Every finding on record at Avir at Beaumont

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and other officials including to the State Survey Agency in accordance with State law through established procedures for 1 of 10 residents (Resident #1) reviewed for reporting allegations of abuse. LVN A failed to report an allegation of abuse immediately to the Administrator after Resident #1 alleged on 08/23/26 at 11:54 a.m., that staff had torn up her bible, went through her purse, and 3 (unidentified) CNAs on night shift had attacked her and hit her in the eye. The facility failed to report an allegation of verbal abuse within 2 hours. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life.Record review of Resident #1's face sheet, dated 08/24/26, indicated she was a [AGE] year-old female, admitted on [DATE], and her diagnosis included disorganized schizophrenia (characterized by disorganized speech, behavior, and emotional expression), hypertension (high blood pressure), anxiety (feeling of worry, nervousness, or unease), hypothyroidism (underactive thyroid), and COPD (chronic obstructive pulmonary disease). Record review of Resident #1's annual MDS assessment, dated 06/24/26, indicated she was able to make herself understood and understood others. She was cognitively intact (BIMS-14). Record review of Resident #1's care plan, dated 07/03/25 (revised 07/28/26), indicated Resident #1 had a long history of psychiatric and behavioral problems, a history of making false accusations, and a history of calling 911. Interventions included two staff when providing care at all times and investigate all accusations. Record review of Resident #1's nurse note, dated 08/23/26 at 11:54 p.m., completed by LVN A, indicated the PD was at the facility for a welfare check. Resident #1 had called the PD and reported staff had torn up her bible, went through her purse, and 3 (unidentified) CNAs on night shift had attacked her and hit her in the eye. LVN A informed the PD that staff had not been in Resident #1's room. The police talked to Resident #1 and told her not to call 911 for non-emergencies and left the facility. During an observation and interview on 08/24/25 at 10:15 a.m., Resident #1 said staff had torn up her bible, went through her purse, and 3 (unidentified) CNAs on night shift had attacked her, refused to turn her over and hit her in the eye. She could not identify the staff or specify the date or time. She pointed out her black eye that appeared to be a dark discoloration of the skin. There was no evidence of a bruise. Resident #1 went through her purse and was focused on her previous facilities of residence in past years. During an interview on 08/24/26 at 10:46 a.m., Family Member B said Resident #1 made false allegations against staff and had a history of making false allegations. Family Member B said they reviewed the camera feed and saw no evidence of abuse. During an interview on 08/24/26 at 11:34 a.m., LVN A said she was trained on A/N/E and reporting requirements. She said she was required to report allegations of abuse to the Administrator and/or the Abuse Coordinator-designee immediately. She said she did not report the allegations immediately because Resident #1 had a history of making false allegations. She said she notified the Administrator of the allegations at approximately 6:30 a.m. on 08/24/26 of Resident #1's allegations. She said residents were at risk of abuse if all allegations were not reported as required. During an interview on 08/24/26 at 9:25 a.m., the Administrator said she was the abuse coordinator. She said allegations were reportable to her immediately, and allegations of abuse were reportable to HHSC within 2 hours. She said she did not receive immediate notification of Resident #1's allegations on 08/23/26. She said she received notification from LVN A on 08/24/26 at 6:30 a.m. She said she did not report the allegations to HHSC within two hours because there was a camera in her room and Resident #1's family reviewed the camera and said Resident #1's allegations were false. She said Resident #1 had a history of making false allegations. She said none of the allegations were reported because the cameras showed nothing to verify the allegations. Record review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention dated 2001 (Revised April 2021) indicated: . 9. Investigate and report any allegations within timeframes required by federal requirements.

Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 10 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure Resident #1's Thyroid-Stimulating Hormone, also known as TSH, was drawn every 3 months as ordered by the physician. This failure could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases. Record review of Resident #1's face sheet, dated 08/24/26, indicated she was a [AGE] year-old female, admitted on [DATE], and her diagnosis included disorganized schizophrenia (characterized by disorganized speech, behavior, and emotional expression), hypertension (high blood pressure), anxiety (feeling of worry, nervousness, or unease), hypothyroidism (underactive thyroid), and COPD (chronic obstructive pulmonary disease). Record review of Resident #1's annual MDS assessment, dated 06/24/26, indicated she was able to make herself understood and understood others. She was cognitively intact (BIMS-14). Her active diagnosis included Thyroid Disorder. Record review of Resident #1's physician orders dated 10/16/25 indicated CBC, CMP, TSH (blood test used to screen for or monitor thyroid disorders) Q4 months -September, December, March, and June. Record review of Resident #1's laboratory results indicated only one laboratory result that included TSH was drawn and resulted on 09/15/25. During an interview on 08/24/26 at 11:45 a.m., the DON said the TSH must have accidentally fallen off the checked box status and was not completed as ordered by the physician. She said labs were reviewed every morning at clinical meeting, but it was missed that Resident #1's TSH was not done. The DON said it was important to ensure labs were drawn as ordered by the physician to ensure the resident's health had been monitored by those lab values. During an interview on 08/24/26 at 1:12 p.m., MD C said it was important labs were completed as ordered, but Resident #1's TSH levels were not critical. He said every 3 months was the usual order for TSH levels, but it was not uncommon for levels to fluctuate, and he would have ordered TSH every 6 months instead of every 4 months to get a better read on the levels, unless the TSH levels were critical. Record review of the facility's policy for Lab and Diagnostic Test Results dated 2001 indicated 9. c. Schedule repeat labs if indicated .

Based on observations, interviews, and record review, the facility failed to provide maintain a comfortable homelike environment for for 4 of 16 Residents (Resident #37, Resident #4, and Resident #111, Resident #13) who were reviewed for a home-like environment. The facility failed to ensure that the walls of Residents #37, #4, 115, and #111 rooms were free of scuff marks and paint damage on 8-04-2026 at 11:00 AM. The facility failed to ensure the corners of the shower in the second shower room on hall 100 were free from mold. This failure could place residents at risk of a clean and comfortable home-like environment which could lead to discomfort and stress. unsanitary environment and an increased risk for slips, trips, falls, injury, and exposure to contaminants while receiving bathing services. Findings included:Record review of Resident #111's face sheet, dated 09/05/26, reflected Resident #111 was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with visual loss both eyes, obesity, unsteadiness on feet, hearing loss, chronic pain, hypertension and chronic kidney disease.Record review of Resident #111's quarterly MDS assessment, dated 0 6/04/26, reflected a BIMS score of 13, indicating his cognition was intact.Record review of Resident #111's care plan, dated ??, reflected there was no care plan relevant to the necessity of a home-like environment.Record review of Resident #13's face sheet, dated 09/05/26, reflected Resident #13 was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with acute kidney failure, type 2 diabetes, hemiplegia and hemiparesis (loss of physical function on one side of the body due to brain or spinal cord injury), obesity, memory deficit, pain and dementia.Record review of Resident #13's quarterly MDS assessment, dated 02/06/26, reflected a BIMS score of 06, indicating his cognition was severely impaired.Record review of Resident #13's care plan, dated ??, reflected that there was no care plan relevant to the necessity of a home-like environment.A Record review of Resident #37's face sheet, dated 8-06-2026, revealed a 77 (male) was admitted to the facility on [DATE]. He was diagnosed with the following. Chronic Obstructive Pulmonary disease (A progressive lung disease characterized by long-term respiratory symptoms and airflow limitation that makes breathing difficult), Generalized Anxiety Disorder (A mental health condition marked by persistent, excessive, and unrealistic worry about everyday activities and events lasting at least six months), Hypertension (a chronic medical condition where the blood pushing against the artery walls is consistently too high), andRecord review of Resident #37's Quarterly MDS Assessment, dated 5/19/2026, revealed a BIMS score of 06, reflecting that he had severe cognitive impairment. Resident #37's Quarterly MDS Assessment showed that he was at risk for malnutrition (protein or calorie).Record review of Resident #37's Quarterly MDS Assessment, dated 5/19/2026, revealed a BIMS score of 06, reflecting he had severe cognitive impairment. Resident #37's Quarterly MDS Assessment showed that he was at risk for malnutrition (protein or calorie).Record review of Resident #4's face sheet, dated 8-06-2026, revealed Resident #4 was admitted on [DATE] and re-mitted on 11/21/2024. He has diagnosis of Hypertensive Chronic Kidney Disease (High blood pressure damages the kidneys over time), Type 2 Diabetes (The body does not use insulin well, leading to high blood sugar), End-Stage Renal Disease (The kidneys stop working completely, needing dialysis or a transplant.), and Major Depressive Disorder (A serious mental health condition causing ongoing sadness and a loss of interest in life).Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 00, indicating they could not complete the BIMS.Record review of Resident #4's care plan, dated ??, reflected there was no care plan relevant to the necessity of a home-like environment.An interview on 08/04/2026 at 1:05 PM, Resident #37 stated that there are a lot of times that he does not get a full plate of food. He stated that sometimes he is hungry because he is not getting enough food.An interview on 8/7/2026 at 12:05 PM, CNA-A stated if she saw any repairs that needed to be done in the residents' room, then she would tell the nurse in charge. She stated that she was aware that some rooms have scuff marks on the walls. She stated that she reported that in the past and nothing was done. She stated that residents have not complained about scuff marks on the walls. She stated that this was not a home-like environment for the residents.An interview on 8/7/2026 at 12:10 PM, LVN-I stated that today was her first day working at the facility. She stated that she knew about the application they used to report scuff marks or any other maintenance issues. She stated that if these things were not fixed, then it would be an issue because the residents would not have a home environment. An interview on 8/7/2026 at 1:15 PM, the MD stated that he and the Assistant Maintenance Director made rounds to check on rooms. He stated that they have an application on the computer they used to fulfill maintenance requests. He stated that anybody in the facility could make a request for repairs. He stated that they tried to get to them as soon as they could. He stated that repairs on the walls were not usually their priority, but they got to them. He stated that he was aware some of the rooms' walls were scuff marked. He stated that when there were a lot of scuff marks on the wall, makes it easier for them to do the whole room. The MD stated the only issue with that was they must move the resident to a different room so they could redo the whole room. He stated that residents having scuffed-up walls was a home-like environment issue. An interview on 08/06/2026 3:15 PM, the DON stated she was not aware of all the different scuff marks in some of the rooms. She stated staff should be making these requests to maintenance so they could be fixed. She stated that the Guardian Angels are volunteers that make rounds to check on issues with rooms. She stated that these issues should have been reported to maintenance. She stated that residents having scuffs on the walls was a home environment issue.An interview on 08/06/2026 3:25 PM, the ADM stated there was a system that the maintenance personnel used for maintenance requests. She stated that she did not know if any of those requests were for scuff marks on the walls to be repaired. She stated that she also should be following up with residents by going to check their rooms to make sure there were no issues. She stated that this was a home environment issue with scuff marks on the wall.The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike environment setting. These characteristics include:inviting colors and decor;clean, sanitary, and orderly environment;In an interview on 08/05/2026, at 2:50 PM, Resident #115, stated the shower room on hall 1A and 1 B was very nasty he escorted me to the shower room and showed me the shower room.During an observation on 08/05/2026 at 2:50 PM, Surveyor observed the shower room with several towels on the floor, with missing tiles, and several bottles of missing product on the floor. The resident stated this shower has been in this condition for several months forcing them to only use one shower. The shower also leaked when it was turned on. Shower was observed with used bandages on the floor. Observed clothes on the floor in the corner of the shower room.During an observation on 08/05/2026, at 2:59 PM, Surveyor observed mold in the corners of the shower in the second shower room on hall 100.In an interview on 8/6/2026 at 11:39 CNA - E, stated during my shift, my responsibility was to ensure the resident shower rooms stayed clean, safe, and free of hazards. I kept an eye on the area and made sure there were no items left on the floor that could cause a slip hazard. I also assist residents whenever they need help. If I notice something left on the shower floor or see damaged flooring, such as missing or loose floor tiles, I take care of it right away. First, I clean up and remove the item to eliminate the hazard. Then I report the issue by entering it into the system using TELLS, and I also verbally notify maintenance in the building. Before assisting a resident with a shower, I check that the shower room is safe and ready for resident use. I make sure the shower chairs are ready, check the restroom area, confirm the water temperature is good for the resident, and check the heater. I also make sure the room was cleaned before each resident used it. This helped ensure residents got proper, safe showers and made it easier for the aides to do their job.In an interview on 8/6/2026, at 12:03 PM, CNA - F stated during her shift, her responsibility was to make sure the resident shower rooms remain clean, safe, and free of hazards at all times. She picked up and removed any items when she finished with care, so the area stayed hazard-free and residents remained safe. CNA F stated if she observed items left on the shower room floor or noticed damaged flooring, such as missing or loose floor tiles, she would inform the nurse right away, then the nurse would document the information in TELLS for follow-up and maintenance. CNA F stated before assisting a resident with a shower, she checked that the shower room was safe and ready for resident use. She stated she made sure the door was able to lock, the floor was dry, and the shower chair wheels locked and unlocked properly. She stated this helped ensure the resident was safe during the shower and that everything worked correctly before care began.In an interview on 8/6/2026, at 3:17 PM, the ADM stated she held an orientation for all employees, new hire training, floor training and they were checked off, she stated staff was in-serviced on laundry but could not give the most recent date, the supervisor audited and used a checklist to ensure task were completed. She stated she required all staff to document everything and it be accurate. In addition, she stated her facility used the TELLS system to document all issues related to maintenance.On 8/6/2026 at 11:00 AM, the ADM stated the facility did not have a policy in place for Showers.

