Based on interview and record review, the facility failed to protect one out of two sampled residents' [Resident #2] right to be free from physical abuse from a resident to resident altercation. Findings include: Per record review, Resident #1 was admitted to the facility to the Memory Care Unit with diagnoses of Alzheimer's disease, and dementia with behavioral disturbances. Resident #2 was admitted to the facility for nursing and rehabilitative services with current diagnoses of Alzheimer's Disease, and bipolar disorder. Per a facility incident report dated 6/12/24 reads, The staff observed [Resident #1] throw a clipboard at [Resident #2], hitting [him/her] in the elbow. Resident #2 then grabbed the clipboard and threw it back at [other resident named not in report]. [Resident #1] then threw it a second time, but it did not come in contact with [Resident #2]. Staff assessed [Resident #2] for injury with a small 0.5 cm [centimeter] skin tear noted. Although [Resident #2] was the victim in this incident [s/he] has been consistently targeting [Resident #1] as of late, approaching [him/her] and making verbally aggressive comments and statements. It is difficult to know if there was an interaction that was not missed prior to this event. Per initial report sent from the facility to the State Agency on 6/12/24, the facility investigated the alleged physical abuse between Resident #1 and Resident #2 on 6/12/24. Their investigation verified the physical abuse between Resident #1 and Resident #2. Per record review of physician note dated 6/13/23 reads, [Resident #2] has had several documented verbal and physical aggressions lately directed towards one or two specific residents, one of which was a resident-to-resident physical altercation. [Resident #2] has apparently voiced negative statements toward another resident even after being asked by the resident to stop. [S/he] has visited activities as a form of redirection and engagement for [him/her] . [Resident #2] has shown some improvement on [his/her] SSRI [Selective Serotonin Reuptake Inhibitor used for depression] increase, however [s/he] still has behaviors that pose a safety risk to [his/herself] and others. This indicates that Resident #2 would be at increased risk to be a victim of abuse due to aggressive behaviors with others. Per review of the facility's Abuse, Neglect, and Exploitation policy [last revised 1/4/24] states, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident was assessed for injuries and complications in accordance with professional standards and per facility policy after sustaining a fall for 1 of 40 residents in the sample (Resident #22). Findings include: Per observation on 8/28/2024 at 8:40 AM Resident #22 was sitting in his/her wheelchair in unit dining/activity area. S/He was slumped forward and observed to have no upper body control. S/He tried several times to lift his/her head, however, was unable to. Resident #22's eyes were closed, and s/he could not speak. During observation s/he began vomiting. At the time of observation there were no staff monitoring in the dining/activity area. Due to safety concerns the LNA and RN were notified of the surveyor observations immediately. The LNA staff took Resident #22 back to his/her room. Resident #22 was emergently transferred to hospital with altered mental status and low blood pressure. Per Emergency Physician note dated 8/28/2024 in Resident #22 record Per RN at [facility] patient had unwitnessed fall overnight while trying to use the bathroom. Initially refused EMS transport however around 6:30 this morning, staff noticed she had slurred speech, AMS [altered mental status] from baseline with unequal pupils. Upon my interview, [Resident #22] expresses that she is having severe pain when [s/he] urinates. S/He stated s/he has tried to ask for help to go to the restroom, but no one came . Resident #22 was admitted to the hospital for pyelonephritis requiring intravenous antibiotics, low blood pressure, and dehydration. Per interview on 8/28/2024 at 8:45 AM, the Licensed Nurse Assistant #1 (LNA) familiar with the resident and his/her care stated that Resident #22 had fallen on night shift at approx. 2:30 AM on 8/28/2024. LNA stated that Resident #22 is normally alert and cooperative and likes to be in his/her room. LNA stated Resident #22 was moved to the dining room that morning because s/he appeared more confused and had been attempting to get out of bed. Per record review, a nursing note dated 8/28/2024 at 2:30 AM Resident [#22] found on the floor in room @ [at] bedside . Resident states [s/he] was trying to get up for toileting. Call light within reach & not used. Apparent injury noted to head. Brusing to the top of the forehead @ a skin tear above the left eye . Resident refuses head to toe assessment . Resident refuses all care to injuries, VS check, & pupil assessments @ this time. Assisted back to bed by staff .Alert with mental status @ baseline .Aggressive with staff during care. Cursing & hitting @ staff. Refusing any assistance & requesting to be left alone . Nursing note dated 8/28/2024 at 3:35 AM Staff attempted to assess resident, VS obtained & recorded . Complained of burning with urination, low grade fever noted . agitation noted with continued staff encounter. Per interview on 8/28/2024 at approx. 2:00 PM Registered Nurse (RN) on duty at time Resident #22's hospital transfer stated that s/he was on shift the previous night and cared for Resident #22. S/He stated during the interview that s/he last checked on him/her just before midnight and the resident was resting, alert and oriented. RN reports that s/he arrived back to work on 8/28/2024 at 6:45 AM. S/he stated that s/he and the LPN completed walking rounds at approx. 7:15 AM and during that time the LPN told him/her that the Power of Attorney (POA) was contacted after the fall and s/he requested that Resident #22 be sent to the emergency room. Per RN, the LPN on duty did not send Resident #22 to the emergency room because Resident refused. RN further stated that Resident #22 does not have a history of refusal of care or behaviors. Per interview of the LNA on 8/29/24 at 6:00 PM, the LNA stated s/he was working on 8/28/2024 when Resident #22 fell. S/He stated Resident #22 was alert and cooperative when s/he checked on him/her at approx.10:00 PM. LNA stated that s/he is not aware of any behaviors or refusal of care for Resident #22. LNA stated that Resident s/he was cooperative with care during his/her shift and prior to the fall. LNA stated s/he last checked on Resident #22 around 2:45 AM on 8/28/2024 after the fall and s/he complained of being cold, LNA stated s/he covered Resident #22 with blankets and left the room. Per Nursing interview on 8/29/24 at 6:30 PM with the License Practice Nurse (LPN) on duty when Resident #22 fell at 2:30 AM on 8/28/2024. S/He stated that s/he did speak with the POA multiple times and that s/he did request the resident be sent to the emergency room. The LPN stated s/he did not send Resident #22 to the hospital even though the POA said to because the resident refused. The LPN stated s/he did not call EMS or contact the Director of Nursing to assess Resident #22. LPN stated s/he did not notify the on-call provider of change in mental status. The LPN stated s/he believed Resident #22 to be at his/her baseline after the fall and that she was not concerned about the change in Resident #22 behavior. According to Resident #22 record review s/he was admitted to the facility on [DATE] for short term rehabilitation. Per Patient Clinical Evaluation dated on 8/19/2024 and completed by the Registered Nurse (RN) of Resident #22, section D. titled Cognitive/Mood 1. Resident is not cognitively impaired, 2. Resident has no history of behaviors . Section 7. Titled Speech a. resident is oriented speech/clear. According to Social Work psychosocial assessment documented on 8/20/2024, Resident #22 lives alone in senior housing and makes his/her own medical decisions. Nursing note dated on 8/20/2024 at 10:38 PM Resident was pleasant with some reports of pain in [his/her] left leg. [S/he] is here for weakness and colitis, rectal bleeding, hypotension, hypothyroidism. [S/He] is occasionally incontinent of bowl and bladder . [S/He] is A&OX3 [alert and oriented to time, person, and place] . According to Resident #22 diagnosis list there is no evidence of behavior or cognitive deficit diagnosis. Nursing note dated on 8/27/2024 at 11:56 PM , Resident is alert, tolerated medication and ADL care well. PRN Ativan was administered . (Ativan is a medication used to treat anxiety). Per record review Resident #22 has the following Care Plan started on 8/19/2024 [Resident #22] has a DNR/DNI COLST [Resident #22] Advanced Directives are in effect and their wishes and directions will be carried out in accordance with their advanced directives on an ongoing basis through the next review date. Per Advance Directive on file resident POA is also on file. According to Resident #22 Advance Directive POA should be activated when Resident #22 is unable to make their own decisions, and POA should be contacted in the event of life-threatening illness. Per facility policy Notification of Changes last revised 4/2023 Residents incapable of making decisions: a. The representative would make any decisions that have to be made . According to [NAME] Statues and Advance Directive: Adults Who Lack Decision-Making Capacity Adult patients who lack decision-making capacity still retain the right to refuse medical treatment in all but exceptional circumstances. The two circumstances where it is permissible to treat over the objection of an incapacitated patient are: If the patient has waived their right to refuse in an advance directive ([NAME] Clause), or If the situation would result in serious and irreversible bodily injury or death if the health care is not provided within 24 hours. Per interview with the Administrator on 8/29/2024 at approx. 5:00 PM stated that s/he was unaware that Resident #22 POA requested resident be sent to the emergency room for evaluation after she fell on 8/28/2024.

