened/wet area near doorway of bathroom. room [ROOM NUMBER]'s wall near the towel holder remained dirty. At 8:27 a.m., the housekeeping supervisor stated the resident rooms were cleaned daily. The housekeeping supervisor was shown the observations of the dirty walls and vents on the doors in hall 100 and 400. He stated he had ordered new dusters and did not know how often the vents on the doors were cleaned. The housekeeping supervisor stated he had not tried to clean the black area off of the wall in room [ROOM NUMBER].

2. Resident #1 had diagnoses which included hypertension, chronic kidney disease, dementia with behavioral disturbances, pain, persistent mood disorder, and blindness. A care plan, dated 10/26/20, was the most recent care plan for resident #1. A comprehensive resident assessment, dated 10/19/21, documented the resident #1 had severe cognitive impairment, required limited assistance with eating, extensive assistance with bed mobility, dressing and personal hygiene and total assistance for transfers, locomotion, toileting and bathing. It documented resident #1 had taken antidepressants, opioids and antipsychotic medications seven out of the last seven days. On 11/17/21 at 10:04 a.m., the MDS coordinator was asked if resident #1's care plan was up to date. She stated, No. Based on observation, interview and record review, the facility failed to review and revise care plans for two (#1 and #4) of 12 sampled residents whose care plans were reviewed. The assistant director of nursing identified 57 residents resided in the facility. Findings A Care Plans policy, dated 12/2016, read in part, .The Interdisciplinary Team must review and update the care plan .When there has been a significant change in the resident's condition .At least quarterly, in conjunction with the required quarterly MDS assessment . 1. Resident #4 had diagnosis which included pressure ulcer to the right hip A Care plan for alteration in skin integrity, dated 01/20/21, documented the resident was at risk for skin breakdown. A quarterly assessment, dated 10/16/21, documented the resident had one stage two pressure ulcer which required a dressing change. Resident #4's care plan was not revised to include the resident's stage II pressure ulcer. On 11/17/21 at 10:00 a.m., the MDS coordinator stated the care plans had not been updated.

2. Resident #111 had diagnoses which included cervical disc degeneration. A physician's order, dated 03/10/21, read in part, .OT/PT and speech to eval and treat as indicated . On 11/22/21 at 2:35 p.m., the administrator (ADM) was asked if the resident received therapy services. She stated, The resident was not part A and did not have a payor source. The ADM was asked if the physician's order had been followed. She stated since they were unable to get documentation from the old therapy company she was not able to answer the question. No documentation was provided to ensure the resident received a therapy evaluation or services as ordered by the physician. Based on record review and staff interviews, the facility failed to conduct nerological checks after an unwitnessed fall for one (#17) of two residents reviewed for falls and failed to ensure physician's orders were followed for one (#111) of 24 residents whose physician's orders were reviewed. Findings: A neuro check policy, read in part, .NEURO CHECKS: q15 min x4: q30 minx2: q1 hr x4: q shift x5. 1. Resident #17 had diagnoses which included dementia and syncope. An incident report, dated 08/19/21, read in part, .Unwitnessed .resident sitting on the floor, in her room .Incident Description .Resident Unable to give Description .Resident was assessed for injuries .initiated neurochecks . On 11/22/21 at 9:42 a.m., the assistant director of nursing was asked for neuro checks for resident #17. At 1:09 p.m., corporate nurse consultant #1 stated they were not able to find any neuro checks for resident #17.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, it was determined the facility failed to ensure residents with limited range of motion received treatment and services to prevent further decrease in range of motion for three (#4, 46 and #53) of seven sampled residents who received range of motion/restorative services. Findings: A Resident Mobility and Range of Motion policy, revised 07/2017, read in parts, .Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM . 1. Resident #46 had diagnoses which included paraplegia. An annual assessment, dated 04/01/21, read in parts, the resident's cognition was intact, he required extensive assistance for transfers and was impaired on both sides for lower extremity range of motion. A care plan, dated 04/09/2020, read in parts, .Problem: Resident has an alteration in musculoskeletal status r/t pain, quadriplegia, rheumatoid arthritis, muscle spasms, lower back pain, neuromuscular disease and medication use. Goals: Resident will maintain current level of mobility through review period. Plan of approach: .Restorative 2-3x/week for upper and lower extremities ROM and upper extremities strengthening . A Functional Maintenance Plan, dated 09/03/21, documented the resident's restorative therapy plan: .Exercise 3x/week; UE Sets: 1, Reps: 15, Weight 1-2lbs. ROM/Stretching: 3x/week (UE) R.O.M. Arch. 3x week (LE) As tolerated/Bilateral/P.R.O.M. A treatment record, dated November 2021, documented treatment was performed on November 1 and November 9, 2021. On 11/15/21 at 9:24 a.m., the resident was asked if he received range of motion or physical therapy for his legs. He stated he got no range of motion for his legs. He stated his legs were drawn up as he was paralyzed from the waist down. He stated no one worked with his legs at all. The resident's legs were drawn into a cross legged position while he was in bed, but when in his wheelchair his legs were bent at the knee in a normal position. On 11/17/21 at 10:34 a.m., the restorative therapy aide was asked if the resident had been receiving therapy three times per week as ordered. She stated, No, he's not. I've been doing staffing full time and I have not been able to see him three times weekly. 2. Resident #4 had diagnoses which included idiopathic neuropathy, rheumatoid arthritis, muscle weakness, and lack of coordination. A quarterly assessment, dated 10/16/21, documented the resident's cognition was intact, required limited assistance of one person for transferring, dressing, toilet use and personal hygiene, had limited range of motion to the upper and lower extremity on one side, and utilized a wheelchair for ambulation. A physician's order, dated 11/12/21, documented to start restorative active range of motion with 1-2 pounds of weight times 10-15 reps as tolerated and transfer training three times a week on Monday, Wednesday and Friday. On 11/17/21 at 10:14 a.m., the restorative aide stated Res #4 was referred to restorative by the director of rehab. She was asked for documentation of restorative therapy. She stated she had not started his restorative therapy. On 11/22/21 at 12:36 p.m., the director of rehab stated Res #4 had a decline and was on OT and PT to get stronger and help with his balance. The director of rehab stated he was discharged from PT and OT and referred to restorative therapy. 3. Resident #53 had diagnoses which included dementia with behavioral disturbances, COVID-19, chronic fatigue and muscle weakness. A quarterly assessment, dated 10/08/21, documented Res #53 had severe cognitive impairment, required extensive assistance of two people for transfers, dressing, toilet use, bathing and required a wheelchair. A nursing restorative care plan, dated 11/01/21, documented Res #53 was on passive range of motion exercises with passive strengthening to the upper and lower body and eating meals with neck brace in place to ensure proper alignment as tolerated to be done three times a week for 6 weeks. A progress note, dated 11/01/21, documented therapy department notified the nurse Res #53 was having difficulty with holding his head up and suggested a soft neck collar stabilizer. The note documented the physician was notified and an order was received for a soft neck collar. An occupational therapy Discharge summary, dated [DATE], documented the resident made consistent progress and his functional abilities have progressed as a result of skilled interventions. The summary documented Res #53 was discharged from skilled therapy services and would be placed with restorative nursing program. On 11/17/21 at 9:31 a.m., the director of rehab/COTA stated Res #53 was discharged from OT and PT on 11/01/21 and was started on restorative therapy. The director of Rehab stated Res #53 was receiving restorative therapy three times a week. At 9:56 a.m., RA #1 was asked how she knew how who was on restorative therapy. She stated the rehab department or the nursing staff would send a referral if a resident needed restorative therapy. During the interview, the director of rehab came into the room and asked the RA if she was providing restorative therapy services for Res #53. The RA stated no. The director of rehab stated it was her fault because she did not send the referral to the RA. The RA was asked if she had been providing restorative therapy to Res #53. She stated no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure staff: ~ wore face masks at all times and appropriately for three (CNA #1, 2, and #3) of three staff observed, and ~ conducted hand hygiene before, during or after providing incontinent care for three (#113, 19, and #35) of three sampled residents who were observed for incontinent care. The ADON identified 57 residents resided in the facility. Findings: A Handwashing/Hand Hygiene policy, revised 08/2019, read in part, .This facility considers hand hygiene the primary means to prevent the spread of infection .Use an alcohol-based had rub .or .soap .water for the following situations .Before and after direct contact with residents .After contact with a resident's skin .After contact with blood or bodily fluids .