Based on observation, record review, and interview, the facility failed to ensure admission to the secured unit was free from involuntary seclusion for 3 of 7 residents (Resident #29, Resident #57, and Resident #68) reviewed for involuntary seclusion. The facility failed to include in Resident #29, Resident #57, and Resident #68s' record:1. Documentation of the clinical criteria met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team on (dated) at (time).2. Documentation that reflected whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect the resident and assure his/her health and safety on (date) at (time). 3. Documentation by the interdisciplinary team of the impact and/or reaction of the resident, if any, regarding placement on the unit; and ongoing documentation of the review and revision of the resident's care plan as necessary, including whether he/she continued to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident on (date) at (time). This failure could place residents at risk of not being assessed properly, not meeting the criteria to be placed on the unit, diminished quality of life, and involuntary seclusion.Findings included: Record review of Resident #29's face sheet, dated 08/06/2026, revealed a sixty-year-old female who was admitted to the facility on [DATE], re-admitted on [DATE], with diagnosis that included cerebral infarction (happens when a blood clot or blocked artery stops blood and oxygen from reaching part of the brain), major depressive disorder (a common mental health condition. It causes ongoing sadness, loss of interest in activities, and low energy lasting at least two weeks), and hemiplegia and hemiparesis following cerebral infarction (Hemiplegia (complete paralysis) and hemiparesis (partial weakness) on one side of the body commonly occur after a cerebral infarction (ischemic stroke). Record review of Resident #29's care plan revealed a focus dated 07/18/2025 of Resident #29 resides in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment related to a diagnosis of dementia as evidenced by impaired safety awareness. I am at risk of injury from others while residing in secure/ memory unit due to altered cognition. Record review of Resident #29's Comprehensive MDS (clinical assessment to determine resident's strength and needs) Assessment, dated 06/17/2026, Section C (Cognitive Patterns) revealed a BIMS score of 12 indicating moderate cognitive impairment and Section E0900 (Wandering - Presence and Frequency) behavior not exhibited. Record review of Resident #57's face sheet, dated 08/06/2026, revealed a seventy-year-old female who was admitted to the facility on [DATE], re-admitted on [DATE] with a diagnosis that included chronic obstructive pulmonary disease (a long-term lung disease that blocks airflow and makes it hard to breathe), dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive decline caused by a separate medical condition, but the medical chart does not list a specific stage or extra behavioral symptoms), and mood disorder due to known physiological condition with mixed other features (a medically-induced mood state where a physical illness or bodily condition directly triggers concurrent depressive and manic or hypomanic symptoms). Record review of Resident #57's care plan revealed a focus, dated 09/28/2020, of impaired cognitive function/dementia or impaired thought processes related to a diagnosis of schizophrenia (a severe chronic brain disorder affecting how a person thinks, feels, and acts appropriate for secure unit as cognition fluctuates) and prefers an all-women's unit. Record review of Resident #57's Comprehensive MDS (clinical assessment to determine resident's strength and needs) Assessment, dated 05/11/2026, e Section C (Cognitive Patterns) revealed a BIMS score of 13 indicating cognitively intact with no or very little impairment and E0900 (Wandering - Presence and Frequency) behavior not exhibited. Record review of Resident #68's face sheet, dated 08/06/2026, revealed a sixty seven year-old female who was admitted to the facility on [DATE], re-admitted on [DATE], with a diagnosis that included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (paralysis (hemiplegia) or weakness (hemiparesis) on the left, dominant side of the body), polyneuropathy (medical condition where many peripheral nerves throughout the body malfunction at the same time), and generalized anxiety disorder (a mental health condition defined by constant, extreme worry and fear about everyday things). Record review of Resident #68's care plan revealed a focus, dated 09/26/2025, of Resident #68 had an elopement/wandering as evidenced by actively exit-seeking on 09/24/2025. Record review of Resident #68s Comprehensive MDS (clinical assessment to determine resident's strength and needs) Assessment, dated 05/11/2026, Section C (Cognitive Patterns) revealed a BIMS score of 13 indicating cognitively intact with no or very little impairment and E0900 (Wandering - Presence and Frequency) behavior of this type occurred 1 to 3 days. Record review of Resident #29's physician's order, dated 06/30/2025, reflected, May reside on the secure unit. Record review of Resident #57's physician's order, dated 04/23/2025, reflected, May reside on the secure unit. Record review of Resident #68's physician's order, dated 09/26/2025, reflected, May reside on the secure unit. During an interview on 08/04/2026 with Resident #68 she said she was fine. She said she felt depressed because she lived in the secure unit, she said she wanted to go home. During an interview on 08/04/2026 at 1:36 PM, LVN K said she worked at the facility for about two and a half years and had worked in the secure unit for about one year. She said she did not know why Resident #68 was on the secure unit. LVN K said Resident #68 preferred to stay in bed a lot. LVN K said as soon as they got Resident #68 up and out of bed, Resident #68 wanted to go back to bed. LVN K said Resident #68 used to go to the adult day program but no longer attended. LVN K said Resident #68 went home with family nearly every weekend. LVN K said Resident #68 did not have any behaviors. LVN K said when Resident #68 first admitted to the secured unit, she wanted to go home but now she was more relaxed and comfortable and did not go to the exit door. LVN K said Resident #68 could not stand any longer but could propel herself in a wheelchair. LVN K said Resident #68 was more exit seeking when she first admitted to the facility. LVN K said Resident #68 could make her needs known and would be fine for a trial period in the regular unit. LVN K said she was not worried about Resident #68 eloping because Resident #68 did not get out of bed that much. During an interview by phone on 08/05/2026 at 2:35 PM with NP Q A she said that most of the time residents are in the secure unit because of elopement and underlying dementia. NP Q she Resident #68 had underlying dementia and she assumed that was why Resident #68 was still in the secure unit. NP Q said that she knew that Resident #68 was confused and had anxiety. NP Q said to her knowledge, Resident #68 was not harmful to herself or others. NP Q said the facility had not discussed Resident #68 getting off the secure unit. NP Q said she had not been with the facility for very long, but they have not done quarterly assessments for evaluating if residents still need to be on the secure unit. She said to her knowledge, the assessments were not done quarterly, by every six months or yearly. She said she had not been in any discussions about taking residents off the secure unit. She said when she visits the facility, she visits only the people who are on her list to visit. During an interview on 08/06/2026 at 10:54 AM with LVN K she said she thought Resident #57 was in the secure unit because when Resident #57 was in the general unit she said a man was sexually assaulting her and made the accusation several times. LVN K said the facility investigated Resident #57's allegations thoroughly and there were no findings that he was sexually abusing her. LVN K said Resident #57 was moved to the secure unit to insure she would not be around that resident. LVN K said she did not know why Resident #29 was in the secure unit. LVN K said she had previously asked Resident #29 if she wanted to leave the secure unit and Resident #29 said no. LVN K said that Resident #29 had all her faculties together and was not harmful to herself or others. During an interview on 08/06/2026 at 11:53 AM, Resident #57 said she did not like being in the secured unit because she could not get a soda and she could not go outside. Resident #57 said if her family were still living she would not be living at the facility and not be living in the secured unit. During an interview on 08/06/2026 at 12:09 PM, Resident #29 said she knew she was in the secure unit and wanted to stay in the secure unit because she liked where her room was located. During an interview on 08/06/2026 at 1:15 PM, the DON said the criteria for a resident to be in the secure unit was the residents BIMS score and if the resident was an elopement concern. The DON said there was no specific BIMS or elopement number that was used, she said it was based on the individual. The DON said they did BIMS scores, elopement evaluations, and care conferences quarterly. The DON said there was no documentation for the residents in the secured unit that said because of this BIMS score and this elopement score this was the explanation why the resident was in the secure unit and why the resident continued to be in the secure unit. During an interview on 08/06/2026 at 1:48 PM, the ADM said there should be an assessment for each resident who was in the secured unit that explained why that resident was in the secure unit and an assessment that explained why that resident continued to be in the secure unit. The ADM said the entire IDT team, that included the psychiatric professional, the floor staff, the DON, and the social worker, should meet quarterly to discuss why the resident was in the secure unit and it should be documented in the residents' eMAR. Record review of the facility policy titled, Secure Unit, dated July 2025, reflected the secure unit was designed to provide a safe and structured environment for residents who were at risk of elopement or harm due to cognitive impairment (e.g. dementia, Alzheimer's disease or other behavioral health concerns). This policy ensures that all residents' rights, safety, and dignity are protected while maintaining compliance with federal and state regulations. The following will be reviewed for all new admissions being considered for the Secure Unit. a. A cognitive assessment (BIMS) will be completed on admission, quarterly and as needed, to validate that the resident has a cognitive deficit.b. Appropriate payor sourcec. History and Physical and Medication reviewd. Wandering, past elopement or potential for elopemente. Cognitive deficitf. Interdisciplinary team to review for appropriateness of admissiong. Consent will be obtained for the non-cognitively impaired residentsh. A physician's orderi. Guardian's consent admission Criteria:Residents must meet medical and cognitive criteria for placement.Review and Quality Improvement:Residents are reviewed quarterly for continued need for the secure unit and as needed.Feedback from residents' families is encouraged and used to improve care.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 5 (Resident #10, Resident #30, Resident #109, Resident #73, Resident #126) of 12 residents reviewed for infection control. The facility failed to ensure that: an environment and laundry process that support effective infection prevention on 08/06/26. The required posting provided for EBP, visual alerts for Resident #10 who had open lesion(s) on the foot, Resident #30 who had a feeding tube, and Resident #109 who had a G-tube on 08/04/26. CNA B and CNA C changes dirty gloves while handling clean items while providing pericare to Resident #73 and Resident #126 on 08/05/26.These failures could place the residents at risk of infectious diseases.Findings included:1.During an observation on 8/5/2026, at 2:44 PM, in the facility's laundry room, the facility was observed to have two washing machines and two dryers, consisting of one commercial dryer and one residential/home-use dryer. The laundry room did not have an organized separation or designated areas to separate clean and soiled laundry, creating the potential for clean linens to become contaminated during the laundry process. In addition, the lost and found items were observed on the dirty side.Observation on 8/5/2026, at 2:44 PM, in the laundry room, noted that the air conditioning system in the laundry building was not functioning. At the time of observation, the thermostat displayed a temperature of approximately 97 F inside the laundry building.In an interview on 8/5/2026, at 2:44 PM, Maintenance, stated that the laundry room has been like this for a while, and she has been going to a local laundry mat in town daily to do the residents' laundry to keep up. She stated that currently, the facility did not have a system in place to keep the residents' clothes clean.In the interview on 8/6/2026, at 11:39 AM, CNA - E, stated to prevent contamination of clean linen, the process starts with how soiled items were handled. She stated that all dirty clothes should be placed directly into a bag, and that the bags were kept easily accessible, so she could contain soiled laundry right away rather than carrying it loose. She also described how clean laundry and soiled laundry should be separated during collection, transport, storage, and distribution. She said she kept dirty items separated by placing them in a bag, ensuring that soiled laundry was not mixed with clean linens at any point. For personal protective equipment, she stated that she wore gloves when handling soiled linen. She also stated PPE should be changed as needed. CNA E, stated if she observed the laundry area or equipment was not clean, or if clean linen became contaminated before it was distributed to the residents, she would report the problem immediately, and she would throw out the contaminated linens and replace them with clean linens before distribution.In an interview on 8/6/2026, 11:50 AM, CNA- F, stated when soiled linen are handled, they should be placed in a garbage bag away from your body and taken to the linen closet. She also described how you separated clean laundry from soiled laundry during collection, transport, storage, and distribution by placing clean items in pillowcases and placing dirty items in a garbage bag. CNA- F, stated that when you handle soiled linen, gloves are required, and you changed them as soon as you place an item into the dirty linen closet. She reported that if she observed the laundry area or equipment is not clean, or if clean linen become contaminated before distribution to residents, she would inform the nurse about the condition. 2.Record review of Resident #10's face sheet, dated 08/06/2026, revealed a fifty-five-year-old female who was admitted to the facility on [DATE], re-admitted on [DATE] and 07/25/2026 with a diagnosis that included schizoaffective disorder, bipolar type (a chronic mental health condition defined by a combination of schizophrenia symptoms (such as hallucinations or delusions) and mood swings of bipolar disorder, including at least one manic episode and often major depressive episodes), chronic obstructive pyelonephritis (a long-term kidney infection caused by a block in the urinary tract), and chronic combined systolic (congestive) and diastolic (congestive) heart failure (a long-term condition where the heart muscle both pumps with too little force (systolic failure) and stiffens so it cannot fill with enough blood (diastolic failure)). Record review of Resident #10's care plan, revealed a focus dated 07/07/2026 of Resident #10 had a left heel arterial ulcer. Resident #10's Comprehensive MDS (clinical assessment to determine resident's strength and needs) Assessment, dated 07/15/2026, Section C (Cognitive Patterns) revealed a score of 13 indicating cognitively intact with no or very little impairment and M1040 (other ulcers, wounds and skin problems) other open lesion(s) on the foot. Record review of Resident #30's face sheet, dated 08/06/2026, revealed a forty eight year-old female who was admitted to the facility on [DATE], re-admitted on [DATE] with diagnosis that included autistic disorder (a lifelong neurodevelopmental condition characterized by differences in brain development), local infection of the skin and subcutaneous tissue (a microbial invasion-frequently bacterial like Staphylococcus or Streptococcus-entering through a break in the skin), and cognitive communication deficit (trouble with communication caused by disrupted thinking skills like attention, memory, and problem-solving, rather than a basic physical problem with speech or language). Record review of Resident #30's care plan, revealed a focus, dated 03/02/2026, of Resident #30 with a potential fluid deficit related to feeding tube dependence. Record review of Resident #30's Comprehensive MDS (clinical assessment to determine resident's strength and needs) Assessment, dated 06/20/2026, Section K - Swallowing/Nutritional StatusK0520 Nutritional Approaches - feeding tube while a resident and Section C - Cognitive Patterns revealed no BIMS score. Record review of Resident #109's face sheet, dated 08/06/2026, revealed a fifty nine year-old male who was admitted to the facility on [DATE], re-admitted on [DATE] with diagnosis that included acute respiratory failure with hypoxia (a sudden, life-threatening condition where the lungs cannot transfer enough oxygen into the blood), aphasia following cerebral infarction (a language disorder caused by tissue damage in brain regions controlling speech and comprehension, usually in the brain's left hemisphere), and aphagia (total inability or refusal to swallow). Record review of Resident #109's care plan, revealed a focus, dated 05/14/2026, revealed Resident # 109 had nutritional problem nothing by mouth enteral nutrition only (G-tube (a medical device placed through the skin of the abdomen directly into the stomach)). Record review of Resident #109's Comprehensive MDS (clinical assessment to determine resident's strength and needs) Assessment, dated 05/25/2026, Section K0520 - Nutritional Approaches - feeding tube (e.g., nasogastric or abdominal (PEG - a flexible medical tube placed through the skin of the abdomen directly into the stomach) and Section C - Cognitive Patterns revealed no BIMS score. Observation on 08/04/2026 at 10:30 AM of the door to Resident #109's room reflected no EBP signage stating STOP, everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a down for the following high-contact resident care activities, dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use - central line, urinary catheter, feeding tube, tracheostomy, wound care - any skin opening requiring a dressing. Observation on 08/04/2026 at 10:39 AM of the door to Resident #30's room reflected no EBP signage stating STOP, everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a down for the following high-contact resident care activities, dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use - central line, urinary catheter, feeding tube, tracheostomy, wound care - any skin opening requiring a dressing. Observation on 08/04/2026 at 10:50 AM of the door to Resident #10's room reflected no EBP signage stating STOP, everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a down for the following high-contact resident care activities, dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use - central line, urinary catheter, feeding tube, tracheostomy, wound care - any skin opening requiring a dressing. Record review of Resident #10's physician's order, start date 03/19/2026, reflected EBP: staff must use gown and gloves during high-contact resident care activities that could possibly to result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions were recommended for residents known to be colonized or infected with a MDRO as well as those who were not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices) every shift for EBP Precautions. Record review of Resident #30's physician's order, start date 07/05/2022, reflected change G-tube syringe daily every night shift. Record review of Resident #30's physician's order, start date 03/19/2026, reflected staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions wererecommended for residents known to be colonized or infected with a MDRO as well as those who were not confirmed to have an MDRO every shift for EBP Precautions. Record review of Resident #109's physician's order, start date 04/04/2022, reflected cleanse G-tube site with ns (normal Saline), pat dry, apply split gauze dressing and secure with tape every night shift. During an interview on 08/06/2026 at 10:16 AM, the RN who was the facility infection control specialist said she received her certification in infection control on 07/19/2026. The RN said EBP signage should be placed outside a residents' room visible for staff to see if the resident had a wound(s), needed catheter care, or any feeding tube or G-tube. The RN said the EBP instructs staff to wear PPE when providing resident care to protect residents from infection or any cross contamination. The RN said there should be a sign on the residents' door that explained what kind of PPE to use and why the PPE needed to be worn. The RN said it was the responsibility of the infection control specialist for making sure the signage was on the residents' doors who needed staff to wear the PPE. The RN said the possible negative effect of not having the EBP signage to notify the staff of the need to wear PPE would be if the PPE was not worn, staff could contaminate the resident they were providing care to and contaminate other residents in the facility. During an interview on 08/06/2026 at 1:48 PM, the ADM she said EBP meant enhanced barrier precautions. The ADM said it was facility procedure for an EBP sign to be placed on the outside of residents' doors so staff knew to wear the proper PPE when giving resident care. The ADM said the EBP signs would help staff stop and put on the correct PPE before they interacted with the residents. The ADM said PPE was worn to protect the residents from infection. The ADM said the staff infection preventionist was responsible for making sure the EBP signs were on residents' doors. The ADM said every nurse in the facility should know