Based on observation, resident interview, staff interview, and record review, the facility failed to provide a respectful and dignified dining experience that enhances residents' quality of life as evidenced by failure to serve meals to residents at a table at approximately the same time, and the facility failed to ensure care was provided to residents to maintain their respect and dignity as evidenced by the failure to assist with care related to Activities of daily living (ADLs) for 8 of 47 sampled residents (#72, #69, #90, #100, #72, #81, #12, and #47). Findings include: During observations made on A Unit (Special Care Unit (SCU), throughout the survey there were several times that residents were noted to be soiled and unattended. 1. On 8/28/2024 at 9:10 AM Resident #72 was observed propelling her/himself down the hallway. S/he stopped in front of this Surveyor pointed at the door at the end of the hall and stated I have to go out there. Can you help me out there? Her/his pants were visibly soiled from the crotch area to halfway down to the knees. The Resident continued to self propel down the hall to the door. At 9:15 AM the Unit Manager approached Resident #72 and brought her/him up the hall to the nurses station area and left her/him there. At 9:20 AM a Licensed Nursing Assistant brought Resident #72 out to the dining room and parked her/him at a table not addressing the wet pants. At 9:40 AM Resident #72 began calling out help me, I am going to throw up and wet my pants. At this time the Resident's pants were still wet. A Registered Nurse (RN) responded give me a minute [name omitted] repeating it 3 times. The RN then moved the Resident back to the nurse's station and gave her/him a cup of water. At 9:46 AM a Licensed Nursing Assistant (LNA) approached her/him and took her/him to the bathroom to change. At approximately 10:15 AM the LNA confirmed that the Resident's pants had been soaked through with urine. 2. On 8/26/24 at 9:10 AM Resident #69 was observed in the dining room with his/her head on the table. There was coffee spilled on floor and her/his socked feet were wet with coffee. At 9:50 AM Resident #69 was observed in the same position with the coffee still on the floor. 3. On 8/26/24 9:50 AM Resident #90 was observed sitting in a wheelchair in the dining room. S/he was periodically standing up from the chair and putting her/his right hand in the back of her/his incontinence brief. Upon approach it was noted that Resident #90's right hand was soiled with a brown substance that appeared to be bowel movement. At approximately 10:00 AM Resident #90 stood up again, a LNA entered the dining room and escorted her/him to the bathroom. At this time this Surveyor approached the LNA and informed her/him that the Resident had been putting her/his hands in her/his pants. The LNA confirmed that the Resident had bowel movement on her/his hands. 4. During observation of the lunch meal service on 8/26/24 at 12:05 PM Resident #69 was sitting at a table eating her/his meal. There were two other Residents sitting at the table, observing Resident #69 eat, who were not served until 12:15 PM. 5. Per observation on 8/26/24 at 4:43 PM of the dining room on the A Unit (Special Care Unit (SCU), there were 15 residents in the dining room and 11 residents out by the nurses station. There were no activities for the residents and no staff present. At 8/26/24 at 4:59 PM, 9 residents were observed sitting in recliners with tray tables in front of them for the evening meal, with no activities and no staff present for supervision or meaningful engagement with residents. Resident #47 had food on her/his face and shirt. At 4:59 PM a Licensed Nursing Assistant confirmed that the food on her/his face was from the lunch meal. 6. At 5:05 PM Resident #12 was seen sitting at a table with 2 other Residents, and did not have their food yet. Resident #12 reached over to another Resident's meal tray and took a cup of milk that had been drank from, and began drinking it. At 5:15 PM a Licensed Nursing Assistant (LNA) approached the table with Resident #12's meal tray. The LNA took the cup of milk from Resident #12 and gave her/him their own milk. 7. Per observation on 8/26/24 at 5:43 PM Resident #81 was sleeping in wheelchair at the dinner table. S/He had dropped her/his fork and fruit cocktail on the floor under her/his chair and no assistance was being offered to this resident. 8. On 8/27/24 at 3:03 PM Resident #100 was observed sitting in a straight back chair in the dining room. S/he was noted to have white film at her/his gum line and food was caked in her/his teeth. At 3:15 PM Resident #100 stood up from the chair, it was noted that the back of her/his pants were soaked through with urine. The Activity Aide that was in the room at the time, confirmed that Resident #100 had been soiled with urine. Per interview with the Unit Manager on 8/29/24 4:45 PM s/he stated that it is the expectation that staff provide assistance to clean Residents after they assist them with meals or if they are soiled. Staff are educated during orientation regarding these expectations.