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment . On 11/16/21 at 4:25 a.m., CNA #1 and CNA #2 were observed in the facility without a face mask. CNA #3 was observed wearing a face mask below her nose. At 4:35 a.m., CNA #3 was observed entering resident #113's room, donned gloves, and assisted the resident to put on a brief. CNA #3 removed her gloves, and left resident #113's room. She was not observed to have completed hand hygiene. At 4:39 a.m., CNA #3 was observed to don gloves, take linens from the clean linen cart and placed them in room [ROOM NUMBER]. CNA #3 then removed her gloves and left the room. She was not observed to have completed hand hygiene. At 4:43 a.m., CNA #3 was observed to enter room [ROOM NUMBER] and handed the resident the call light. On 11/16/21 at 5:02 a.m., CNA #2 donned a pair of gloves, provided incontinent care to Res #53 who was incontinent of bowel. She discarded the adult brief, and her gloves. The CNA did not perform hand hygiene after removing her gloves. The CNA went to the clean linen cart outside of the room to get clean linen. She donned a new pair of gloves and removed the residents sheets and placed them on the floor. The CNA continued to make the residents bed. She touched the roommates items, and the privacy curtain while wearing the gloves she had used to change the sheets. The CNA did not perform hand hygiene prior to donning a new pair of gloves. At 5:35 a.m., CNA #3 and CNA #4 entered resident #19's room. Both CNAs put on gloves. CNA #4 provided resident #19 with peri-care. After the peri-care had been provided, CNA #4 placed a clean brief, and clothing on resident #19. She transferred the resident to the wheelchair, lowered her bed height with the bed remote, and handed resident #19 her bag and a blanket. CNA #4 was not observed to complete hand hygiene after soiling her gloves, and touched the clean brief, the resident's clothing, the bed remote, the resident's bag, and blanket. At 5:45 a.m., CNA #3 was asked what she had been instructed on regarding face masks. She stated, To always have them on and above your nose. CNA #3 was asked when she should complete hand hygiene. She stated, Before you go give care and when you get done. On 11/16/21 at 6:05 a.m., CNA #2 stated she usually washed her hands or used hand sanitizer after she provided incontinent care. She stated she should have washed her hands after she provided incontinent care to Res #53, before she touched the clean linen. The CNA stated she should not have put the dirty linens on the floor. She stated normally she carried a bag with her. On 11/17/21 at 8:25 a.m., the assistant director of nursing was asked what the policy was for handwashing. She stated, Before and after patient contact. She was asked what the policy was for staff wearing masks. She stated they should wear masks 24/7.

Based on interview and record review, the facility failed to have an RN (registered nurse) director of nursing and have RN coverage eight hours a day/seven days a week. The assistant director of nursing identified 57 residents resided in the facility. Findings: Facility schedules for October and November 2021 documented registered nurse coverage by registered nurse #1 on the weekends only. There was no documentation a registered nurse was scheduled to work Monday through Friday. Daily assignment sheets for November were observed not to have an RN scheduled during the week. On 11/14/21 at 12:26 p.m., the assistant director of nursing was asked the name of the director of nursing. He stated they did not currently have a director of nursing and had not had one for over a month. On 11/23/21 at 8:30 a.m., the scheduling coordinator was asked if registered nurse #1 worked seven days a week. She stated, No. At 8:59 a.m., licensed practical nurse #1 was asked if registered nurse #1 was the only registered nurse currently on the working schedule. He stated, At the moment, Yes. He stated, She works double weekends. At 9:06 a.m, the administrator was informed of the lack of a director of nursing and of registered nurse coverage. She stated they had been advertising for a director of nursing.