to put an EBP sign on the door of a resident who required PPE to deter infection and cross contamination. During an interview on 08/06/2026 at 2:05 PM, LVN O said she was responsible for arranging the residents' PPE and putting the EBP signs on residents' doors. She said it was important that the EBP sign was on the door so staff would know what was needed for the residents' care. LVN O said wounds, G-tubes, dialysis ports, and catheters were prone to infection and staff needed to cover themselves when performing resident care. LVN O said a possible negative effect of not having the EBP sign on the door was that staff needed the sign to identify what care the residents needed to take care of them correctly. LVN O said it was her responsibility and the responsibility of the nurses to put the EBP signs on residents' doors who needed EBP. During an interview on 08/06/2026 at 3:24 PM, LVN J said he was trained in infection control and EBP. He said if a resident had a wound, dialysis port, G-tube, or feeding tube staff needed to wear PPE in the room when providing resident care. LVN J said there should be an EPB sign posted on the door to the residents' room who needed EBP. LVN J said a negative effect of not wearing PPE would be that staff might transfer an infection to another resident if they did not wear EPB when providing care to a resident who needed EBP. LVN J said it was the responsibility of the nurses and the DON to make sure there were EBP signs on the doors of residents who needed EBP. 3.Resident #73Record review of Resident #73's face sheet, dated 08/05/26, reflected Resident #73 was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with muscle weakness, constipation, urinary tract infection, pressure ulcer of right hip and lack of coordination. Record review of Resident #73's annual MDS assessment, dated 06/02/26, reflected a BIMS score of 07 indicating her cognition was severely impaired. Record review of Resident #73's care plan, dated 03/09/25, reflected the resident had an ADL self-care performance deficit r/t pressure ulcer, muscle weakness (generalized), and lack of coordination. The relevant intervention was providing assistance with hygiene. Resident #126Record review of Resident #126's face sheet, dated 09/05/26, reflected Resident #126 was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was an [AGE] year-old male diagnosed with hypotension (low blood pressure), abnormalities of gait and mobility, constipation, COPD, fracture of right and left femur(thigh bone), and unsteadiness on feet. Record review of Resident #126's quarterly MDS assessment, dated 08/04/26, reflected a BIMS score of 06 indicating her cognition was severely impaired.Record review of Resident #126's care plan, dated 03/09/25, reflected that the resident had an ADL self-care performance deficit r/t hip fracture, unsteadiness on feet, lack of coordination, muscle wasting and abnormalities of gait and mobility.During an observation on 08/05/26 at 1:40 PM, CNA B was providing peri-care for Resident #73. CNA B entered Resident #73's room, put on gloves without washing her hands, and began the peri-care. She wiped Resident #73's front and back with wet wipes dispensed directly from the packet, repeatedly touching the wet wipe packet while dispensing individual wipes. After completing the cleaning, she took a new brief using the same soiled gloves and placed it on Resident #73. She also used the same gloves to adjust the blanket and bedsheets. After finishing the peri-care, she kept the wet wipe packet with the remaining wet wipes in Resident #73's drawer. She did not change her gloves during the entire process. During this procedure, she soiled items like the wet wipe packet, the resident's blanket, and the new brief. After completing the peri-care, she removed her soiled gloves and left the room with the waste from the peri-care. She did not wash her hands afterward. During an interview on 08/05/26 at 1:55pm, CNA B stated that this was her first CNA job and she started at the facility two weeks ago. She stated that she had three days of orientation after hire, during which she observed other experienced CNAs performing peri-care. She stated that she did not receive hands-on training during the orientation and that no staff observed her performing peri-care or corrected any mistakes she might have made in the last two weeks. She said that after the three days of orientation, she was directly assigned to residents to complete CNA tasks, including peri-care. CNA B stated that she was supposed to change her gloves between handling soiled and clean items. She also stated that she was supposed to wash her hands before and after each task, as failing to do so could risk infection through contamination. CNA B said that she did not follow these protocols because she was unaware of the policies and procedures for peri-care and no one had shown or explained them to her. She stated her only peri care learning experience had been the observation of other CNAs performing peri-care at the facility over the past three days. During an observation on 08/05/26 at 2:30 PM, CNA C provided peri-care to Resident #126. CNA C put on gloves after washing her hands and arranged the wet wipe packet on the side table of the resident, along with Resident #126's soda bottle, fork, and knife. After that, she opened the brief and cleaned Resident #126's front and back with wet wipes dispensed directly from the wipe packet. During this process, she touched the entire wipe packet with her soiled gloves. After completing the peri-care, she stored the contaminated wipe packet, containing wet wipes, at Resident #126's bedside in his room for future use. During an interview on 08/06/26 at 2:40 PM, CNA C requested the HHSC investigator to walk through the peri-care she had performed on Resident #126. She stated that she thought she was doing it correctly and stated, however now she realized that by touching the wet wipe packet with soiled gloves, she contaminated the packet meant for future use. She stated that this action risked spreading infectious germs through contamination. She also stated that she should have removed Resident #126's soda bottle, fork, and knife from the side table before arranging the peri-care items to avoid the risk of contamination. CNA C said that following infection control protocols was very important during peri-care, as it helps limit the spread of infectious diseases. She said that she had received in-service training in the past on peri-care but could not recall exactly when it occurred.In an interview on 08/06/2026 at 1:09pm, the Maintenance Director stated he made rounds in the facility, and used the TELLS systems to get work orders fixed in the facility. As they get work orders, they repair them. He stated right now he has 60 orders to complete. Anyone can make a report. He stated that if repairs were not done in a timely manner residents could be exposed to pest and tripping hazards.During an interview on 08/06/26 at 3:30pm, the DON stated that she did not know how long the laundry room had been in this condition. She stated all linens should be bagged and placed in barrels, and staff were required to always wear gloves when handling soiled linens. She also stated that if laundry in the facility was not handled properly, residents could receive dirty linens or clothes. The DON said it was the responsibility of the infection control specialist to make sure that an EBP sign was posted on the door for residents who had wounds, a G-tube, a catheter or any indwelling medical device. The DON said she trained staff on the policies and procedures regarding EBP and EBP signage. The DON said the possible negative effect of not having EBP sign on the outside of a resident's room who needed EBP was that staff would not know what PPE to wear. The DON stated that CNA B was hired two weeks prior and completed about one week of orientation. The DON reported that, during the orientation, CNA B observed many peri-care tasks being completed by senior CNAs. She stated the facility did not observe her performing any peri-care tasks independently before she began performing them on residents independently. The DON stated that it was the facility's usual practice to ask new recruits to demonstrate their skills on manikins (anatomical models, dummies used for training), what they learned during training, before they started performing care on residents. The DON stated that it was a mistake that the facility had not observed CNA B's competency in peri-care before allowing her to commence performing the task on residents. The DON stated that, according to facility protocol, CNA B was supposed to wash her hands before and after performing peri-care tasks and change her gloves in between if she handled clean items. The DON also stated that CNA B and CNA C should not have handled the wet wipe packet with uncleaned gloves, and they should have discarded the wet wipe packet with left over wipes instead of storing them for future use, as the packet was contaminated. The DON stated that CNA B and CNA C would receive one-on-one training and that all CNAs would be trained on proper peri care procedures as soon as possible. The DON stated the wrong practices of CNA B and CNA C posed a risk of spreading infectious diseases at the facility through contamination and emphasized the importance of proper infection control procedures.Record review of facility policies revealed the facility did not have a policy in place for Laundry.Record review of facility policy titled, Enhanced Barrier Precautions, dated March 2024, reflected that EBPs are used as an infection prevention and control intervention to reduce the transmission of multidrug resistant organisms to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contract resident care activities when contact precautions to not otherwise apply. EBP's are indicated when contact precautions do not otherwise apply to residents with wounds and or indwelling medical devices. Wounds generally include chronic wounds (pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds). Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. Record review of facility policy titled, Perineal Care, revised February 2018, reflected: The purpose of this procedure is to provide cleanliness and comfort to the resident to prevent infections and skin irritation and to observe the residents skin condition. Beginning steps:Wash hands, wear gloves and follow standard precautions if contact with blood or body fluid is likely.3.If resident is heavily soiled with feces turn resident on side and clean away feces with tissue whites or incontinent brief. Discard soiled gloves along with the soil brief and or wipes in trash bag. Cover the resident provide safety measures and wash hands with soap and water.5.Sanitize hands and put on gloves6.Proceed with perineal care. Closing steps:a. Clean and store reusable items disposables per center guideline.b. If glowed following center guidelines and the appropriate time to avoid environmental contamination. Sanitize hands.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #09) of 5 residents reviewed for care plans.The facility failed to implement Resident #09's care plan of checking his right fistula for Bruit and Thrill every shift as ordered by the physician.This failure could place residents at risk of complications related to dialysis.Resident #09Record review of Resident #09's face sheet, dated 09/05/26, reflected Resident #09 was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with end stage renal (kidney) disease, hypotension, type 2 diabetes, hypertension, acquired absence of right foot, retention of urine and muscle wasting,Record review of Resident #09's quarterly MDS assessment, dated 07/03/26, reflected a BIMS score of 15 indicating his cognition was intact.Record review of Resident #09's care plan, dated 05/04/22, reflected he needed dialysis (hemodialysis) r/t end stage renal disease. The relevant intervention was checking right fistula(a surgical connection made between an artery and a vein,) for bruit and thrill (A bruit is an abnormal whooshing or swishing sound heard with a stethoscope over a blood vessel, while a thrill is a physical vibration felt by hand over that same area) every shift and notify MD and dialysis unit if none noted. The date the care plan initiated was 09/22/2022 and revised on 03/25/2025.Record review of the physician order reflected: Check right Fistula for Bruit and Thrill every shift-Notify MD and dialysis unit if none noted.-06/28/23.Record review of Resident #09's 2026 MAR revealed the physician's order for checking the right fistula was not transcribed into the MAR.There were no documentations in progress notes, dialysis communication log, or assessments showing that this intervention was completed as ordered by the physician, since 06/28/23.During an observation and interview on 08/05/26 at 10:45 am, it was revealed that Resident #09 was in his room in his wheelchair. He stated he goes for dialysis at a dialysis center out of the facility on Tuesday, Thursday and Saturday. He stated the staff did vitals and assessments prior to departure to the dialysis center, however, not every day or every shift. He stated the facility transported him without any interruptions. He stated he did not have any concern at the moment regarding the services provided by the facility to facilitate his dialysis treatment.During an interview on 08/05/26 at 12:30pm, LVN L stated sometimes when she was on duty, she prepared Resident #9 for dialysis. She stated she took his vitals and checked the fistula for any issues or concerns before sending him out for dialysis and documented in the dialysis communication log. She stated she was not sure if his fistula was checked and documented on every shift.During an interview on 08/06/26 at 3:30 PM, the DON stated that the care plan should be implemented by the staff without fail to ensure the well-being of the residents and the quality-of-care provided. She said that she was not sure why the intervention of physician's order for checking the thrill and bruit of Resident #09's fistula every shift as listed in the care plan was not implemented. She stated that somehow the physician's order was not transcribed into the MAR, and as a result, the staff missed documenting this intervention. She stated that the staff checked Resident # 09's vitals and all other nursing interventions related to dialysis preparation whenever he went out for dialysis. The DON said that she would immediately address the issue by transcribing the physician's order into the MAR as stated in the care plan. She also stated that Resident #09 was safe at the facility and that there were no concerns or issues related to his dialysis so far. The DON additionally stated there were no concerns reported by the dialysis center regarding Resident #09's dialysis preparation.During an interview on 08/06/26 at 3:50 PM, the ADM stated that it was important to ensure the implementation of the interventions listed in the care plan. She stated she was uncertain why Resident #09's dialysis care plan was not properly implemented and documented. She stated she would discuss this concern in the QAPI meeting and work to resolve it as soon as possible, as well as implement measures to prevent such mistakes in the future.Record review to the facility policy titled, Care Plans Comprehensive Person Centered, revised March 2022, reflected: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the students physical psychosocial and functional needs is developed and implemented for each resident.Policy interpretation and implementation:1.The interdisciplinary team in conjunction with the resident and his/ her family or legal representative develops and implements a comprehensive person-centered care plan for each resident. 3.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.9.Care plan interventions are chosen only after data gathering proper sequencing of events careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making

Based on observation, interview, and record review, the facility failed to ensure that the medical records were in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that were complete, accurately documented, readily accessible; and systematically organized for 2 of 5 residents (Resident#22 and Resident #94) reviewed for medical records.The facility failed to ensure LVN M not documenting on MARs, the water bottle and oxygen cannula connected to the oxygen concentrator of Resident#22 and Resident #94 as changed on 08/02/26, when it was not completed on that day, as ordered by the physician on 08/04/26.This failure could place residents at risk for not receiving the nursing and medical care on time.Findings included: Resident #22Record review of Resident #22's face sheet dated 08/04/26 reflected Resident #22 was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed withacute and chronic respiratory failure, with hypoxia, hypotension, heart failure, pain, obesity, chronic kidney disease.Record review of Resident #22's quarterly MDS dated [DATE] reflected a BIMS score of 13, indicating his cognition was intact.Record review of Resident #22's care plan, dated 05/28/25, reflected that the resident has altered respiratory status/difficulty breathing r/t chronic resp failure with hypoxia. The relevant intervention was oxygen at 2 LPM prn SOB Q shift.Record review of Resident #22's physician's order reflected: Change O2 tubing/water every week and PRN every night shifts every Sunday. -Start Date-03/08/2026.During an observation on 08/04/26 at 10:45 am it was revealed that Resident #22 was on continuous oxygen therapy. Observation of the humidifier bottle and cannula revealed that the date written on them were 07/27/26.Record review of the August,26 MAR of Resident #22 revealed LVN M documented that the Oxygen tubing &humidifier bottle were changed on 08/02/26. Resident #94Record review of Resident #94's face sheet dated 08/05/26 reflected Resident #94 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female diagnosed withCOPD (difficulty to breathe), cerebral infarction (stroke), dementia, obesity, hypertension, and muscle weakness.Record review of Resident #94's quarterly MDS dated [DATE] reflected a BIMS score of 09, indicating her cognition was moderately impaired.Record review of Resident #94's care plan, dated 03/09/25, reflected that she uses oxygen therapy r/t shortness of breath. The relevant intervention was providing continuous supply of oxygen via nasal prongs/mask (2-5) LPM.Record review of Resident #94's physician's order, dated, reflected : Change O2 tubing &humidifier bottle every night shift every Sunday. -Order Date-03/07/2026.During an observation on 08/04/26 at 11:30am it was revealed that Resident #94 was and on continuous oxygen therapy. Observation of the humidifier bottle and oxygen cannula revealed that there were no dates of change marked on them.Record review of the MAR of Resident #94 revealed LVN M documented that the oxygen tubing and humidifier bottle were changed on 08/02/26.During an interview on 08/04/26 at 2:35 pm, LVN M stated that she served as the night shift nurse for Hall 200 on 07/27/26. She indicated that She generally worked in the afternoon shift however on 07/27/26 she worked in the night shift. She stated that it was the responsibility of the Sunday night shift nurse to change the humidifier bottles and oxygen tubes for residents in that hall. She identified Residents #22 and Resident#94 as being on continuous oxygen therapy provided by an oxygen concentrator. LVN M said that she had planned to change these items but, due to being occupied with other nursing tasks, she forgot to do so. She said that regular changing of these components was necessary to minimize the risk of respiratory infections and stated that failing to do so compromised infection control protocols. She said that it was the duty of every nurse to adhere to physician's orders by administering medications, therapies, and treatments as prescribed. She stated that she was aware that nurses are supposed to sign the MAR only after completing the task. She said that she marked the task as completed in advance in MAR, before actually performing it, and stated that this practice was not compliant with professional standards. She said she would not repeat this mistake in the future.During an interview on 08/04/26 at 12:20pm, LVN L stated that the physician's order specifically stated that the humidifier bottle and the cannula were to be changed every Sunday during the night shift. She noted that although she routinely checked the equipment daily, she did not notice in the last two days that the changes had not been completed. She stated that routine replacement was important to reduce the risk of infection. She stated that she had not noticed that there were no dates on Resident # 94's water humidifier and the date of change on Resident #22's water humidifier was marked as completed on 07/27/26. LVN B explained that part of her responsibilities included the administration of medication and treatments, and she would only document in the MAR after administering each medication or treatment, not beforehand.During an interview on 08/06/26 at 3:00 pm, the DON stated that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced with new ones as ordered by the physician. The DON clarified that it was the responsibility of the nurse on the Sunday night shift to ensure that this task was completed routinely. She stated that nurses were supposed to document a task in the medical record only after it was completed. She said that false documentation could negatively impact the residents' care plan and that in turn negatively impact the quality of care. She stated it looked like LVN M had not followed the facility policy for documentation and stated she was determined to fix this deficiency through further training and education. Record review of the facility policy titled, Charting and Documentation, revised July 2022, indicated, Policy Statement:All services provided to the resident progress toward the care plan goals or any changes in residence medical physical functional or psychosocial condition shall be documented in residence medical record the medical recourse should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.documentation in the medical record will be objective ( not opinionated or speculative) complete and accurate. Documentation of procedures and treatments will include care specific details including the date and time the procedure treatment was provided.