Based on observations, interviews, and record review, the facility failed to ensure that resident care plans described the resident specific care and services that will be furnished so that the resident can attain or maintain his/her highest practicable physical, mental and psychosocial well-being for 10 of 40 sampled residents (Residents #65, #67, #50, #282, #41, #87, #34, #93, and #109, and #76) related to activities of daily living (ADL). Findings include: Per record review, Residents #65, #67, #50, #282, #41, #87, #34, #93, #109, and #76 care plans reveal that they have ADL self-care performance deficits. An intervention related to ADL care for all the above residents read Nursing staff to provide as much assistance that is needed to complete care tasks ( .). There are no resident specific care interventions to describe what type of assistance these residents require to carry out activities such as feeding assistance, transferring, ambulation, and hygiene care. 1. Per record review, Resident #65's dining profile states that s/he needs constant supervision and verbal cues/prompting while eating. This information is not included in his/her care plan. Resident #65's therapy profile, last updated on 8/14/24, states that s/he is dependent on staff for all ADLs including transferring and hygiene and uses a wheelchair. This information is not included in his/her care plan. 2. Per record review, Resident #109's dining profile states that s/he is on aspiration precautions and requires constant supervision and verbal cues/prompting while eating. This information is not included in his/her care plan. Also, the care plan does not include resident specific interventions related to hygiene task support. 3. Per record review, Resident #87's dining profile states that s/he needs constant supervision and verbal cues/prompting while eating and if left in bed, will need assistance with feeding. This information is not included in his/her care plan. 4. Per record review, Resident #50's dining profile states that s/he is on aspiration precautions and requires constant supervision while s/he is eating. This information is not included in his/her care plan. 5. Per record review, Resident #41's therapy profile, last updated on 8/20/24, states that s/he requires maximum assistance or is dependent on staff for all ADLs including bed mobility, hygiene, and transferring and uses a tilt in space wheelchair. This information is not included in his/her care plan. 6. Per record review, Resident #34's therapy profile, last updated on 8/21/24, reveals that s/he requires minimum 1 assist for bed mobility and requires staff assistance for transferring. This information is not included in his/her care plan. 7. Per record review, Resident #76's therapy profile, last updated on 5/29/24, reveals that Resident #76 can ambulate with a walker and distant staff supervision. This information is not included in his/her care plan. Also, the care plan does not include resident specific interventions related to hygiene task support. 8. Per record review, Resident #93's dining profile, last updated on 2/23/24 states that s/he is to have his/her head of bed elevated while eating. This information is not included in his/her care plan. 9. Per record review, Resident #282's care plan does not include resident specific interventions related to hygiene task support. 10. Per record review, Resident #67's care plan does not include resident specific interventions related to hygiene task support. Per observation during the recertification survey between 8/25/24 and 8/29/24, the above residents were observed not being provided the assistance required to complete ADL tasks. See F 677 for more information. Per interview on 8/29/24 at 4:15 PM, the Nurse Consultant explained that care plans should be as person centered as possible, including what type of assistance residents require to receive proper ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. Per record review, Resident #9 was admitted to the facility on [DATE] with diagnoses of Alzheimer's with late onset and dementia with agitation. Per observation on 8/25/2024 at approximately 3:00 PM, Resident #9 was observed lying in bed with the door closed, the room was dark. The resident was crying and occasionally calling out. During the next few hours, the staff did not enter the resident's room until approximately 5:10 PM, when dinner arrived. On 8/26/2024, at approximately 9:15 AM, Resident # 9 was observed in the main dining room sitting by self at a table with breakfast food on her/his face. The resident continued to sit alone for the next two hours without staff interaction. At approximately 11:15 AM, Resident #9 was observed making repetitive noises, and another resident was patting his/her arm; no intervention from staff was observed, though staff were in the room. Per record review, a care plan entry dated 5/23/2023, [Resident] has an ADL(Activities of daily living) self-care performance deficit/limited mobility r/t (related to) weakness, confusion sx (symptoms) dementia, with an intervention encourage [resident] to participate to the fullest extent possible with each interaction. There are no resident-specific interventions. Per interview with the Unit Manager on 8/28/2023 at approximately 2:20 PM, s/he confirmed that the care plan was not person-centered regarding ADLs. Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) without assistance receives the proper level of assistance for 11 of 40 sampled residents (Residents #65, #67, #50, #282, #41, #87, #34, #93, #109, #76, and #9) Findings include: 1. Per record review, Resident #65's care plan reads [Resident #65] has swallowing difficulty r/t [related to] Hx [history]: coughing/pocketing on advanced textures with Dx [diagnoses]: Dysphagia [difficulty swallowing] s/p [status post] SLP [speech-language pathologist] evaluation, revised 2/4/22, with the following intervention [Resident #65] will eat per therapy directed dining profile, which will be located in chart, and therapy profile binder, initiated 11/16/21. Resident #65's dining profile, last updated on 11/17/21, states that s/he needs constant supervision and verbal cues/prompting while eating. Other descriptions of his/her current status include offering the main dining room and placing bites of food on a utensil and saying, take a bite. Cough to clear and alternate liquids and solid are listed as swallowing strategies. Resident #65's care plan reads [Resident #65] has an ADL Self Care Performance Deficit r/t cognitive impairment and limited mobility, revised on 5/4/21, with an intervention for Nursing staff to provide as much assistance that is needed to complete care tasks, initiated on 12/15/21. Resident #65's therapy profile, last updated on 8/14/24, states that s/he is dependent on staff for all ADLs including transferring and hygiene and uses a wheelchair. Per observation on 8/25/24 at 5:46 PM, Resident #65 was in the dining room with his/her food in front of him/her. S/He appears to be asleep in his/her wheelchair. It wasn't until 6:02 PM, that a Licensed Nursing Assistant (LNA) went over to Resident #65, put a piece of dinner on the fork and handed it to him/her. Per observation on 8/28/24 at 12:00 PM, Resident #65 was sitting in the dining area with lunch in front of him/her. Resident #65 did not receive any assistance or cueing for at least 25 minutes until an LNA approached him/her at 12:25 PM saying take a bite. Per observation and interview on 8/28/24 at 2:40 PM, Resident #65 had very long nails which appear to have a brown tint and dirt on the underside of each nail. S/He said s/he wanted his/her nails cut and had asked staff to cut them. Per observation and interview on 8/28/24 at 5:34 PM, Resident #65 was in his/her bed with the curtain drawn and a tray of food in front of him/her. S/He stated that s/he does not want to be in bed for dinner and wanted to get up. There was no way to see Resident #65 from the hall and there were no staff in the hallway. Per interview on 8/28/24 at 3:46 PM, the Therapy Director explained that if a dining profile says constant supervision, the resident should not be eating alone in their room. 2. Per record review, Resident #109's care plan reads [Resident #109] has swallowing difficulty r/t PMHx [past medical history] of Dysphagia with recurrent aspiration pneumonia. On thickened liquids, revised on 6/20/24 with an intervention to Provide textures of foods/fluids per physician diet order and any SLP recommendations, initiated 6/17/24. Resident #109's dining profile, last updated on 6/28/24, states that s/he is on aspiration precautions and requires constant supervision and verbal cues/prompting while eating. [NAME] tuck with swallow, double swallow, alternated liquids and solids, and small single sips, and eat slowly are swallowing strategies listed. Per observation on 8/26/24 at 5:11 PM, Resident #109 is eating in his/her room, alone. There are no staff to be seen in the hallway. Per observation on 8/29/24 at 5:17 PM, Resident #109 is alone in his/her room with dinner and there are no staff in the vicinity. S/He is intermittently coughing while s/he is eating. Per observation and interview on 8/28/24 at 2:50 PM, Resident #109 revealed medium length nails with a dirt-like substance under each nail. S/He said s/he would like his/her nails cut. Resident #209's Spouse said that s/he would like his/her nails cut. 3. Per record review, Resident #87's care plan reads [Resident # 87] has swallowing difficulty r/t dx: dysphagia following cerebral infarction [stroke] revised on 7/17/21 with interventions that include provide feeding/ dining assistance as needed, initiated on 3/15/24 and during meals and after each meal observe for signs/symptoms