Based on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls for 1 ( Hall200 Treatment Cart)of 2 treatment carts reviewed for pharmacy services. The facility failed to ensure that the treatment cart that stored wound care medications and materials was locked, and medications were secured and not accessible to other staff, residents, or visitors when not in use on 08/04/26 at 09:40am.This failure could place residents at risk of injury and result in residents not receiving doses of medication as well as not being maintained at their best therapeutic level.Findings included: During an observation and interview on 08/04/26 at 09:40 a.m. at the nursing station situated in hall 200, it was revealed that one of the medication carts was not locked. An inspection of the cart showed that it contained wound care supplies and medications and four residents were near the treatment cart. LVN L, who was at the nursing station, immediately returned and locked the cart. LVN L stated that the cart was a treatment cart used to store extra wound care materials. She stated that when the treatment cart ran out of supplies or when nurses needed wound care items, they accessed that cart for supplies. She said that she did not know who had forgotten to lock the cart. LVN L stated that locking medication or treatment carts was essential to prevent residents or unauthorized people from accessing them, as it posed a safety concern. LVN L stated it was the facility policy and expectation that if staff were walking away from the medication cart it needed to be locked and secured. During an interview on 08/04/26 at 10:50 a.m., LVN H who was in hall 100 at that time stated that he was the wound nurse at the facility. He stated that whenever his treatment cart ran out of materials, he would access the extra storage treatment cart located at the hall 200 nursing station. He also stated that he always locked the treatment cart when it was not in use. He said, on this day, he did not access the extra treatment cart for wound care materials because his treatment cart still had all necessary supplies. LVN H stated that leaving the cart unlocked posed a risk, as many residents at the facility were known to wander and could take the treatment solutions or materials, potentially leading to negative effects. He said that he was unsure who failed to lock the treatment cart, as nurses have access to the cart to obtain supplies needed for tasks such as stoma (a surgical opening on the outside of the body) care and catheter care. During an interview on 08/06/26 at 3:20 p.m., the DON stated that it was her expectation that nursing staff locked the medication cart whenever they were away from it and kept all information private. She stated that leaving the cart unlocked and unattended posed a risk, as patients could open it, remove medications, and potentially experience negative consequences if they took medications that were not prescribed for them or harm themselves with treatment supplies.During an interview on 08/06/26 at 3:50 p.m., the ADM stated that the facility policy was to keep the medication and treatment carts always locked when not in use. She said her expectation was that all staff members would comply with this policy.Record review of the facility policy Medication Labeling and Storage, revised February 2023, reflected: The facility stores all medications and biologicals in locked compartments under proper temperature humidity and light controls only authorized personals have access to keys.Compartments, (including but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use and trays or carts used to transport such items are not left unattended if opened or otherwise potentially available to others.

Based on interview and record review, the facility failed to ensure that menus met the nutritional needs of the resident as required. [KA3.1]for 1 of 29 [KA4.1]residents reviewed for dietary services.Resident #37's food tray delivered to the room did not contain the same portion that other residents in the facility received on 8/05/2026) at 1:15 PM.[KA5.1]This failure could place residents at risk for poor nutrition and reduced quality of life.Findings included:1.A Record review of Resident #37's face sheet, dated 8-06-2026, revealed a 77 (male) was admitted to the facility on [DATE]. He was diagnosed with the following . Chronic Obstructive Pulmonary disease (A progressive lung disease characterized by long-term respiratory symptoms and airflow limitation that makes breathing difficult), Generalized Anxiety Disorder (A mental health condition marked by persistent, excessive, and unrealistic worry about everyday activities and events lasting at least six months), Hypertension (a chronic medical condition where the blood pushing against the artery walls is consistently too high), andRecord review of Resident #37's Quarterly MDS Assessment, dated 5/19/2026, revealed a BIMS score of 06, reflecting that he had severe cognitive impairment. Resident #37's Quarterly MDS Assessment showed that he was at risk for malnutrition (protein or calorie). During an interview on 08/05/26 at 1:45pm stated that he was blind and it had not make any difference to him. Record review of resident #37's care plan, dated 5/21/2026, revealed Resident #37 did not have restrictions on food portions. An interview on 08/04/2026 at 11:31 AM, Resident #37 stated there were times when he got his food late, and the food was cold. He stated that the facility didn't have enough staff serving lunch. An interview on 08/04/2026 at 1:05 PM, Resident #37 stated when the resident's tray was delivered to his room, it was a very small portion. Resident #37 stated this happened a lot. He stated that he did not complain about it. A picture was taken of the residents lunch tray. An interview on 8/7/2026 at 12:05 PM, CNA-A [KA19.1]stated she has not seen residents getting small portions of food when it is delivered to their rooms. She stated that if she sees a resident getting an unusually small portion of food, she wouldn't go to the kitchen and ask for a replacement or a bigger portion. She stated that her resident does not get her regular-sized portion of food; they could be hungry for the rest of the day until the next meal, or they could lose weight.An interview on 8/7/2026 at 12:10 PM with LVN-I stated that she's not seen residents getting small portions of food delivered to the rooms. She stated that if she were to see that, then she would report that to the dietitian and the nurse on duty. She stated that residence should not be getting a small portion of food unless that is something in the care plan or requested by the resident. She stated that a resident could lose weight or go hungry if they were getting an unusually small portion of food.An interview on 08/07/2026 at 1:22 PM, CK [KA20.1][KA21.1]reviewed the following. She stated that residents should not serve small portions of food unless it was on their ticket for them to get a small portion. The cook was shown in the picture [KA22.1]with a small portion[KA23.1] of food, and she stated that should not happen. She was unaware that the small poertion was served to Resident #37. She stated if a resident's ticket that shows a regular portion that is what they should get. She stated that she was the one that was making the lunch trays for the residents and did not recall the small portion. She stated that if a resident did not get the correct portion of food, they could go hungry. She stated that this portion should not have been sent out to the residents. She stated that she has had in-service training on resident portions based on the ticket. An interview on 08/07/2026 at 1:30 PM, the Regional Dietary Manager revealed that residents who got a regular diet should be served a 3-ounce portion of protein. When he looked at the picture that was taken[KA24.1], he stated that that was not a 3-ounce portion of chicken given to the resident. He stated that if there was a small portion on the plate and the resident was ordered a regular portion, they should remake the plate or give the resident more food. He stated that if residents were not given regular portions of food, this could cause weight loss, and the residents could go hungry.An interview on 08/06/2026 at 2:50 PM, the DM [KA25.1] stated that all residents should be getting the same portion of food unless their ticket indicated otherwise. She looked at the picture that was taken of the resident's food and stated that this should not have happened[KA26.1]. She stated that the floor staff should have caught this by sending the plate back to the kitchen so they could get more food. She stated that if residents were not getting a full portion of food, that could cause weight loss.An interview on 08/06/2026 3:15 PM, the DON[KA27.1] stated that all residents' portions should be the same unless noted on their ticket. She stated that if floor staff saw a resident's portion smaller than what the ticket indicated, then they should report that to the nurse. She stated that the CK is responsible for the portions that the residents receive. She stated that, based on the picture shown to her, that portion was not a regular-size portion. She stated that the CK is responsible for putting the portion on the plate and the floor nurse to check if the portion is correct. She stated that if residents were not getting a regular portion of food, they could go hungry or cause weight loss.An interview on 08/06/2026 3:25 PM, the ADM stated that she has not seen any resident get smaller portions of food than what was on their ticket. She stated that none of the residents complained to her about getting small portions of food. She stated that if residents were getting small portions, and that was not on their ticket, it could cause weight loss, or the resident could be hungry until the next meal.Record review of the food policy, dated 2-2023, revealed the following, For point-of-service dining, the Dining Services Department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient[KA.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 5 residents (Resident#22 and Resident #94) reviewed for respiratory care.The facility failed to ensure the humidifier water bottle and oxygen cannula connected to the oxygen concentrator of Resident #22 and Resident #94 were changed every Sunday as ordered by the physician, on 08/04/26 at 10:45am and 11:30am.This failure could place residents at risk for respiratory infections through contamination.Findings included:Resident #22Record review of Resident #22's face sheet, dated 08/04/26, reflected Resident #22 was initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed withacute and chronic respiratory failure, with hypoxia (insufficient oxygen), hypotension (lower blood pressure), heart failure, pain, obesity, and chronic kidney disease.Record review of Resident #22's quarterly MDS Assessment, dated 05/16/26, reflected a BIMS score of 13 indicating his cognition was intact.Record review of Resident #22's care plan, dated 05/28/25, reflected that the resident had altered respiratory status/difficulty breathing r/t chronic respiratory failure with hypoxia. The relevant intervention was oxygen at 2 LPM prn sob Q shift.Record review of Resident #22's physician's order reflected : Change O2 tubing/water every week and PRN every night shifts every Sunday. -Start Date-03/08/2026.During an observation on 08/04/26 at 10:45 am it was revealed that Resident #22 was on continuous oxygen therapy. Observation of the humidifier bottle and cannula of the oxygen concentrator revealed that the date written on them were 07/27/26.Record review of the August 2026 MAR of Resident #22 revealed LVN M documented the oxygen tubing & humidifier bottle were changed on 08/02/26.During an observation on 08/04/26 at 1:30pm it was revealed that the date on the humidifier bottle and the cannula of the oxygen concentrator of Resident #22 was 08/04/26. Resident #94Record review of Resident #94's face sheet, dated 08/05/26, reflected Resident #94 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female diagnosed withCOPD (difficulty to breathe), cerebral infarction (stroke), dementia, obesity, hypertension (high blood pressure) and muscle weakness.Record review of Resident #94's quarterly MDS assessment, dated 02/06/26, reflected a BIMS score of 09 indicating her cognition was moderately impaired.Record review of Resident #94's care plan, dated 03/09/25, reflected she used oxygen therapy r/t shortness of breath. The relevant intervention was providing continuous supply of oxygen via nasal prongs(a slender, pointed projection or spike that sticks out from an object)/mask (2-5) LPM.Record review of Resident #94's physician's order reflected: Change O2 tubing &humidifier bottle every night shift every Sunday. - Order Date-03/07/2026.During an observation on 08/04/26 at 11:30am it was revealed that Resident #94 was on continuous oxygen therapy. Observation of the humidifier bottle and oxygen cannula revealed there were no dates of change marked on them. Record review of the August 26 MAR of Resident #94, dated revealed LVN M documented the oxygen tubing and humidifier bottle were changed on 08/02/26.During an observation on 08/04/26 at 1:30pm it was revealed that the date on the humidifier bottle and the cannula of the oxygen concentrator of Resident #22 and Resident #94 was 08/04/26.During an interview on 08/04/26 at 12:20pm, LVN L stated that the physician's order specifically stated that the humidifier bottle and the cannula were to be changed every Sunday during the night shift. She stated that although she routinely checked the equipment daily, she did not notice in the last two days that the changes were been completed. She stated routine replacement was important to reduce the risk of infection. LVN L said she had not noticed that there were no dates on Resident # 94's water humidifier and the date of change on Resident #22's water humidifier was marked as completed on 07/27/26. She said she was going to replace them with immediately. LVN L stated part of her responsibilities included the administration of medication and treatments, and she would only document in the MAR after administering each medication or treatment, not beforehand.During an interview on 08/04/26 at 2:35 pm, LVN M stated that she served as the night shift nurse for Hall 200 on 07/27/26. She indicated that she generally worked the afternoon shifts, however on 07/26/26 she worked the night shift. She stated that it was the responsibility of the Sunday night shift nurse to change the humidifier bottles and oxygen tubes for residents on that hall. She stated Residents #22 and Resident #94 were on continuous oxygen therapy provided by an oxygen concentrator. LVN M said that she had planned to change these items but, due to being occupied with other nursing tasks, she forgot to do so. She said that regular changing of these components was necessary to minimize the risk of respiratory infections and stated that failing to do so compromised infection control protocols. She said that it was the duty of every nurse to adhere to physician's orders by administering medications, therapies, and treatments as prescribed. She stated that she was aware that nurses were supposed to sign the MAR only after completing the task. She said she marked the task as completed in advance on the MAR, before actually performing it, and stated that this practice was not compliant with professional standards. She said she would not repeat this mistake in the future.During an interview on 08/06/26 at 3:00 pm, the DON stated that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced with new ones as ordered by the physician. She stated this practice was intended to minimize the risk of respiratory infections caused by contaminated equipment. The DON further stated that it was the responsibility of the nurse on the Sunday night shift to ensure that this task was completed routinely. She also stated that all nurses on other shifts had a duty to verify that the Sunday night nurse completed this task and to make replacements as soon as they were noticed. She stated that nurses were supposed to document a task in the medical record only after it was completed. She said that false documentation could negatively impact the residents' care plan and that in turn negatively impact the quality of care.Record review of the in-service since March 2026 revealed there were no in services on safe handling of respiratory equipment.Record review of the facility policy titled, Oxygen Administration, revised October 2010, reflected: The purpose of this procedure is to provide guidelines for safe oxygen administration.Oxygen/ nebulizer tubing / mask to be changed by nursing department weekly and documented in the electronic health record.