of aspiration, initiated on 3/15/24. Resident #87's dining profile, last updated 11/8/23 states that s/he needs constant supervision and verbal cues/prompting while eating and if left in bed, will need assistance with feeding. Multiple swallowing strategies include cough to clear, alternate liquids and solids, and small single bites- chew bites very well, slow rate of intake, and small single sips. Per observation on 8/28/24 at 5:49 PM, Resident #87 was in his/her bed with his/her dinner in front of him/her on the bedside table. There are no staff around. S/He was saying please help me with food and drinks. Per observation on 8/29/24 at 5:10 PM, Resident #87 was in bed with a food tray in front of him/her and no staff present. The LNA who dropped off the food tray to Resident #87 was approached and asked if it was appropriate for Resident #87 to be left alone to eat; s/he said s/he can't answer that question because s/he doesn't know the residents on this unit. 4. Per record review, Resident #50's care plan reads [Resident #50] has swallowing difficulty r/t Dx: Dysphagia, oropharyngeal phase s/p SLP evaluation, revised on 3/12/23 with an intervention to follow feeding profile/care plan, initiated on 3/15/24. Resident #50's dining profile, last updated on 5/22/24 states that s/he is on aspiration precautions and requires constant supervision while s/he is eating. Other descriptions of his/her current status include full set up of meals, cut up food, alternate liquids and solids, and full supervision and support will need feeding assistance on occasion if Parkinson's [movement disorder] meds [medications] are not timed correctly. Per interview on 8/25/24 at 6:25 PM, Resident #50's Representative explained that Resident #50 is not getting help with eating a lot of the time and s/he has a hard time feeding his/herself, especially if his/her Parkinson's meds have worn off. S/He has observed staff leave food in front of Resident #50 and walk away, sometimes they will even leave him/her in bed to eat by his/herself. Per observation on 8/26/24 at 5:11 PM, Resident #50 is in his/her room with food on the bedside table. There are no staff helping him/her eat and not staff are around in the hall. Resident #50 is trying to eat but appears to be having a very difficult time getting food to his/her mouth. Per observation on 8/28/24 at 12:00 PM, Resident #50 was sitting in the dining area with lunch in front of him/her. Resident #50 is not assisted with eating for at least 26 minutes until 12:26 PM when an LNA went over to his/her table to help him/her. 5. Per record review, Resident #41's care plan reads [Resident #41] has an ADL self-care performance deficit/limited mobility r/t decreased mobility, deconditioning, repeated falls, overactive bladder, cognition, revised on 3/25/24 with an intervention that [Resident #41 will receive the needed amount of assistance to complete ADL tasks. The level of assistance may vary from day to day and task to task, revised 3/25/24. Resident #41's therapy profile, last updated on 8/20/24, states that s/he requires maximum assistance or is dependent on staff for all ADLs including bed mobility and transferring and uses a tilt in space wheelchair. Per observation on 8/25/24 at 3:38 PM, Resident #41 was sitting in the common area in his/her wheelchair, which was tilted back approximately 30 degrees. S/He was yelling out for staff to help and there were no staff in sight. S/he explained that s/he has been sitting out here for hours and wants to go back to bed but no one is helping him/her. Resident #41 called out for staff every few minutes saying things like are you kidding? anyone? . can't wait another day to go to the bathroom. I need to go this minute .I am pleading with you [and] I can't wait any longer. S/He is not approached by staff until 4:21 PM, 43 minutes after s/he was first observed requesting help. Per observation and interview on 8/28/24 at 2:40 PM, Resident # 41 had long fingernails with a dark brown substance underneath almost all of them. S/He said s/he would like them cut and cleaned. 6. Per record review, Resident #34's care plan reads [Resident #34] has an ADL self-care performance deficit/limited mobility r/t deconditioning r/t hospitalization for PNA [pneumonia], spinal stenosis, OA [osteoarthritis], hx of falls, cardiac issues, revised on 7/17/24 with interventions that include encourage [Resident #34] to use bell to call for assistance, revised on 3/17/24, and that [Resident #34] will receive the needed amount of assistance to complete ADL tasks. The level of assistance may vary from day to day and task to task revised 3/7/24. Resident #34's therapy profile, last updated on 8/21/24, reveals that s/he requires minimum 1 assist for bed mobility and requires staff assistance for transferring. Per observation and interview on 8/28/24 at 8:57 AM, Resident #34 was wearing a johnny (hospital gown) in bed. S/He explains that s/he needs to go to the bathroom but doesn't know how to get help because s/he does not have call bell in reach. The call bell is not visible. Resident #34 called out for help every few minutes saying that s/he needs help going to the bathroom. By 9:25 AM, Resident #34 is in tears and no staff have approached him/her to help. At 9:37 AM, 40 minutes since first observed yelling for help, the Unit Manager assisted Resident #34 to the bathroom. Per observation on 8/28/24 at 5:44 PM, Resident #34 was sitting on the edge of his/her bed, still in a johnny, crying out for staff for help. S/He said she needs help with the bathroom and doesn't know where his/her call bell is. The call bell is not in his/her reach; it is on the floor on the other side of his/her bed. 7. Per record review, Resident #76's care plan reads [Resident #76] has an ADL self-care performance deficit/limited mobility r/t Macular Degeneration [eye disease that causes vision loss], and anxiety, revised on 2/13/24 with an intervention that [Resident #76] will receive the needed amount of assistance to complete ADL tasks. The level of assistance may vary from day to day and task to task revised 2/13/24, and place the call light within reach of [Resident #76] and encourage to use it for assistance as needed, revised on 2/13/24. Resident #76's therapy profile, last updated on 5/29/24, reveals that Resident #76 can ambulate with a walker and distant staff supervision. Per observation and interview on 8/29/24 at 11:39 AM, Resident #76 was sitting in his/her recliner in his/her room and explained that s/he needed help but couldn't find his/her call bell. The call bell was not in his/her reach; it was on the opposite side of his/her bed. S/He stated that s/he wants to be in the common area for lunch but no one has come to ask him/her if s/he wants to go and s/he needs help to get to there. Resident #76 was not seen in the dining room during any part of lunch service. At 2:00 PM, Resident #76 explained that no one came to help him/her get to the lunch room before lunch was served. S/He stated that s/he still would like help getting to the common area. Resident #76 is seen in his/her doorway with his/her walker. S/He is asking loudly for a ride to the common area. At 2:09 PM, 2.5 hours after s/he first stated s/he wanted to go to the common area, a therapy staff member helped him/her get to the common area in a wheelchair. 8. Per record review, Resident #93's care plan reads [Resident #93] has an ADL self-care performance deficit/limited mobility r/t weakness, deconditioning, limited physical mobility, cognitive deficits, revised on 5/25/22 and his/her dining profile, last updated on 2/23/24 states that s/he is to have his/her head of bed elevated while eating. Per observation on 8/28/29 at 5:38 PM, Resident #93 was observed trying to eat his/her dinner while laying in bed with the head of the bed completely flat. The curtains were separating the room in half and Resident #93 was unable to be seen by any staff in the hall. 9. Per record review, Resident #282's care plan reads [Resident #282] has an ADL self-care performance deficit/limited mobility r/t Parkinson's disease, Progressive functional and cognitive decline, revised on 5/9/24 with an intervention that [Resident #282] will receive the needed amount of assistance to complete ADL tasks. The level of assistance may vary from day to day and task to task revised 5/9/24. Per observation and interview on 8/28/24 at 3:01 PM, Resident #282 had overgrown nails that had a dark brown substance under each nail. Resident #282 stated that s/he would really like them cut. 10. Per record review, Resident #67's care plan reads [Resident #67] has an ADL self-care performance deficit r/t dementia, fluid volume excess, use of adaptive equipment, weakness, revised on 5/26/20, with an intervention for nursing staff will provide any level of assistance that is required to complete care tasks r/t day to day r/t disease process and level of participation. Per observation and interview on 8/28/24 at 5:04 PM Resident #67 had long, overgrown nails. S/He said s/he would like his/her nails cut.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide engaging activities both in and out of resident rooms for 1 of 40 sampled residents (Resident #78); failed to provide an ongoing activities program to support residents in their choice of group, individual, and independent activities to meet the interests of and support the well-being of each resident as evidenced by a lack of opportunities for residents to go outside of 1 of 3 units (Unit B); and failed to provide weekend activities for all interested residents. Findings include: 1. Per observation and interview on 8/29/24 at 3:05 PM, Resident #78 was in his/her bed staring ahead with no stimulation. S/He stated that s/he is interested in having more independent activities to do and more 1 on 1 activities. When asked about what type of activities s/he is interested in, s/he stated that s/he enjoys music and s/he has discussed his/her interest of audio books with staff but does not have them and is still interested. S/He explained that s/he does refuse activities sometimes but does like to go to things like music, and s/he doesn't always get asked to attend because s/he says no to going sometimes. Per observation, Resident #78 was not observed to be participating in any independent activities during 8/25/24 through 8/29/24. Per record review, Resident #78's care plan read, [Resident #78] is at risk/experiencing psychosocial distress related to current placement and change in functional status; hx [history] of suicidal attempt in 2022 and verbalized thoughts [s/he] would be better off dead, revised 8/3/23 with an intervention to Break cycle of inactivity. Establish a list of activity events that [Resident #78] enjoys to help re-establish self-worth. Encourage participation. There are no interventions in Resident #50's care plan that are specific to his/her enjoying music. Resident #78's care plan also reads, [Resident #78] prefers bed rest with little activity interest, initiated on 7/1/24, with a goal that s/he will express satisfaction with independent activity such as reading or audio books, and an intervention that [Resident #78] has been offered large print books and audio books. This is something [s/he] expressed interest in. [S/He] has refused or has not made use of these requests regularly. [S/He] often prefers naps, initiated on 7/1/24. There are no interventions in Resident #78's care plan about to continuing to offer audio or large print books, or anything else that s/he might have interest in. Per interview on 8/29/24 at 2:25 PM, the Activities Director explained that Resident #78 often declines participation in activities but sometimes does show interest. When asked about the care plan intervention Break cycle of inactivity. Establish a list of activity events that [Resident #78] enjoys to help re-establish self-worth. Encourage participation, s/he explained that s/he was unaware of the care plan intervention. S/He explained that the activities department does not track when residents refuse participation in activities or if residents are participating in independent activities. S/He explained that there is no list of activities that Resident #78 likes to participate that s/he is aware or a way to track if staff are encouraging the resident to participate in activities that interest him/her or a way to measure the effectiveness of this intervention, including offering both large print and audio books to the resident. 2. Multiple residents on Unit B expressed interest in spending time outdoors. Observations, interviews, and record review revealed that this interest was not supported by the facility. a. Per record review, Resident #50's Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) Preferences for Routine and Activities assessment dated [DATE] reveals that it is somewhat important for him/her to go outside and get fresh air when the weather is good. There are no interventions in Resident #50's care plan that are specific to this preference. Per interview on 8/25/24 at 6:25 PM, Resident #50's Representative explained that Resident #50 loves to go outside and, s/he is not going outside enough and s/he is concerned about this. S/He explained that s/he had made staff aware that it is important for Resident #50 to go outside and has been told that there just isn't a place to bring residents unless they want to sit in the parking lot because s/he is not allowed to use the courtyard. The Representative stated that Resident #50 really enjoyed going outside in the past and is concerned that Resident #50 will lose interest in spending time outside because s/he is not offered and can only go out to the parking lot area with his/her visitors. b. Per record review, Resident #23's MDS Preferences for Routine and Activities assessment dated [DATE] reveals that it is very important for him/her to go outside and get fresh air when the weather is good. There are no interventions in Resident #23's care plan that are specific to this preference. Per interview on 8/29/24 at 9:27 AM, Resident #23 stated that s/he goes outside with visitors if s/he can but staff usually don't have the time to go outside with him/her and s/he would really like to spend time outside. Per observation, Resident #623 was not observed to be outside at any point during 8/25/24 through 8/29/24. c. Per record review, Resident #106's MDS Preferences for Routine and Activities assessment dated [DATE] reveals that it is somewhat important for him/her to go outside and get fresh air when the weather is good. There are no interventions in Resident #106's care plan that are specific to this preference. Per interview on 8/29/24 at 12:21 PM, Resident #106 said, s/he does not get to go outside and would like to do so. Per observation, Resident #106 was not observed to be outside at any point during 8/25/24 through 8/29/24. d. Per record review, Resident #65's MDS Preferences for Routine and Activities assessment dated [DATE] reveals that it is It is important for him/her to spend time outdoors. There are no interventions in Resident #50's care plan that are specific to this preference. Per observation, Resident #65 was not observed to be outside at any point during 8/25/24 through 8/29/24. e. Per record review, Resident #67's MDS Preferences for Routine and Activities assessment dated [DATE] reveals that it is not very important for him/her to spend time outdoors. There are no additional MDS activities preference assessments since his/her last activities assessment over a year earlier. Per interview on 8/29/24 at 9:25 AM, Resident #67 said s/he wants to go outside and hasn't been outside at all. S/He explained that staff sometimes say it is too cold to go out when it is scheduled and can't go outside whenever s/he wants to. Per observation, Resident #67 was not observed to be outside at any point during 8/25/24 through 8/29/24. f. A review of the Unit B activity program calendars for July 2024 and August 2024 reveal that there were only 3 activities that took place outside during the two months, on 7/2/24, 8/2/24, and 8/16/24. g. Per interview on 8/29/24 at 2:25 PM, the Activities Director revealed that there is an issue in having residents on unit B to be able to have outside time. S/He explained that Unit B residents do not have an area that they can use and going outside is not user friendly when activity staff are not here and even then, there are not enough staff to take residents out when they want all the time. The Activities Director explained that s/he is not aware that many people want to go outside. When asked how preferences to go outside are determined, sh/e explained that it is asked for the annual MDS assessment and does not review it at any other time. 3. Per observation on 8/25/24 (Sunday), no activities took place on Unit B. A review of the Unit B activity program calendars for July 2024 and August 2024 reveal that there were no scheduled activities on Saturdays or Sundays. 4. Per observation on 8/25/2024 at 7:10 PM there were 4 residents sitting in the dining room with no staff present. One resident stated that s/he had been waiting for staff to put a movie on since the end of dinner. On 8/26/24 at 4:43 PM the dining room on the A Unit (Special Care Unit (SCU) there were 15 residents in the dining room and 11 out by the nurses station. There were no activities and no staff present. At 8/26/24 at 4:59 PM 9 residents were observed sitting in recliners with tray tables in front of them for the evening meal. There were no staff present and no activities or other stimulation. Per review of the SCU activity calendar for 7/29/24 through 8/30/24 there were no scheduled activities on Saturdays or Sundays. Per review of the August SCU activities participation logs there was no participation documented on 8/4, 8/11, 8/18, and 8/25. Per interview on 8/29/24 at approximately 3:00 PM the Activities Director (AD) stated that the activity department has been short staffed since March. When fully staffed the facility offers activities 9:30 AM - 6:00 PM seven days per week. There are currently three activities staff members which makes it difficult to keep the structure of the activities program. The AD confirmed that there were limited activities throughout the facility and there were no activities scheduled on Sundays. Per interview on 8/29/24 at 4:45 PM the SCU Unit Manager (UM) stated that the unit is activities based and s/he does not think there were activities on 8/25/2024. When there are no activities nursing staff try to give the residents activities to do. There is not someone stationed in the dinning room with them all the time, but staff try to do frequent checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Per observation on 8/27/2024 at approx. 11:00 AM Resident #18 was sitting alone in the dining/activity area weeping, asking for help several times. During the observation the License Nursing Assistant (LNA) arrived to assist Resident #18. The LNA did not explain to Resident #18 what s/he was doing and pulled the wheelchair backwards. Resident #18 stated who's there, what are you doing. Resident #18 was observed again later that afternoon sitting alone in the activity area asking for help several times, no staff were with resident at time of observation. On 8/28/2024 approx. 