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 2 living rooms for the secure Unit 300 (C and D Halls of the secure unit) and 1 of 7 (Resident #1 room) resident rooms reviewed for physical environment.The facility failed to ensure physical environment was clean and Hall C and Hall D living rooms was free of dirt, debris and sticky spots covering the floor.The facility failed to ensure Resident #1's bathroom was free of musty odor, dirty towel beside the toilet that was wet and discolored. The facility failed to ensure Resident #1 bedroom floor was clean and free of a crushed dead wood roach (an insect was brown with wings approximately 2 3/4 inch to 3 inches long and lives outside in trees) with a dark brown substance under the crushed wood roach.These failures could lead to residents residing in a unsafe, unfunctional, unsanitary, and uncomfortable environment and could experience a diminished quality of life. Findings included:Record review of the face sheet dated 07/22/2026 indicated Resident #1 was admitted on [DATE] and he was [AGE] years old with diagnoses including high blood pressure (when blood pushed too hard on artery walls), heart disease (conditions affecting heart structure and function), anxiety (excessive fear and worry) and dementia (decline in mental ability severe enough to interfere with daily life).Record review of the quarterly MDS assessment dated [DATE] indicated Resident #1 was cognitively intact with BIMS of 14. Resident #1 had no rejection of care or behaviors that were noted during this assessment period.During an observation and interview on 07/21/2026 at 10:45 a.m., Resident #1 said his toilet was still leaking about a month. He said maintenance had caulked the toilet last week. Resident #1 was observed flushing the toilet, and it poured water around the bolt on the right side of the toilet base on a dirty towel on the floor. The bathroom had a musty odor. He said he stepped on a wood roach this morning. He pointed towards his chair in his bedroom to the approximately 2 3/4 inches to 3 inches dead roach and under the roach was dark substance.During an observation on 7/21/2026 at 11:00 a.m., The living room floor in the secure unit 300 for C and D halls had small 1/2 inch round spots with a dark grayish/sticky substance. There were approximately 30 spots.During an interview on 07/22/2026 at 11:30 a.m., Resident #1 said he had thrown the wood roach away and said the housekeeper did not sweep or mop his room yesterday and not yet today.During an interview on 07/22/2026 at 11:45 a.m., Housekeeper A said she was responsible for Secure unit 3, (Halls C and D). She said she dusted and emptied the garbage for Resident #1's room yesterday (07/21/2026). She said she sweeps and mopped every resident room every day. She said she should have swept and mopped Resident #1's room. She said in the living room, she swept and mopped every day. Housekeeper A said the spots come off the wheelchair wheels. She said the spots must be scraped then swept and mopped. During an interview on 07/22/2026 at 11:55 a.m., the Maintenance supervisor said the plumber came out on Monday (07/20/2026) and the plumbing company had to get parts for the wax ring and flange (toilet parts which provide a watertight, gas-tight seal and directs waste smoothly into a drainpipe). He said the bathroom should have been mopped and towels replaced frequently by housekeepers and reported. He said he looked for wood roaches and did not see any roaches on July 13 and July 14, and he did not notify pest control company because they were already scheduled monthly.During an interview on 07/22/2026 at 12:00 p.m. the housekeeping supervisor said her expectations were for all areas to be swept and mopped every day. She said cleaning the areas prevents spread of germs and makes the facility homelike. She said if a leak occurs housekeeping was to clean and place clean towels and report the leak to herself. She said no one reported the leak in Resident #1's bathroom.During an interview on 07/22/2026 at 12:30 p.m., the Administrator said her expectation was for the facility to be clean and homelike for the residents. She said housekeepers were to sweep and mop all resident care areas every day and place towels on leaks and report to maintenance. She was not aware the toilet was still leaking. She said pest control company comes out every month and as needed. Record review of the pest log dated July 2026 indicated on July 13, and July 14, unnamed staff reported 5 wood roach. Record review of the Homelike Environment policy dated February 2021 indicated Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary and orderly. Record review of the Pest Control dated May 2008 indicated Our facility shall maintain an effective pest control program.1. This facility maintains an on-going pest control program to ensure that the building is kept insects and pest free.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. 1. The facility failed to ensure the dishes were clean and sanitized.2. The facility failed to ensure equipment was clean and sanitized.3. The facility failed to label and date dry food items stored in containers.4. The facility failed to ensure the food was not stored past expiration date. These failures could place residents that eat out of the kitchen at risk for contamination and foodborne illnesses.Findings include: Observation and interview with the DGM of the kitchen on 07/07/26 at 5:15 a.m. indicated: 1 of 2 large stainless steel commercial dispensers with a brown slimy looking substance in the spigot; the DGM said it was build-up of tea and should have been taken apart and cleaned.on the dry/clean racks co-mingled with clean dishes were 4 plastic clear cups, 2 with a red substance coating the insides of the cups and 2 crusted with a whitish yellow substance ;44 cups were on carts that were being used for residents' snacks and beverages. There were also 5 dark blue plate lid coverings with food particles adhered to the inside and outside co-mingled with other cleaned plate lids, and 1 dark blue plastic bowl with a white substance adhered to the inside and outside of the bowl co-mingled with other cleaned bowls. The DGM said he did not know who placed the dirty dishes with the clean dishes and he placed them on a tray to be rewashed. DGM said the blue bowl should have been thrown away taken out of rotation.Further observation of the Kitchen indicated, under a large stainless-steel table were 4, 20-gallon white rubber storage containers; container #1 was 1/4 full of flour and around the inside of the container were brown and yellow caked on substances, a written date of 04/13/25 on the outside of the container and a written date of 05/05/24 on the outside of the container lid and in the crevices of the handles on the container was build-up of a brown/yellow substance; container #2 was 1/4 full of cornmeal with a written date of 04/20/25 on the outside of the container and with written date of 06/05/24 on the outside of the container lid and in the crevices of the handles on the container was build-up of a brown/yellow substance; container #3 was 1/4 full of rice with a written date of 04/17/25 on the outside of the container and with written date of 06/05/24 on the outside of the container lid and in the crevices of the handles on the container was build-up of a brown/yellow substance and had a hair stuck to it; container #4 was 1/4 full of sugar with no written date on the outside of the container or on the outside of the container lid and on the lid were black particles. During an interview on 07/07/2026 at 5:30 a.m. the DGM said it was the responsibility of all the dietary staff to ensure products were labeled and stored correctly and the DM was the person responsible for monitoring kitchen staff and ensuring products are labeled, sealed and dated and usually checked every Monday but had not had a chance today because she had not arrived to the facility. The DGM said all kitchen staff completed the required food preparation and food storage training. The DGM said the potential harm to residents would be food poising, rodents getting into stored food if not properly sealed, sickness, bacteria on food. The DGM said the failure occurred due to staff not paying attention. During an interview on 07/07/2026 at 6:00 a.m. [NAME] A said he has been employed with the facility for 2 months and had never used any of the dry goods in the white rubber containers since he has been employed but would use the individual bags stored in the dry goods pantry. He said he would make sure the individual bags were labeled with date and time opened and name of what's in the storage bag so that others would know what's in it and when it was opened. [NAME] A said he was not aware of the dirty dishes being stored and comingled with clean dishes. [NAME] A said he would not serve food or drinks in dirty dishes and if the dishes were still dirty or had residue in them, he would run them through the washer a second time. [NAME] A said he has been trained in food handling, storage and kitchen equipment/dishes cleaning and storage. [NAME] A said expired food and equipment/dishes not kept clean could make residents sick. An interview with the Administrator on 07/07/26 at 6:30 a.m. said her expectation was for kitchen staff to follow policies on food storage, preparation, and that everything was dated. She said the DM was responsible for monitoring that kitchen staff were following the facility's policy. The Administrator said not storing and preparing food appropriately could cause residents to be given food beyond the expiration date and not the correct time frame. The Administrator said it could also affect the freshness and quality of residents' food. During an interview on 07/07/2026 at 10:11 a.m. DM said she had been employed with the facility for a week and it was the responsibility of all the dietary staff to ensure products were labeled and stored correctly. The DM said she was the person responsible for monitoring kitchen staff and ensuring products are labeled, sealed and dated and usually checks every week but had not had a chance today because of being late. The DM said all kitchen staff completed the required food preparation and food storage training. The DM said storing dirt dishes, not cleaning equipment, and not labeling/dating foods was not acceptable because it could cause cross contamination. The DM said these behaviors were not good, and it did not meet her expectations. The DM said the failure occurred due to staff being in a hurry and could have missed some of the dirty ones (dishes). The DW stated she would not like to drink from the clean cups that were on the carts because they were dirty. The DM stated the residents could get sick with some kind of bacteria or get a GI infection. The DM said the rubber storage container were not ok to use. The DM said she was in the process of changing them out to a different kind she said loose particles could come off the container handles causing cross contamination when the cooks handled them, then touched something else and the residents could get sick. The DM said the cooks should have tossed them out and let her know so she could replace them. The DM stated she did not know why the containers were not dated with the correct date, but she would throw the contents out. The DM said there was a cleaning log with all days initialed. The DM stated she felt kitchen staff were just signing off without doing the job-they do things in a hurry to get out of here, to be honest with you. Record review of facility's policy titled Environment, dated May 2014, indicated, 1. The food service director will ensure the physical plant is maintained in a clean and sanitary manner. 4. The food service director will ensure a routine cleaning schedule is in place for all cooking equipment storage areas and surfaces. Record review of facility's policy titled Ware washing, dated May 2014, indicated, 4. The food service director ensures that all dishware is air dried and properly stored. Record review of the Food and Drug Administration Food Code, dated 2022, indicated, . 3-201.11 Safe, Unadulterated, and Honestly Presented. Compliance with Food Law. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and PASRR evaluation report into the resident's assessment, care planning, and transitions of care for 1 of 2 (Resident #1) residents reviewed for PASRR services. -The facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting from 09/23/2025. This failure could place residents who have a mental health diagnosis, developmental disability, or intellectual disability at risk from not receiving services identified by the IDT in a timely manner. Findings included: Record review of Resident #1's face sheet dated 06/10/2026 indicated a [AGE] year-old male with a readmission date of 03/14/2025 with diagnoses of encephalopathy (a group of disorders that affect the brain and cause altered mental state), dementia (loss of cognitive functioning), bipolar 2 (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), mild intellectual disorder (mild intellectual developmental disorder, is a neurodevelopmental condition characterized by below-average intellectual functioning), cognitive communication deficit (occurs when a person struggles to communicate effectively because of impairments in cognitive processes such as attention, memory, executive function, and social cognition, rather than problems with speech or language mechanics.) tourette's disorder (presence of both motor and vocal tics).Record review of Resident #1's Quarterly MDS dated [DATE], Section C- Cognitive Patterns indicated he had a BIMS score of a 03 (severe cognitive impairment.). Section GG-Functional Abilities indicated Resident #1 was dependent (helper does all the effort required to complete the activities of daily living.). Record review of Resident #1's Care plan dated 10/22/2025 indicated focus: Resident #1 had an ID, DD and was PASARR positive. Resident #1's listed goal was to have specialized services recommended by local authorities by PASARR specialized program as needed. The listed interventions were coordinated services with LMHA (local mental and behavioral health authorities).Record review of PASARR spreadsheet dated 3/11/2026 indicated Attached is the spreadsheet of nursing facilities (NFs) that have been contacted. These NFs were informed that per 26 TAC Chapter 554, Subchapter BB S554.2704 (i)(7). The resident has not received a Medicaid service because of the following: The NF was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so. The NFSS Request submittal by the NF was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the resident (Resident #1).Record review of Resident #1's PCSP dated 09/23/2025 indicated the meeting held was for his annual IDT/ SPT meeting. Section A2800. (Nursing Facility Specialized Services) had findings for related for PT and OT assessment and therapy services coded as new. At the time, Resident #1 had a new identified need for ST assessment and therapy services. new services that were identified were:D. Specialized Assessment Occupational Therapy (OT) E. Specialized Assessment Physical Therapy (PT)F. Specialized Assessment Speech Therapy (ST)G. Specialized Occupational Therapy (OT)H. Specialized Physical Therapy (PT)I. Specialized Speech Therapy (ST)Section A3000. IDD Specialized Services dated 09/23/2025 indicated he had a new need for- F. Habilitation CoordinationThe comment section stated Resident doing well in facility. Will be evaluated for therapy services. Section A2500. Meeting Participation dated 09/23/2025 indicated the Director of Rehabilitation was present and signed off on recommendations.During an interview on 06/10/2026 at 10:48 a.m. with MDS Nurse A, she said she recalled Resident #1 and his PASRR situation. She said Resident #1 was PASARR 2 and was initially approved to receive PASARR services on 02/25/2025. She said that the state needed to know within 20 days of specialized services being identified. She stated that the timeline for Resident #1's specialized services identification and therapists' signature was not within the 20-day NFSS requirement. She said Resident #1 received specialized services from PT, OT and ST while on PASRR and when they took him off PASARR. She said the potential outcome would be residents having a delay in needed services. She stated there could be a decline in a resident's wellbeing. During an interview on 06/10/2026 at 11:30 a.m. with the Director of Rehabilitation, she said she was aware Resident #1 was PASARR positive (an individual who was identified for having a mental health or intellectual and developmental disorder who required additional screening and services upon entry into a nursing facility) and was present during his care plan meetings. She said she noticed Resident #1 was declining while on PASRR. At the meeting she recommended that Resident #1 be removed from PASRR and put on rehabilitation services to increase his mobility since he declined while on PASRR services. She said she told the Coordinator for LMHA (local mental and behavioral health authorities) to put not needed instead of new on the services. She said she reached out to the coordinator by email, including the Administrator, when they received a call from HHSC on February 26, 2026, and again on April 7, 2026. She said the potential risk to the resident was miscommunication regarding the resident's services. She said Resident #1 received specialized services from PT, OT and ST while on PASARR and when they took him off PASARR. She stated it was shared responsibility amongst the whole team to meet the NFSS deadlines. During an interview on 06/10/2026 at 12:15 p.m. with the DON, she that PASARR was comprised of PT, OT, ST, Director of Rehabilitation, the LMHA and the MDS Nurse. She said that MDS typically coordinated the PASARR. She said that the MDS nurse completed all the documentation in the health record software and conversed with LMHA for the annual IDT meetings. She said she would be notified by MDS if there was any participation required on her part. She said she was not aware of the timelines for NFSS. She said that she and MDS needed to adhere to the timelines and monitor to ensure they were completed before required deadlines. She said the delay in services would negatively affect the resident and added she could not elaborate based on limited clinical knowledge on therapy. During an interview on 06/10/2026 at 12:55 p.m. with the Administrator, she said she could not recall the exact details of Resident #1's case. She said that the IDT team and MDS were responsible for ensuring the NFSS timelines were met. She stated that the IDT needed to report it within 20 days and was unaware if the facility met the requirement for specialized services for Resident #1 until HHSC called them twice.Record review of facility Policy titled PASARR dated 01/20/2026 indicated PurposeThe aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. Procedure Post IDT Meeting Responsibilities Once the IDT makes its determinations about specialized care, the facility will;1. Include all specialized services and support activities the residents comprehensive plan of care and provide a copy to the LA (local authority). 2. The facility will initiate the request for specialized services within 20business days of the IDT meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal and order CMWC and/or DME within 5 business days of receiving approval from HHSC in the online portal.