8:39 AM Resident #18 was sitting in the dining/activity area asking for help, with a gait belt around his/her waist. Resident # 18 is shivering stating s/he is cold, asking for his/her daughter. Per record review Resident #18 was admitted to the facility on [DATE] with a history of failure to thrive and post tramatic stress disorder. Resident #18 had a completed psychosocial assessment on 8/16/2024 which revealed a history of post-traumatic stress disorder (PTSD) related to abuse history. There is no evidence that a care plan was initiated related to history of post traumatic stress disorder, there are no identifiable triggers to alert staff on the care plan to care for the resident with PTSD. Per interview with the director of social services on 8/28/2024 at 12:30 PM, stated once PTSD is identified a special care plan is developed for the resident and should address trauma and triggers that may be associated to the past events. SW stated the triggers are important on the care plan so that staff know how to care for the resident. SW confirmed during interview that there was no active care plan for Resident #18 who has a confirmed history of PTSD. Based on staff interviews and record review, the facility failed to ensure that residents who are trauma survivors receive trauma-informed care that mitigates triggers that may re-traumatize residents for two of 5 residents sampled for trauma (Residents # 91, #18). Findings include 1. Per record review, Resident # 92 was admitted on [DATE] with a diagnosis of PTSD (Post Traumatic Stress Disorder) and Dementia. A Psychosocial Quarterly Evaluation with a date of 7/12/2023 indicates a diagnosis of PTSD, with supporting trauma documentation obtained from the resident's family. Per review of Resident # 92's record, no evidence was found that Resident # 92 was assessed for triggers that may re-traumatize the Resident. No evidence was found in Resident #92's plan of care regarding the Resident's triggers or how staff can provide care that avoids re-traumatizing the resident. Additionally, there is evidence of only three quarterly assessments in the resident's medical record. Per interview with an LNA on 8/28/2024 at approximately 2:15 PM, s/he stated s/he was unaware of Resident #92's diagnosis of PTSD or of any identified triggers. Per interview on 8/29/2024 at approximately 11:10 AM, the Medical Social Worker stated the Psychosocial Assessments should be done quarterly, but the Social Service Department was not up to date completing the assessments. Additionally, s/he indicated, I do not push residents or family members to identify their triggers. S/he stated there should be a specific Trauma care plan included in Resident # 92's plan of care. Per interview with the Unit Manager on 8/29/2024 at approximately 3:00 PM, s/he confirmed that Resident # 91's care plan should contain information to assist staff in providing care that avoids re-traumatizing the resident. S/he was not aware that the Psychosocial assessments were not being done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and services to attain the highest practicable well-being for each resident and in accordance with each resident's plan of care, potentially impacting all residents of the facility. Per review of the Facility assessment dated [DATE], the percentage of residents that require a one or two person assist for activities of daily living (ADL) is 49% for transferring, 11% for eating, and 45% for toileting and residents that are completely dependent on staff assistance for ADLs is 25% for transferring, 15% for eating, and 25% for toileting. The facility determined the staffing needs to meet the care requirements of the resident population is based on meeting or exceeding the minimum PPD requirements. 1. Per interview and observation on 8/28/24 at 5:13 PM, Resident #79 was yelling from his/her room for help. His/Her call light is on. S/He explained that s/he had pushed his/her call light 30 minutes ago and needs pain medications as s/he is in 8 out of 10 pain. At 5:18 PM, a Licensed Nursing Assistant (LNA) went into Resident #79's room, turned off the call light and then left the room saying s/he would let a nurse know. At 5:45, 32 minutes after Resident #79 was first observed yelling out for help, a Licensed Practical Nurse (LPN) went to the room with medications saying that s/he was too busy to come sooner because s/he was giving other residents their medications. 2. Per observation of medication administration on 8/29/24, 4 residents were administered medications over an hour later than prescribed. Per interview on 8/29/24 at 10:30 AM, the Registered Nurse who administered medications late for Residents #13 and #45 revealed that medications were late because the unit is big and there are a lot of medications to administer. Per interview on 8/29/24 at 7:04 PM, the Licensed Practical Nurse who administered medications late for Residents #50 and #20 explained that it is very busy on the unit and medication passes get interrupted because aides need his/her assistance since there are not enough aides staffed for the unit. 3. Per record review, Resident #34's therapy profile, last updated on 8/21/24, reveals that s/he requires minimum 1 assist for bed mobility and requires staff assistance for transferring. Per observation and interview on 8/28/24 at 8:57 AM, Resident #34 was wearing a johnny in bed. S/He explains that s/he needs to go to the bathroom but doesn't know how to get help because s/he does not have call bell in reach. The call bell is not visible. Resident #34 called out for help every few minutes saying that s/he needs help going to the bathroom. By 9:25 AM, Resident #34 was in tears and no staff had approached him/her to help. At 9:37 AM, 40 minutes since first observed yelling for help, the Unit Manager assisted Resident #34 to the bathroom. 4. Per record review, Resident #76's care plan reads [Resident #76] has an ADL [activities of daily living] self-care performance deficit/limited mobility r/t [related to] Macular Degeneration [eye disease that causes vision loss], and anxiety, revised on 2/13/24 and therapy profile, last updated on 5/29/24, reveals that Resident #76 can ambulate with a walker and distant staff supervision. Per observation and interview on 8/29/24 at 11:39 AM, Resident #76 was sitting in his/her recliner in his/her room and explained that s/he needed help but couldn't find his/her call bell. The call bell was not in his/her reach; it was on the opposite side of his/her bed. S/He stated that s/he wants to be in the common area for lunch but no one has come to ask him/her if s/he wants to go and s/he needs help to get to there. Resident #76 was not seen in the dining room during any part of lunch service. At 2:00 PM, Resident #76 explained that no one came to help him/her get to the lunch room before lunch was served. S/He stated that s/he still would like help getting to the common area. Resident #76 is seen in his/her doorway with his/her walker. S/He is asking loudly for a ride to the common area. At 2:09 PM, 2.5 hours after s/he first stated s/he wanted to go to the common area, a therapy staff member helped him/her get to the common area in a wheelchair. 5. Per record review, Resident #50's dining profile, last updated on 5/22/24 states that s/he is on aspiration precautions and requires constant supervision while s/he is eating. Other descriptions of his/her current status include full set up of meals, cut up food, alternate liquids and solids, and full supervision and support will need feeding assistance on occasion if Parkinson's [movement disorder] meds [medications] are not timed correctly. Per interview on 8/25/24 at 6:25 PM, Resident #50's Representative explained that Resident #50 is not getting help with eating a lot of the time and s/he has a hard time feeding his/herself, especially if his/her Parkinson's meds have worn off. S/He has observed staff leave food in front of Resident #50 and walk away. Sometimes they will even leave him/her in bed to eat by his/herself. Per observation on 8/28/24 at 12:00 PM, Resident #50 was sitting in the dining area with lunch in front of him/her. Resident #50 is not assisted with eating for at least 26 minutes until 12:26 PM when an LNA went over to his/her table to help him/her. 6. Per record review, Resident #41's therapy profile, last updated on 8/20/24, states that s/he requires maximum assistance or is dependent on staff for all ADLs including bed mobility and transferring and uses a tilt in space wheelchair. Per observation on 8/25/24 at 3:38 PM, Resident #41 was sitting in the common area in his/her wheelchair, which was tilted back approximately 30 degrees. S/He was yelling out for staff to help and there are no staff in sight. S/he explained that s/he has been sitting out here for hours and wants to go back to bed but no one is helping her. Resident #41 calls out for staff every few minutes saying things like are you kidding? anyone? . can't wait another day to go to the bathroom. I need to go this minute .I am pleading with you [and] I can't wait any longer. S/He is not approached by staff until 4:21 PM, 43 minutes after s/he was first observed requesting help. 7. Per record review, Resident #65's dining profile, last updated on 11/17/21, states that s/he needs constant supervision and verbal cues/prompting while eating. Per observation on 8/25/24 at 5:46 PM, Resident #65 was in the dining room with his/her food in front of him/her. S/He appeared to be asleep in his/her wheelchair. It wasn't until 6:02 PM, that an LNA went over to Resident #65, put a piece of dinner on the fork and handed it to him/her. Per observation on 8/28/24 at 12:00 PM, Resident #65 was sitting in the dining area with lunch in front of him/her. Resident #65 did not receive any assistance or cueing for at least 25 minutes until a LNA approached him/her at 12:25 PM saying take a bite.

2. Medication administration was observed on 8/29/24 at 6:28 PM for Resident #50. The Licensed Practical Nurse (LPN) administered 1.5 tablets of Carbidopa-Levodopa Oral Tablet 25-100 MG (used to treat symptoms of Parkinson's disease) and 0.5 tablets of Entacapone Oral Tablet 200 MG (used to treat symptoms of Parkinson's disease). Per review of Resident #50's physician orders, these two medications were ordered to be administered at 5:00 PM. At 6:52 PM the LPN administered 4 ounces of Ensure and 2 drops of Artificial Tears Ophthalmic Solution 1 % in both eyes to Residenti #20. Per review of Resident #20's physician orders, these two medications were ordered to be administered at 5:00 PM. Per interview at 7:04 PM, the LPN confirmed that the above medications were administered over an hour late. S/He explained that it is very busy on the unit and medication passes get interrupted because aides need his/her assistance since there are not enough aides staffed for the unit. Based on observation, interview, and record review the facility failed to ensure medication error rates were not 5% or greater. The total error rate for all observations was calculated at 72% for 4 of 10 sampled residents (Residents #50, #20, #13, and #45). Findings include: 1. Medication administration was observed on 8/29/24 between 10:15 AM and 10:30 AM for Resident #13 and Resident #45. The Registered Nurse (RN) administered Resident #13's medication which included Tylenol 650mg, Asprin81mg, Vit D 2000U 2 tabs, Apixaban 5mg (used to prevent blood clots), Gabapentin 300 mg (used to treat nerve pain), Multi Vitamin with minerals, and Oxycodone 7.5mg (used to treat pain), Per review of Resident #13's physician orders, these medications were ordered to be administered at 8:00 AM. The RN then administered Resident # 45's medications which included Allopurinol 300mg (used to treat or prevent gout), Amlodipine 5mg (used to treat (used to treat high blood pressure), Zoloft 150mg (used to treat depression), Hydrochlorothiazide 12.5 mg (used to treat high blood pressure and fluid retention), and Metformin 500 mg (used to treat diabetes). Per review of Resident #45's physician orders, these medications were ordered to be administrated at 8:00 AM. Per interview with the RN at 10:30 AM, the unit is very big and there are a lot of medications to administer. The RN confirmed that the above medications were administered over an hour late.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that resident environments were free of accident hazards related to providing safe water temperatures of less than 120 degrees Fahrenheit (F). Findings include: 1. Per observation on the Special Care Unit ((SCU) a unit that Residents with diagnoses of dementia or other cognitive impairments reside) on 8/25/24 at 4:30 PM, the hot water was assessed from a faucet in the bathroom of room [ROOM NUMBER]. The water was too hot to hold a hand under. Using a thermometer calibrated at 32.2 degrees F, the temperature of the water was 125.8 degrees F. The bathroom sink in room [ROOM NUMBER] was then checked and the temperature was 127.3. Five minutes later at 4:45 PM, the sink in the bathroom of room [ROOM NUMBER] was found to be 124 degrees F. The sample was then expanded to include other resident bathroom sinks throughout all three units. The following water temperatures were discovered: B Unit Resident bathroom sinks #215 - 124 degrees F # 221- 124.3 degrees F #207 - 127.02 degrees F C Unit Resident bathroom sinks #319 - 121.2 degrees F #324 - 122.4 degrees F #308 - 123 degrees F #305 - 122 degrees F During an interview on 8/25/24 at approximately 5:45 PM the facility Administrator was asked to feel the water coming from the faucet in the bathroom of room [ROOM NUMBER]. S/he placed her/his hand under the water, removed it, and agreed that the water did feel hot. The temperature at this time read 127.2. Facility policy titled Safe Water Temperatures, last revised on 2/2024 reads Water temperatures will be set to a temperature of no more than 120 [degrees] F or the state allowable maximum water temperature. At approximately 6:05 PM the Environmental Services Director (ESD) arrived, and along with the facility Administrator and two Surveyors began checking water temperatures. Using the facility thermometer, the bathroom sinks water temperatures in rooms #308, #207, #102, and #124 were all under 120 degrees F. In room [ROOM NUMBER] the Surveyor's thermometer read 121 degrees F, and in room [ROOM NUMBER] it read 120.4 degrees F. Per interview on 8/25/24 at 6:15 PM the ESD stated that s/he checks the water temperatures weekly in random resident bathrooms. If water temperatures are found to be high s/he will adjust the mixing valve. The ESD stated that s/he calibrates her/his thermometer weekly. On 8/29/24 at 7:15 PM the water temperature in the bathroom of room [ROOM NUMBER] checked by two Surveyors using a thermometer that had been checked for accuracy per manufacturer instructions read 124.3 degrees F. Per the facility matrix printed on 8/26/25, 75 of the 130 residents in the facility are identified as having dementia or Alzheimer's. Cognitive impairment can put residents at increased risk for burns caused by scalding.

Based on interviews and record review, the facility failed to notify the resident in writing of a transfer/discharge for one applicable resident (Resident #1). Findings include: Record review reveals that Resident #1 was admitted to the facility for rehabilitation on 3/8/24 following a hospital stay related to a fall. S/He has diagnoses that include Down syndrome, anxiety, mild intellectual disabilities, and obsessive-compulsive behavior. While Resident #1's medical record profile lists Resident #1 as having a financial guardian, Resident #1 is listed as his/her own self, indicating that s/he is his own guardian. On 6/14/24 at 11:25 AM, a Social Service Specialist confirmed that while Resident #1 was at the facility, s/he was his own person. On 3/13/24, Resident #1 has a BIMS of 13 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness). Per a 5 day investigation summary of a facility reported resident to resident incident sent to the State Agency on 5/10/24, the facility implemented an involuntary discharge for Resident #1 on 5/2/23. The summary reveals that Resident #1's family member was informed of the involuntary discharge by phone that day and by email on 5/3/2024 but does not indicate that the facility ever informed Resident #1 of a notice of discharge or their right to appeal. Per review of Resident #1's electronic medical record and paper chart, there is no evidence that Resident #1 was given a notice of discharge. There is a transfer discharge notice that reveals it was provided to Resident #1's family member by phone on 5/2/24 and by email on 5/3/24. Per interview on 6/10/24 at 4:51 PM, the Administrator confirmed that the only notice of discharge was given to Resident #1's family member by phone on 5/2/24 and by email on 5/3/24. Per interview on 6/19/24 at 10:09 AM, Resident #1 indicated that s/he was not notified of the facility's decision to discharge him/her on 5/2/24. S/He stated that s/he was confused as to why he was going to the hospital. S/He did not receive a discharge notice in writing and was not informed of his/her right to appeal the discharge. Resident #1 stated that s/he would have done anything to go back to the facility. S/He explained that while s/he has a financial guardian, s/he makes all other decisions because s/he is his/her own self. Resident #1 stated that s/he is still residing at the hospital while they find a long term placement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to ensure that comprehensive care plans were revised with person-centered, effective interventions to prevent falls for 1 resident [Res. #78] of 27 sampled residents. Findings include: 1.) Review of Res.#78's medical record reveals the resident was admitted to the facility on [DATE] after a hospital stay subsequent to syncope [fainting or passing out] and a fall. Res. #78's admitting diagnoses included repeated falls, dizziness, syncope and collapse, impaired visual function, and a history of stroke. Review of Res.#78's Care Plan reveals the resident was identified upon admission as at risk for falls related to deconditioning, weakness, history of falls, pain, anxiety, and shortness of breath. The Care Plan also notes the resident has had an actual fall. Review of Res.#78's medical record reveals the resident suffered a fall on 5/19/23. Progress notes record Resident found on the floor in the bathroom. [S/he] states [s/he] lost [h/her] balance and fell from toilet. [S/he] was found sitting up. [S/he] has a small bruise on upper right back and a small bruise on Right Upper Quadrant above a bruise already present. Physician notes record It was reported by nursing that [Res.#78] experienced a fall while [s/he] was in the bathroom, injuring [h/her] left knee. The Care Plan lists as a new intervention Reminder to Call for assistance in and out of bathroom. and Offer/provide assistance with toileting routinely. Further review reveals the 5/19/23 intervention echoing an intervention already in place upon admission, dated 4/28/23, reading Educate/remind [Res.