Based on observation, interview and record review the facility failed to ensure that residents with loss of bladder control receive treatment or services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents reviewed for incontinent care. (Resident #1) The facility failed to provide Resident #1 assistance with timely incontinence care from 09:30 a.m. until 01:45 p.m. on 10/06/2025. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.Findings included: Record review of Resident #1's face sheet, dated 10/06/2025, indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS assessment, dated 08/19/2025, indicated Resident #1 had severe impairment of cognition abilities with a BIMS score of 05. Resident #1 was noted to be dependent on staff for toileting, showering, and lower body dressing. Resident #1 required substantial/max assistance with eating and oral hygiene. Resident #1 was always incontinent of urinary and bowel. During observations of Resident #1 on 10/06/2025 from 09:30 a.m. through 2:00 p.m., the following was noted: 09:30 a.m. - Resident #1 was watching TV while sitting in a wheelchair. No urine or body odor noted. 10:38 a.m. - A Priest visited facility and Resident #1 received communion; 10:47 a.m. - Resident #1 received one cup of water from the staff; 11:32 a.m. - Resident #1 transported via wheelchair to dining room for the noon meal; 11:36 a.m. - Resident #1 transported via wheelchair to outside smoking area for smoke time; 11:48 a.m. - Resident #1 returned to dining room for noon meal; 12:33 p.m. - Resident #1 remains in dining room eating meal; 12:54 p.m. - Resident #1 transported to common area Unit 100 and sat in wheelchair in front of the TV; 1:20 p.m. - Resident #1 remained sitting in front of the TV with his head down and was seen occasionally dozing off and on. No urine or body odor noted; and 1:45 - 2:00 p.m. Resident #1 was finally provided incontinent care after 4.5 hours of observations. Resident #1 was transported to his room by CNA A. Resident #1 was transferred to bed by CNA A and CNA B. Resident #1's brief was removed, and he had recently had bowel movement. Resident #1's brief was wet but not soaked. No open areas noted to buttocks. Incontinent care was provided, and CNA A applied a barrier ointment to Resident #1's buttocks as a preventative. Resident #1 tolerated well. During a joint interview on 10/07/2025 at 11:05 a.m., CNA B said they checked on residents as they passed by them or if they called out to them. She said they were supposed to do every 2-hour checks on residents, to assess whether they had been incontinent and the staff were constantly all over the area. She added it was important to check residents at least every 2 hours for incontinence due to potential skin breakdown from sitting in wet briefs. CNA B said they performed spot checks on residents to see if they need any care performed. CNA A said Resident #1 was not a heavy wetter and she should stop and check on Resident #1 and the others more frequently. CNA A said Resident #1 had no skin breakdown currently. She said she applied a barrier ointment to the buttocks with each incontinent episode as a preventative. During an interview on 10/07/2025 at 12:45 p.m., the Administrator said her expectations were for staff to check residents on rounds at least every 2 hours and throughout their shift when residents were in common areas. She added the staff should be offering fluids, snacks, and generally conversing with residents. During an interview on 10/08/2025 at 10:00 a.m., the DON said she expected the CNAs and the Nurses to work together to complete incontinent care as needed. The DON stated CNAs were responsible for doing rounds every 2 hours on residents to ensure they were clean and dry. The DON stated nurses were also responsible for checking on their residents to ensure they were doing okay. The DON stated leaving Resident #1 wet with urine or stool placed him at risk of skin breakdown, infection, and pressure sores. The DON said there was no facility policy on perineal care or incontinent care of residents. Record review of the facility's Activities of Daily Living policy, dated February 2025, indicated the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a) hygiene and c) elimination.

Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained for 1 of 7 residents (Resident #1) reviewed for controlled medications. The facility did not have documentation on Resident #1's July 2025 and August 2025 MARs indicating she was administered her Lorazepam (controlled antianxiety medication) prn when it was signed out on the controlled medication count sheet. The controlled medication count sheet did not indicate the medication doses were wasted. This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion. Findings included: Record review of the physician orders for August 2025 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included acute respiratory failure (a serious condition that makes it difficult to breathe on your own), generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), and autistic disorder (autistic disorder-a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication and includes limited and repeated patterns of behavior). Resident #1 had an order dated 07/15/25 for Lorazepam 1mg via g-tube every 8 hours as needed for anxiety/agitation for 90 Days. Record review of the current MDS dated [DATE] indicated Resident #1 rarely/never made herself understood, sometimes understood others, had short term and long term memory problems, had severely impaired cognitive skills for daily decision making, had active diagnosis of anxiety, and did not take any antianxiety medication during the lookback period. Record review of the controlled medication count sheet for Resident #1 indicated the Lorazepam 1mg had one tablet removed:* on 07/21/25 at 10:00 p.m.;* on 07/29/25 at 06:00 p.m.;* on 07/31/25 at 09:00 p.m.;* on 08/13/25 at 06:00 p.m.; and* on 08/15/25 at 08:00 p.m Record review of the July 2025 MAR indicated there was no documentation Resident #1 received a Lorazepam 1mg tablet on 07/21/25, 07/29/25, or 07/31/25. Record review of the Nurse Notes indicated there was no documentation of Resident #1 receiving a Lorazepam 1mg tablet on 07/21/25, 07/29/25, or 07/31/25. Record review of the August 2025 MAR indicated there was no documentation Resident #1 received a Lorazepam 1mg tablet on 08/13/25 or 08/15/25. Record review of the Nurse Notes indicated there was no documentation of Resident #1 receiving a Lorazepam 1mg tablet on 08/13/25 or 08/15/25. During an observation on 08/21/25 at 01:30 p.m., Resident #1 was sitting in her wheelchair in the common area at the nurse station. She was calm without agitation. An interview was attempted but the resident was not able to answer questions appropriately. During an interview on 08/19/25 at 02:00 p.m., LVN A reviewed the controlled medication count sheet and the July and August 2025 MARs. She said it appeared Resident #1's Lorazepam was signed out on the count sheet but there was no documentation of the medication being administered to the resident on the MARs for the dates the medication was signed out. During an interview on 08/19/25 at 02:15 p.m. the ADON reviewed the controlled medication count sheet and the July and August 2025 MARs. She said it would appear Resident #1's Lorazepam was not given to the resident but was signed out on the count sheet. She said she could not verify the resident had been administered the medication based on the July and August 2025 MARs. She said it could possibly be a drug diversion. During an interview on 04/24/25 at 02:30 p.m., the Administrator and DON reviewed Resident #1's controlled medication count sheet and the July and August 2025 MARs and acknowledged Lorazepam was signed out on the count sheet but there was no documentation of the medication being administered to the resident on the MARs for the dates the medication was signed out. They also reviewed the Nurse Notes which did not have any documentation of the medication being administered to the medication. They said the adverse outcome could be a drug diversion.Record review of the Administering Medications policy revised April 2019 indicated the following: .22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on interview and record review, the facility failed to ensure its residents were free of any significant medication errors for 2 (Resident #1 and Resident #2) of 10 residents reviewed for medications. The facility failed to hold Losartan per parameters stated in physicians' orders for a total of 8 doses in July 2025 for Resident #1. The facility failed to hold Metoprolol per parameters stated in physicians' orders for 4 doses and Clonidine per parameters stated in physicians' orders for a total of 9 doses in July 2025 for Resident # 2. These failures placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications.Findings Included: 1. Record review of Resident #1's face sheet indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Alzheimer's disease (progressive disease that destroys memory and other important mental functions), severe protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and malignant neoplasm of overlapping sites of bronchus and lung (a cancerous tumor which is located in the lungs and in the two main airways of the body that join the windpipe to each lung). Resident #1 discharged on 07/28/2025 to an acute care hospital. Record review of Resident #1's significant change in status MDS assessment dated [DATE], indicated she was severely impaired cognitively with a BIMS score of 01. She required maximal assistance with self-care and mobility. Record review of Resident #1's Comprehensive Care Plan last revised 02/15/2024, indicated she had hypertension with interventions to give antihypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness and report to MD as necessary. Record review of Resident #1's physicians' orders indicated: Losartan Potassium Oral Tablet 25 mg give 1 tablet by mouth at bedtime for high blood pressure hold for SBP 110 & below & DBP 60 & below order dated 05/26/2025. Record review of Resident #1's MAR for July 2025 Blood Pressure monitoring indicated: 07/07/2025 at 7:00 p.m. BP 102/61, 07/08/2025 at 7:00 pm. BP 110/60, 07/09/2025 at 7:00 p.m. BP 110/62, 07/10/2025 at 7:00 p.m. BP 104/61, 07/17/2025 at 7:00 p.m. BP 99/67, 07/19/2025 at 7:00 p.m. BP 104/72, 07/20/2025 at 7:00 p.m. BP 105/61 and 07/25/2025 at 7:00 p.m. BP 126/58. Record review of Resident #1's MAR for July 2025 indicated Losartan was not held on: 07/07/2025 at 7:00 p.m. BP 102/61 by RN D, 07/08/2025 at 7:00 pm. BP 110/60 by LVN C, 07/09/2025 at 7:00 p.m. BP 110/62 by RN D, 07/10/2025 at 7:00 p.m. BP 104/61 by RN D, 07/17/2025 at 7:00 p.m. BP 99/67 by RN D, 07/19/2025 at 7:00 p.m. BP 104/72 by RN D, 07/20/2025 at 7:00 p.m. BP 105/61 by RN D and 07/25/2025 at 7:00 p.m. BP 126/58 by RN D. Unable to interview Resident #1, no longer resided at the nursing facility and has been admitted to an inpatient hospice facility. 2. Record review of Resident #2's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: high blood pressure, cognitive communication deficit, anxiety and depression. Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated she had active diagnoses in the last 7 days of hypertension (condition in which the force of the blood against the artery walls is too high) and she was moderately impaired cognitively with a BIMS score of 10. She used a manual wheelchair for mobility but was totally dependent on staff for mobility and assistance with transfer to and from a bed to wheelchair. Record review of Resident #2's Comprehensive Care Plan last revised 12/13/2024, indicated she had hypertension with interventions to give antihypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness and report to MD as necessary. Record review of Resident #2's physician's orders indicated: Clonidine HCl Tablet 0.1 mg give 1 tablet by mouth three times a day related to hypertension HOLD IF BP < 110/60 OR PULSE <60; order dated 02/06/2022. Record review of Resident #2's physician's orders indicated: Metoprolol Tartrate Oral Tablet give 25 mg by mouth two times a day for hypertension HOLD FOR BP < 110/60. Record review of Resident #2's MAR for July 2025 Blood Pressure monitoring indicated: 07/04/2025 at 1:00 p.m. BP 100/65, 07/07/2025 at 1:00 p.m. BP 92/68, 07/08/2025 at 7:00 a.m. BP 101/60, 07/08/2025 at 1:00 pm. BP 101/60, 07/14/2025 at 7:00 a.m. BP 109/70, 07/14/2025 at 1:00 p.m. BP 109/70, 07/22/2025 at 8:00 p.m. BP 107/60, 07/27/2025 at 1:00 p.m. BP 110/54, and 07/29/2025 at 8:00 p.m. BP 106/72. Record review of Resident #2's MAR for July 2025 indicated Clonidine was not held on: 07/04/2025 at 1:00 p.m. BP 100/65 by LVN A, 07/07/2025 at 1:00 p.m. BP 92/68 by LVN F, 07/08/2025 at 7:00 a.m. BP 101/60 by LVN A, 07/08/2025 at 1:00 pm. BP 101/60 by LVN A, 07/14/2025 at 7:00 a.m. BP 109/70 by LVN A, 07/14/2025 at 1:00 p.m. BP 109/70 by LVN A, 07/22/2025 at 8:00 p.m. BP 107/60 by LVN B, and 07/29/2025 at 8:00 p.m. BP 106/72 by LVN E. Record review of Resident #2's MAR for July 2025 indicated Metoprolol was not held on: 07/08/2025 at 7:00 a.m. BP 101/60 by LVN A, 07/14/2025 at 7:00 a.m. BP 109/70 by LVN A, 07/22/2025 at 8:00 p.m. BP 107/60 by LVN B, and 07/29/2025 at 8:00 p.m. BP 106/72 by LVN E. During an interview on 08/11/2025 at 9:00 a.m., Resident #2 said she received her medications as prescribed, and they monitored her BP routinely. Resident #2 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if she did have any, she would notify the nursing staff. Resident #2 said staff checked her BP prior to administering her BP meds and would hold med if the blood pressure was low. During an interview on 08/11/2025 at 3:00 p.m., LVN E said she checked the BP and then reviewed the resident's MAR to determine if the blood pressure medication was to be administered. She said some residents had parameters to hold the blood pressure medication if the BP was low. She said if the resident's BP was low, she held the medication and documented on the MAR. LVN E said that Resident #2 does have parameters with her evening BP medications and during July MAR review was unable to provide explanation of why she administered Resident #2 her evening BP medication when her BP was out of parameters but said it must have been an error. She said if BP medication administered when BP was low, residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. She said she received training about administering BP medication back in May 2025. During an interview on 08/11/2025 at 3:15 p.m., LVN G said the residents' blood pressure should be checked each time the blood pressure medication was due. She said the blood pressure protocol ordered by the physician should be followed. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications were not given to increase it, that could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. During an interview on 08/11/2025 at 5:00 p.m., LVN C said the residents' blood pressure should be checked by the nurse each time the blood pressure medication was due. She said the blood pressure protocol ordered by the physician should be followed. She said if Resident #1's blood pressure was low and was still given a blood pressure medication, it could get too low. She said residents was at risk for passing out or dizziness resulting in a fall or injury. During an interview on 08/11/2025 at 5:30 p.m., LVN H said the residents' blood pressure should be checked by the nurse each time the blood pressure medication was due. She said the blood pressure protocol ordered by the physician should be followed. She said if the residents' blood pressure was low and was still given a blood pressure medication, it could get too low. She said residents were at risk for being lightheaded, passing out or dizziness resulting in a possible fall or injury. She said she would contact the physician if she was unsure of the parameters or dosing, or if BP medication was repeatedly being held or missed. During an interview on 08/12/2025 at 11:40 a.m., LVN A said she checked residents' BP prior to administering BP medications. She said she checked the BP and then reviewed the resident's MAR to determine if the blood pressure medication was to be administered. She said some residents had parameters to hold the blood pressure medication if the BP was low and medications to administer if BP was low. She said she checked the BP, reviewed and administered the medication if within acceptable parameters. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications were not given to increase it, it could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. During an interview on 08/12/2025 at 11:28 a.m., RN D, said he administered Resident #1's BP medications during the evening shift. He said prior to administer BP medication he checked the MAR for parameters and then checked the resident's BP if it was out of parameters, he would hold the BP medication and document on the MAR. He said that he recalls Resident #1's BP being low during her evening BP med dosing and the medication would be held. He said he would contact the physician if he was unsure of the parameters or dosing, or if BP medication was repeatedly being held or missed. RN D said if it showed he administered a BP medication when the BP was out of parameters it must have been documentation error because he held Resident #1's BP medication if it was out of parameter. RN D said if the blood pressure dropped too low Resident #1 could have dizziness, unresponsiveness, or even possibly death. RN D said he was recently terminated so he was unable to review the residents' MAR for clarification. During an interview on 08/12/2025 at 1:30 p.m., the DON said she expected her nurses to follow physicians' orders. She stated she expected them to read the MAR and follow parameters. The DON said if cardiovascular medication was ordered with parameters, parameters were to be checked prior to administration the medication and to be held if out of the ordered parameters. She said it was the nurse's responsibility to check vitals prior to administering any cardiac medications with parameters. She said if BP medication administered and BP is low (out of parameters) the resident could experience symptoms of hypotension including syncope (fainting or passing out), confusion, and even death. During an interview on 08/12/2025 at 1:45 p.m., the Administrator said she expected her staff to follow physicians' orders and to check parameters prior to administering cardiac medications if ordered and if BP or pulse is out of parameters not to administer and document on MAR and/or progress note. Record review of a facility's Administering Medications policy revised April 2019, indicated Policy: Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders including any required time frame. 11. The following information is checked/verified for each resident prior to administering medications: a. allergies to medication; and b. vital signs if necessary .

Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 6 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure Resident #1's Comprehensive Metabolic Panel, also known as CMP (a blood test that checks for a wide range of substances in your blood, including proteins, enzymes, electrolytes, and minerals), Complete Blood Count also known as CBC (a blood test that measures amounts and sizes of your red blood cells, hemoglobin, white blood cells and platelets), carcinoembryonic antigen also known as CEA (blood test measures the level of a specific protein in the blood, primarily used to monitor certain types of cancer), Thyroid-Stimulating Hormone also known as TSH (blood test to assess level of thyroid stimulating hormone and thyroid function and metabolism) and Thyroxine test also known as T4 (blood test that helps diagnosis thyroid conditions) was drawn every 14 days as ordered. This failure could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level.Finding included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Alzheimer's disease (progressive disease that destroys memory and other important mental functions), severe protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and malignant neoplasm of overlapping sites of bronchus and lung (a cancerous tumor which is located in the lungs and in the two main airways of the body that join the windpipe to each lung). Resident #1 discharged on 07/28/2025 to an acute care hospital. Record review of Resident #1's significant change in status MDS assessment dated [DATE], indicated she was severely impaired cognitively with a BIMS score of 01. She required maximal assistance with self-care and mobility. Record review of Resident #1's comprehensive care plan last revised 04/23/2025, indicated she had potential nutritional problem related to low body weight, cancer, and protein calorie malnutrition with interventions of health shakes with meals, magic cup, house supplement, liquid protein and obtain and monitor lab/diagnostic work as ordered, and report results to MD and follow up as indicated. Record review of Resident #1's physician's orders indicated: Obtain CBC w/diff, CEA, CMP, T4, and TSH every 14 day(s) for 6 occurrences start order dated 05/30/2025 and end date 08/08/2025. Record review of Resident #1's electronic health record lab results indicated that her CBC w/diff, CEA, CMP, T4, and TSH was due on 05/30/2025, 06/13/2025, 06/27/2025, 07/11/2025, 07/25/2025 and 08/08/2025. Her CBC w/ diff was obtained on 05/30/2025, 06/12/2025, 07/01/2025, and 07/25/2025. No indication that CBC w/ diff was obtained on 06/27/2025, and 07/11/2025 as ordered by physician. Her CEA was obtained on 05/30/2025 and 06/12/2025. No indication CEA was obtained on 06/27/2025, 07/11/2025, and 07/25/2025 as ordered by physician. Her CMP was obtained on 05/30/2025, 06/12/2025, 06/26/2025, 07/21/2025, and 07/25/2025. No indication CMP was obtained on 07/11/2025 as ordered by physician. Her TSH and T4 was obtained on 05/30/2025, 06/12/2025, 07/01/2025, and 07/25/2025. No indication TSH and T4 was obtained on 06/27/2025 and 07/11/2025 as ordered by physician. During an interview on 08/11/2025 at 3:05 p.m. and 3:20 p.m., LVN E and LVN G said when the nurses received an order for a lab, they would enter it in their electronic medical record system as a lab order and into a lab request electronic system. She said the two systems communicated and the request would generate a lab results entry into the medical records identifying that the labs were ordered and when obtained the results uploaded into the medical records. She said it was the responsibility of the nurse to go into the electronic medical record system periodically throughout the shift to check for lab and x-ray results, review results and report to the NP/MD if applicable. During an interview on 08/11/2025 at 5:05 p.m. and 5:35 p.m., LVN C and LVN H said when receiving orders from a physician via phone, fax or paper, the order was entered into the electronic medical record. They said if a lab was included on the order, the order must be entered into the electronic lab request system to notify the lab of the request. They said the lab system has a place to include date due and if reoccurring event, so one time ordered labs would have the specific date identified but if reoccurring labs would identify dates and that it was a reoccurring event. They said labs due were discussed during shift change and they print a copy of the lab request and place it at the nurses' station to identify any labs coming due and/or results pending. They said it was their responsibility to go into electronic medical records system several times during the shift to check for lab results, review and report to NP/MD if applicable. They said if the results were for upcoming appointments that the labs were also sent in the transfer packet. They said when residents were transferred out of facility to appointments or ER visits, they sent a copy of the resident's face sheet, list of medications and any recent labs with them to the appointment/ER visit. During an interview on 08/11/25 at 4:45 p.m., the ADON said she expected labs to be drawn per the physician's order. The ADON said she was unaware that Resident #1's was missing her labs until questioned by the state surveyor and provided the surveyor a copy of all Resident #1's labs in the electronic lab system for review. The ADON said she reviewed the labs routinely for completion. The ADON explained the process of entering the lab request into the electronic lab system for collection and how it communicated with the facility electronic medical records. The ADON was not able to provide why Resident #1's labs were not obtained as ordered. The ADON said that Resident #1 was transferred from Unit 3 to Unit 1 at the end of June 2025 and new management company made some changes with the electronic lab system. The ADON said she was made aware by the DON some labs had been missed on Resident #1 found during a discharge chart audit and concerns made by surveyor on 08/09/2025. The ADON said that the facility had initiated a new lab tracking form since identifying the issue. During an interview on 08/12/2025 at 1:30 p.m., the DON said she had identified missed labs on Resident #1 during surveyor intervention on 08/09/2025 and Resident #1 discharge chart review. She said she had initiated a new lab tracking form and was going to add lab collection per physician orders and obtaining results to the QAPI. The DON was not able to provide why Resident #1's labs were not obtained as ordered. The DON said she recalled all ordered labs were not completed on June 26, 2025, for Resident #1, and lab was contacted on 07/01/2025 to collect missed labs stat. The DON said that Resident #1 was transferred from Unit 3 to Unit 1 at the end of June 2025 and new management company made some changes with the electronic lab system which could have interfered with the reoccurring order for Resident #1's lab. The DON said it was important to ensure labs were drawn per the physician's order to ensure their health had been monitored per those lab values. The DON said Resident #1 did not miss any cancer center appointments or treatments due to the missed labs. During an interview on 08/11/2025 at 2:45 p.m., CM M with cancer center said that Resident #1 did not miss any scheduled appointment due to missing lab results, she said they ordered the labs every 14 days to verify that they would have a set of labs to review at least monthly for the required treatment provided. She said they expected labs to be drawn as ordered but unfortunately that does not always happen. She said that the missed labs did not alter Resident #1 cancer treatment plan. During an interview on 08/12/2025 at 1:45 p.m., the Administrator said she expected labs to be drawn as ordered. She said the DON/ADON oversaw the labs. She said the DON had already let her know they had identified missed labs on Resident #1 during surveyor intervention on 08/09/2025 and Resident #1 discharge chart review. The Administrator said it was important that labs were drawn per the physician's orders to ensure the residents were getting the highest quality of care for their health. Record review of the facility's policy titled Test Results revised April 2007 indicated . the resident's attending physician will be notified of the results of diagnostic test. 1. Results of laboratory, radiological, and diagnostic test shall be reported to the resident's attending physician or to the facility. 2. Should the test results be provided to the facility, the attending physician shall be promptly notified of the results. 3. The director of nursing services, or charge nurse receiving the test results, shall be responsible for notifying the physician of such test results. Signed and dated/electronic signature as applicable of all diagnostic services shall be made a part of the residence medical records. Requested a policy regarding laboratory services with no policy provided by the exit conference.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 2 of 4 residents (Resident #3 and #4) reviewed for reporting allegations of abuse. The facility failed to report physical abuse and verbal abuse to the State Agency within 2 hours when it was reported to DON/delegated abuse coordinator Resident #3 threw a TV remote at Resident #4 causing a laceration to Resident #4's nose on 07/26/2025 at 7:48 p.m. and Resident #3 made a statement regarding needing a gun, so he could shoot up some people in this place on 07/30/2025 at 4:52 p.m. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: 1. Record review of Resident #3's face sheet dated 08/07/2025 indicated he was a [AGE] year-old male, admitted on [DATE], and his diagnoses included chronic kidney disease (gradual loss of kidney function), anxiety disorder (persistent and excessive worry that interferes with daily activities), and dementia (loss of cognitive functioning). Record review of Resident #3's admission MDS assessment dated [DATE] indicated he can make himself understood and understands others. He had a BIMS score of 12 which indicated moderate cognitive impairment. He had verbal behavioral symptoms directed towards other occurring 1 to 3 days during the 7 days look back window and no physical behavioral symptoms identified. Record review of Resident #3's care plan dated 07/26/2025 indicated he was involved in a resident-to-resident altercation involving a TV remote. Interventions included residents were separated, room change performed, placed on 1:1 monitoring, MD and Psych services notified. Care plan dated 08/06/2025 indicated resident has potential to be verbally aggressive related to dementia, ineffective coping skills, mental/emotional illness, and poor impulse control with interventions analyze key times, places, circumstances, triggers and what de-escalates behavior and document, assess and anticipate resident's needs; administer medications as ordered and give the resident as many choices as possible about care and activities. Record review of Resident #3's nurse progress note authored by RN D indicated on 7/26/2025 at 11:30 p.m., Resident approached nurses' station and informed nurse my roommate was cursing and yelling at me and then threw the remote and hit me in the stomach, so I threw it back and busted his face. Resident #3 and Resident #4 were separated. RN D assessed Resident #3 with no new injuries noted at the time of the assessment. RN D notified DON, ADON, and the administrator of the incident. RN D inquired about local police department notification and the corporate nurse informed him this incident was not reportable to the local police department. Corporate Nurse spoke with the Resident #3 over the phone. Resident #3 was moved to another room and 1:1 monitoring was initiated. Resident #3 was his own responsible party, and MD was notified of the resident altercation. Record review of Resident #3's nurse progress note authored by RN D indicated on 7/30/2025 at 5:00 p.m., Resident #3 was watching TV show featuring guns and made the comment at 4:45 p.m. that I need a gun, so I can shoot up some people in this place. RN D notified DON at 4:52 p.m. of the incident. Resident #3 was placed on q 15-minute behavioral monitoring. Psych services was notified of incident. 2. Record review of Resident #4's face sheet dated 08/07/2025 indicated he was a [AGE] year-old male, initially admitted on [DATE] and readmitted on [DATE], and his diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), delusional disorders (mental health condition in which a person can't tell what's real from what's imagined), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated he usually made himself-understood and usually understands others. His BIMS was a 99 indicating that he was unable to successfully complete the interview to obtain a BIMS score. No behaviors of verbal or physical abuse were noted. Record review of Resident #4's care plan dated 07/26/2025 indicated verbal aggression of cursing at roommate and interventions included analyze key times, places, circumstances, triggers and what de-escalates behavior and document, assess and anticipate resident's needs; administer medications as ordered and give the resident as many choices as possible about care and activities. Record review of Resident #4's nurse's progress note authored by RN D indicated on 7/26/2025 at 11:28 p.m., Resident #3 (Resident #4's roommate) approached nurses' station and stated, Resident #4 (his roommate) threw the remote at me, so I threw it back and it busted his face. Resident #3 and Resident #4 were separated. RN D assessed Resident #4 and found a 2 cm laceration across his nose with a TV remote on floor next to Resident #4's bed. Resident #4 stated he was trying to fuck with me or something, I don't want him back in here. I'll beat his ass if he comes back in here. Resident #4 is bedbound/wheelchair bound with limited mobility. RN D notified MD/NP, DON, ADON, and the administrator of the incident. RN D inquired about local police department notification and the corporate nurse informed him this incident was not reportable to the local police department. NP provided orders for neurological checks, monitoring and wound care to laceration. RP notified of the incident. Wound care provided to nose laceration. Resident #3 (roommate) moved to a different room. Record review of the facility's provider investigation report (PIR) dated 08/01/2025 indicated the resident-to-resident incident (Resident #4 threw the TV remote at Resident #3 and Resident #3 threw the TV remote back at Resident #4 hitting him in the nose causing an injury) occurred on 07/26/2025 at 7:45 p.m. and was reported to the state agency on 07/27/2025 at 2:02 p.m. greater than two hours after the allegation was made. Record review of TULIP (state online abuse reporting portal) did not indicate any reports from facility regarding resident allegation of harm to self or others related to Resident #3's statement on 07/30/2025. During an interview on 08/06/2025 at 10:15 a.m., Resident #3 said he recalled the incident with him and his original roommate. He said Resident #4 had his TV up loud in a Spanish language and he told him to turn it down and off Spanish since he could not understand Spanish and he started cussing at him and threw the TV remote at him, so he threw it back at him hitting him on the nose causing an injury. He said he went to the nurses' station and told them what happen and said he just reacted and did not mean to harm Resident #4. Resident #3 denied the incident regarding wanting a gun to shoot up in this place, and he denied making any suicidal or homicidal ideations. He said, but one of the reasons I am here is because I can't remember. He said he was pleased with his new room and TV. During an interview on 08/06/2025 at 10:35 a.m., Resident #4 did not recall the incident between him and Resident #3 and denied any abuse from staff or other residents and said he felt safe at the facility. During an interview on 08/06/2025 at 12:15 p.m., CNA H said she was in-serviced on types of abuse and to keep residents safe and report abuse allegations to the administrator immediately. During an interview on 08/06/2025 at 12:30 p.m., CNA J said she was in-serviced on types of abuse and to keep residents safe and report abuse allegations to her nurse, DON, and the administrator/AC. She said report any concerns related to resident safety to the administrator immediately. During an interview on 08/06/2025 at 1:45 p.m., LVN F & LVN G said they were in-serviced on abuse and neglect. They said if abuse or neglect alleged to make sure resident is safe and then notify the administrator/AC immediately. They said would complete assessment, report to RP, NP/MD. During an interview on 08/06/2025 at 4:45 p.m., RN D said on 07/26/2025 around 8:00 p.m. Resident #3 came to nurses' station and reported his roommate (Resident #4) had thrown a TV remote at him, so he threw it back at him and hit him in the face with it. He said he told another staff member to monitor Resident #3 while he went to assess Resident #4 in their room. He said Resident #4 did have a laceration across his nose that was bleeding, and he was upset regarding the incident and did not want Resident #3 back in the room. He said he notified the MD/NP, DON, ADON, and the administrator of the incident. He said he provided ordered wound care to Resident #4, assigned both residents to be monitored (Resident #3 was placed on 1:1 monitoring, and Resident #4 had neurological checks with q 15-minute monitoring) and moved Resident #3 to another room. He said he questioned the DON and Corporate nurse about reporting the incident to the local police but was directed by the corporate nurse this incident was not to be reported. He said the administrator was on vacation, so the DON and corporate nurse was back up for her as the abuse coordinator. He said he was aware any resident-to-resident incidents had to be reported immediately to the abuse coordinator or designee, and he did report the incident immediately to the DON. RN D said he was the nurse on shift on 07/30/2025 when Resident #3 made a statement about needing a gun, so he could shoot up some people in this place which watching a TV show with guns (old western). He said he placed Resident #3 on behavioral monitoring because the resident was new to the facility, and he did not know if this was a behavior or post traumatic statement. He said Resident #3 did not have access to a gun nor was he acting aggressive during the statement just continued to watch the TV, but staff changed the channel to prevent in trigger of behaviors. He said he notified the DON of the statement and incident and was directed to