#78] to request assistance prior to transfer/ambulation. The facility's Post Fall Investigation dated 5/19/23 records Care Plan updated- Yes, with no new interventions listed. Further review of Res.#78's medical record reveals the resident suffered another fall on 6/3/23. Incident Notes record Resident's roommate yelled for help. On entering the room Resident was found on the floor at the end of the bed laying on [h/her] back and more on [h/her] left side[S/he] complains of pain on the back of [h/her] head and a small bump was felt. [S/he] also complains of left hip pain but is able to flex and straighten [h/her] leg. Resident taken by ambulance at 5:00 PM to University of [NAME] Medical Center for evaluation. 5 days later, Res.#78 returned to the facility. Physician Notes record upon h/her return Res.#78 was seen after a fall that resulted in a closed head injury. Review of Res.#78's Care Plan after the fall on 6/3/23 reveals the added intervention [S/he] was reminded to ask for help when going to the bathroom. Further review of the resident's Care Plan reveals the near identical intervention Reminder to Call for assistance in and out of bathroom added after the previous fall, on 5/19/23, which in turn reiterated the 4/28/23 intervention Educate/remind [Res.#78] to request assistance prior to transfer/ ambulation. The facility's Post Fall Investigation dated 6/3/23 records Care plan updated- Yes: reminders for resident to request assistance when going to the bathroom. An interview was conducted with the facility's Director of Nursing [DON] on 6/14/23. The DON confirmed the facility's policy 'Fall Response and Management' policy instructs if a patient falls implement immediate interventions to prevent a repeat fall and Revise the Care Plan with interventions. The DON confirmed regarding the above referenced falls for Res. #78, failed interventions were repeated and the resident care plan was not revised with new interventions to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to ensure residents received adequate supervision to prevent falls and/or injury from falls for 1 resident [Res. #78] of 27 sampled residents. Findings include: 1.) Review of Res.#78's medical record reveals the resident was admitted to the facility on [DATE] after a hospital stay subsequent to syncope [fainting or passing out] and a fall. Res. #78's admitting diagnoses included repeated falls, dizziness, syncope and collapse, impaired visual function, and a history of stroke. Review of Res.#78's Care Plan reveals the resident was identified upon admission as at risk for falls related to deconditioning, weakness, history of falls, pain, anxiety, and shortness of breath. The Care Plan also notes the resident has had an actual fall. Review of Res.#78's medical record reveals the resident suffered a fall on 5/19/23. Progress notes record Resident found on the floor in the bathroom. [S/he] states [s/he] lost [h/her] balance and fell from toilet. [S/he] was found sitting up. [S/he] has a small bruise on upper right back and a small bruise on Right Upper Quadrant above a bruise already present. Physician notes record It was reported by nursing that [Res.#78] experienced a fall while [s/he] was in the bathroom, injuring [h/her] left knee. The Care Plan lists as a new intervention Reminder to Call for assistance in and out of bathroom. and Offer/provide assistance with toileting routinely. Further review reveals the 5/19/23 intervention echoing an intervention already in place upon admission, dated 4/28/23, reading Educate/remind [Res.#78] to request assistance prior to transfer/ambulation. Further review of Res.#78's medical record reveals the resident suffered another fall on 6/3/23. Incident Notes record Resident's roommate yelled for help. On entering the room Resident was found on the floor at the end of the bed laying on [h/her] back and more on [h/her] left side. [S/he] complains of pain on the back of [h/her] head and a small bump was felt. [S/he] also complains of left hip pain but is able to flex and straighten [h/her] leg. Resident taken by ambulance at 5:00 PM to University of [NAME] Medical Center for evaluation. 5 days later, Res.#78 returned to the facility. Physician Notes record upon h/her return Res.#78 was seen after a fall that resulted in a closed head injury. Review of Res.#78's Care Plan after the fall on 6/3/23 reveals the added intervention [S/he] was reminded to ask for help when going to the bathroom. Further review of the resident's Care Plan reveals the near identical intervention Reminder to Call for assistance in and out of bathroom added after the previous fall, on 5/19/23, which in turn reiterated the 4/28/23 intervention Educate/remind [Res.#78] to request assistance prior to transfer/ ambulation. An interview was conducted with the facility's Director of Nursing [DON] on 6/14/23. The DON confirmed the above referenced falls for Res. #78, that failed interventions were repeated and the resident care plan was not revised with new interventions to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to recognize and competently and thoroughly address the physical, mental, and psychosocial needs of 1 of 8 sampled residents who reside on the special care unit (Resident #9). The facility also failed to implement individualized approaches to care that are directed toward understanding, preventing, relieving, and/or accommodating Resident #9's expressions of distress with the provision of personal care. Findings include: A review of the medical record, Resident #9 was admitted to the facility on [DATE] with diagnoses that include: Alzheimer's disease, dementia with agitation, and restlessness and agitation. Resident #9 is resistive and combative with care, which includes yelling, hitting, and pinching staff during care or when others come close to her/him. A care plan focus initiated on 3/15/23 indicates Resident #9 has a behavior problem R/T (related to) compulsiveness, disruptive behavior, physical aggression/physically abusive, refusal of care and treatment R/T Dementia, outbursts and anxiety hitting staff with cane/pounding people's feet refusing care. The stated goal is [Name omitted] will not injure staff or others during personal care through the evaluation date. The care plan goal fails to identify interventions to implement to ensure that the resident is not injured and remains safe during combative refusals of care. The care plan also does not address individualized approaches to care that are directed toward understanding, preventing, relieving, and/or accommodating Resident #9's expressions of distress with the provision of personal care. Per interview on 06/12/23 at 1:00 PM Resident #9's Power of Attorney (POA), s/he has noticed that Resident #9 often has bruising on her/his arms and hands. The POA continued to explain that the bruising is a result of Resident #9 resisting and refusing care due to dementia and her/his religious beliefs. According to the POA Resident #9 had been resistive to care prior to residing at the facility and it was difficult to care for her/him at home. Per observation of Resident #9 on 6/12/23 at approximately 2:30 PM, there was bi lateral bruising noted to tops of hands and lower arms. Per interview with a Licensed Nursing Assistant (LNA) on 06/13/23 at approximately 11:00 AM s/he stated s/he was familiar with Resident #9. S/he stated that the resident will punch, pull hair, and pinch; it often takes at least two and sometimes three people to perform care. One staff member will hold the resident's hands in front to distract the resident while the other provides incontinence care from behind. Per interview on 06/14/23 at approximately 1:45 pm with another LNA Resident #9 is very challenging and repeatedly demonstrates aggressive behavior during care, particularly incontinence care. S/he said Resident #9 often yells, You can't look down there; only God can do that, and I am a [NAME] of God; you cannot touch me there. The LNA stated that they use two aides for care, one will often use the blanket to wrap her while performing incontinence care from behind. During interview on 6/14/23 at approximately 1:00 PM the Unit Manager (UM) confirmed that there are no interventions identified in Resident #9's care plan that would assist or instruct staff to provide appropriate resident-centered care based on her/his needs. S/he also confirmed that there are no documented interventions to prevent injury to the resident during resistive and combative exhibiting expressions of distress during care related to dementia. At approximately 3:00 PM on 6/14/2023 the UM stated the nursing staff would verbally pass on methods that seem to work with the resident however, the care plan does not reflect interventions needed to provide care while maintaining Resident #9's safety and honor her/his religious beliefs related to her/his personal care.

Per interview and record review the facility failed to ensure that annual performance reviews were completed for 4 of 4 staff members in the applicable sample. On 6/14/23 this surveyor requested the 2022 annual performance reviews of 5 sampled staff members. On 6/14/23 at 3:15 PM the Administrator was unable to produce the reviews and confirmed that they had not been completed since 2021.