continue to monitor the resident and notify MD/NP and psych services. RN D said that during the incidents with Resident #4 he followed facility protocol and reported the incidents to the DON who was the designated AC because the administrator was on vacation. RN D said he had been in-serviced on abuse, neglect, reporting allegations and timeframes to report. During an interview on 08/07/2025 at 1:30 p.m., CNA K said she was in-serviced on abuse and neglect including types of abuse and to report any abuse or neglect to the administrator immediately. During all interviews with staff on 08/06/2025 and 08/07/2025, including 2-RN's, 11- LVN's, 12 - CNA's, 2 - therapist, 2 - activity assistants, 1 - transportation aide, and 1 housekeeper, the staff were able to give examples of abuse and were able to identify interventions when dealing with behaviors. They said they had received training on identifying and reporting abuse immediately to the abuse coordinator, which was the administrator. During an interview on 08/07/2025 at 2:10 p.m., the DON said she was the acting abuse coordinator during the absence of the administrator, she said she was notified of the allegations with Resident #3. She said the first allegation between Resident #3 and Resident #4 was reported to her on 07/26/2025 but thought she had 24 hours to report after conferencing with her corporate nurse regarding the incident. She said she originally thought it needed to be reported to the state within two hours and should have reported it. She said she now realizes this was an allegation of resident-to-resident abuse and is required to be reported to the state agency within two hours. She said she had been re-trained by the administrator and all staff in serviced regarding abuse and neglect and reporting timeframes. She said the incident with Resident #3 making a statement regarding a gun on 07/30/2025 was not originally reported as stated in the nurses note, she said the reporting staff reported to her Resident #3 was watching a western and said he wanted a gun like the cowboys, and also seemed restless, so she instructed the nurse to contact Psych services for restlessness and to monitor Resident #3 every 15 minutes and if other behaviors noted to let her know. The DON said she assessed Resident #3 after the reported incident and he was in no distress and when asked about wanting a gun, he stated all cowboys have guns and I just wanted one. She said Resident # 3 denied having any intentions of harming others or himself. She said upon reviewing Resident #3's medical records after the reported incident she noticed RN D had not documented regarding the behavior, so he was counselled, and a late entry was documented. She said the late entry documented on 07/31/2025 in Resident #3's medical record was not the same verbiage that was originally reported on 07/30/2025 during the onset of the incident. She said when reviewed the late entry on 08/01/2025 she and the facility psych services reassessed Resident #3, and he denied suicidal or homicidal ideations and could not recall the incident regarding wanting to be a cowboy with a gun. She said if she would have been notified of a suicidal or homicidal ideation originally, she would have reported the allegation to the state agency within 2 hours. She said Resident #3 was a new resident to the facility and she did not know if his allegation was a behavior, experiencing sun downers, or the TV show triggered a post traumatic incident. She said she expected staff to report all allegations of abuse accurately to the abuse coordinator or designee and all allegations of abuse should be reported to the state agency within 2 hours of the allegations. During an interview on 08/07/2025 at 2:20 p.m., the Administrator said she was out on vacation during the last 2 weeks of July 2025, and the DON and corporate nurse were the designated abuse coordinators. She said reviewing back over the two incidents with Resident #3 she would have categorized the incidents as abuse and reported the allegations to the state agency within 2 hours. She said she had re-trained the DON regarding reporting abuse allegations and to utilize the long-term care regulatory provider letter issued in August of 2024 for guidance. She said her expectations was for all allegations of abuse to be reported to her/abuse coordinator immediately. She said allegations of abuse should be report within 2 hours to the State Agency. Record review of facility policy titled Abuse, Neglect and Exploitation dated 07/2022 indicated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 3 residents (Resident # 47, Resident #87, and Resident #106) reviewed for abuse. The facility failed to ensure Resident #47 was free from sexual abuse when Resident #106 touched her face, hair, and breast area inappropriately on 05/28/2025. The facility failed to ensure Resident #87 was free from physical abuse when Resident #87 and Resident #106 had a physical altercation on 06/05/2025. The noncompliance was identified as PNC. The IJ began on 05/28/2025 and ended on 06/05/2025. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for emotional distress, fear, decreased quality of care, and further abuse. Findings included: Resident #47 Record review of Resident #47's face sheet, dated 06/18/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] with more recent admission date of 01/29/2025. Resident #47 had diagnoses which included PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #47's quarterly MDS assessment, dated 04/04/2025, indicated she made herself understood and usually understood others. She had severe cognitive impairment, identified with a BIMS score of 6. She required supervision or touching assistance with most activities of daily living. Record review of Resident #47's care plan dated 02/23/2025 and revised on 05/30/2025 indicated Resident #47 had potential for episodes of PTSD related to previous rape (as triggered by unwanted, unexplained touch). She was not having any negative effects from history of PTSD. Interventions included encourage resident to verbalize feelings and provide verbal and physical reassurance. Ensure all staff was aware of Resident #47's PTSD potential triggers and attempt to alleviate to the extent possible. Also, Resident #47 was sexual assaulted by another male resident. Intervention included head-to-toe assessment performed by female nurse, psych consult, and resident removed from area to safe environment. Record review of Resident #47's undated witness statement indicated the following: . I was eating breakfast in the cafeteria at about 8:30 a.m., a white male [Resident #106] came up and sat on my right side. He told me he did not have a girlfriend and was glad he met me. I told him I was going outside to smoke, with him following me I gave him a cigarette believing he would go away, but he continued to follow me. He started rubbing my breast through my clothing even though I told him to stop. An employee saw what happened and told the administrator. Record review of Resident #47's progress notes dated 05/28/2025 at 09:00 a.m. authored by the DON indicated [Resident #47] had another male resident (Resident #106) rubbing her back during smoke break, then went to touch her breast area. He was immediately separated from her, and she was brought to the front Administrator's office for statement. She stated that she did not tell him it was okay to touch her breast area. Police department notified at this time. Head to toe assessment performed with no negative findings noted. Physician was notified and gave order to consult Psychiatric services. Nurse practitioner for Psych services was notified, Telehealth performed at this time, no new orders noted at this time. Resident #47 stated, I am ok, just don't want to think about it Psych NP will see her again on Friday. Record review of Resident #47's progress note dated 05/30/2025 at 10:44 a.m. and authored by Psych NP F indicated Patient [Resident #47] seen for follow up related to incident this week. Patient [Resident #47] is pleasant. She stated she had a history of past rape, and multiple times. She stated she is okay since he touched her, just made her think of the past. New diagnosis of PTSD, and new order for Xanax (used to treat anxiety and panic disorders) 0.25 mg - one tablet daily at 11:00 a.m. for 14 days to manage effective coping. Record review of Resident #47's progress note dated 06/02/2025 at 4:58 p.m. authored by the Social Worker indicated visited with resident [Resident #47] today. She states she is feeling better. She states she is sleeping well and not having any negative dreams. She voiced no issues at this time. Resident #106 Record review of Resident #106's face sheet, dated 06/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #106 had diagnoses which included metabolic encephalopathy (a brain disorder characterized by altered mental status due to various factors like electrolyte imbalances, organ dysfunction, or nutritional deficiencies) and personality disorder (a group of mental health conditions characterized by inflexible and unhealthy patterns of behavior and thinking that differ from cultural norms). Record review of Resident #106's admission MDS assessment, dated 05/16/2025, indicated he makes himself understood and understood others. He had no cognitive impairment, identified with a BIMS score of 12. He required partial/moderate assist with toileting, personal hygiene, and bathing. Record review of Resident #106's care plan dated 05/28/2025 indicated Resident #106 had an episodic behavior of grabbing, suicidal ideations, and aggression. Intervention was admission to behavioral hospital for evaluation and admission. Place on 1:1 care until admission. Record review of Resident #106's progress notes dated 05/28/2025 at 09:00 a.m. (as a late entry) authored by DON indicated Resident was witnessed by staff, rubbing a female resident's back, then went and placed hand on top of breast area during smoke break. Resident was immediately separated and placed 1:1 with CNA. When asked about the incident, he said it was consensual. I explained she did not see it that way and we had to notify the police. Resident stated I am going to my cave because I cannot commit suicide in the gym. Physician notified and received order to send to behavioral hospital. Record review of Resident #106's progress note dated 05/28/2025 and authored by Psych NP G indicated [AGE] year-old male presents for weekly visit. Patient has indwelling catheter in place. Another resident reported being inappropriate with her. Psych and police notified. Patient being sent to behavioral center. Record review of the facility's PIR (Provider Investigation Report), dated 06/04/2025, incident category as abuse, resident inappropriately touched another resident's breast and signed by the Administrator on 06/04/2025. PIR indicated the incident occurred 05/28/2025 at 09:00 a.m. in the smoking area. Record review of Resident #106's progress notes indicated readmission to facility from the behavioral center on 06/05/2025. Resident #106 was admitted to all-male secure unit for behaviors and monitoring. There were no changes to medicine regimen. Record review of Resident #106's care plan updated 06/05/2025 indicated goal/interventions to include placing in an all-male environment on secure unit to monitor behaviors and signs of depression such as isolation and crying. Resident #106 had a physical altercation with another resident. Interventions included monitor and document all behaviors, refer to psychiatric services, and was placed on 1:1 care. Record review of Resident #106's electronic clinical record indicated on 06/05/2025 he signed an Unauthorized Discharge/Release of Responsibility (AMA) form and discharged from facility. (AMA is against medical advice) During an observation and interview on 06/18/2025 at 9:45 a.m., Resident #47 was sitting in her room in her wheelchair. She said Resident #106 had come up beside her and touched her shoulder and breast. She said she had felt angry and fearful at the same time, and she did not want him touching her. Resident #47 said staff had intervened quickly. She said the incident was reported to the police and she was told Resident #106 was in another part of facility behind double locks. She said all she knew was that he was not in the facility. During an interview on 6/18/2025 at 10:30 a.m., the Administrator said Residents #47 and #106 had been talking in the dining area and Resident #106 followed Resident #47 to the smoking area. While outside, Resident #106 put his hand on Resident #47's breast. The Administrator said the incident was witnessed by ADON E. Residents were immediately separated, and Resident #106 was placed on 1:1 monitoring due to expressing suicidal ideation. When administrator interviewed Resident #106, he denied the allegation. She said the incident had been reported to police. She said the police had taken written statements from Resident #47 and ADON E. During an interview on 06/18/2025 at 1:30 p.m., ADON E said she was a witness to this incident. She said the residents were outside in the courtyard for smoke break. She said the maintenance man was with the residents at that time. She says he motioned for her to come outside when she was passing by the window facing the smoking area. She said about the time she got out to Resident #47, she saw that Resident #106 had his hand on her chest area. She said he was sitting by her side, and both were in wheelchairs. She said that he was touching the upper chest region area of Resident #47. She said Resident #106 normally did not come out of his room, and that he had just started coming out of his room a little more. She said he looked happy. She said Resident #106 was usually quiet. When asked about Resident #47's cognitive status, she said she is alert and interviewable. She stated her cognition would vary and sometimes she was all over the place. She said when she saw Resident #47, she did not seem afraid and was not crying. She said she wheeled Resident #47 straight to the Administrator's office to report. During an interview on 06/18/2025 at 2:05 p.m., Maintenance A said on 05/28/2025 at approximately 09:00 a.m., he had been supervising the residents who smoked. He said yesterday was the first time Resident #47 and Resident #106 had met. He said Resident #106 never comes out of his room. He said he observed Resident #106 getting close to Resident #47 which he thought was odd behavior. He said Resident #106 had touched the face and caressed hair of Resident #47. He said she looked uncomfortable and pulled away from Resident #106. Maintenance A said he saw ADON E passing near windows with outside view to the smoking area, and he motioned her [ADON E] to come outside. He said Resident #47 was a large busty woman and he did not see Resident #106 touch her breast nor put his hand inside her blouse at the time. He said ADON E acted quickly and took Resident #47 to the Administrator's office to report the incident. During an interview on 06/18/2025 at 2:23 p.m., RA H said she had served breakfast trays on 05/28/2025. She said Resident #47 and Resident #106 were sitting at the same table and having a cordial conversation and were laughing. She said this was the first time she had seen Resident #106 out of his room. RA H said she saw no discomfort between the two residents at breakfast. RA H said at around 09:00 a.m., she was instructed to monitor Resident #106 on a 1:1 basis. She said he was crying during her monitoring. She said he made statement that he was going to jail and was praying over the situation. She said Resident #106 required assistance for some activities of daily living. She said he had a foley catheter (inserted into bladder to drain urine) and would try to empty the drainage bag himself. During an interview on 06/18/2025 at 2:44 p.m., the SW said she visited with Resident #47 for several days following the incident on 05/28/2025. She said Resident #47 was doing well until incident which triggered uncomfortable memories. Resident #47 said she felt safe knowing Resident #106 was no longer residing at the facility. The SW said she was unaware of Resident #47 having a diagnosis of PTSD because she had never mentioned it to her. During an interview and record review on 6/18/2025 at 4:00 p.m., surveyor reviewed an undated Handwritten Witness Statement with ADON E. She said when the police came to the facility, he had requested ADON E to complete. In this statement she wrote As I walked past smoking area, I noticed [Resident #106] rubbing on Resident #47's neck, face, and breast region. I asked Resident #47 was this behavior consensual. She verbalized no. I removed Resident #47 from the smoking area and brought her to administrator office. After review of the written statement, ADON E verified her statement by signature and date. Resident #87 Record review of Resident #87's face sheet, dated 06/18/2025, indicated a [AGE] year-old male who was originally admitted to the facility on [DATE] with more recent admission date of 03/10/2025. Resident #87 had diagnoses which included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #87's discharge-return anticipated MDS assessment, dated 06/09/2025, indicated a short-term memory problem severely impaired for cognitive skills for daily decision making. He required supervision or touching assistance with most activities of daily living. Record review of Resident #87's care plan dated 06/05/2025 and indicated Resident #87 had a physical altercation with another resident. Interventions included to monitor and document all behaviors, placed on 1:1 care, seen by psych service NP, and new order received for behavioral center referral related to delusions. Resident #87 resided on the memory care unit related to unaware of his safety needs and wandering. Interventions included encourage social interaction, give simple specific instructions for accomplishing tasks, maintain consistent routines, orient to reality as needed, and prevent excessive stimulation. Record review of Resident #87's progress notes dated 06/05/2025 at 03:30 a.m. authored by LVN M indicated approached room [ROOM NUMBER] and Resident (#87) was standing near door skin tear noted to left and right hand. When asked what happened, resident did not respond. Sites cleaned and dressed. Head to toe evaluation done. Resident nose appeared to be red. No blood noted. Family notified. EMS called to transport resident to emergency room for eval. Record review of Resident #87's progress note dated 06/05/2025 at 04:40 a.m. authored by LVN M indicated raised area to forehead and small laceration to upper lip. When EMS arrived, resident refused to go to ER. This nurse asked resident what happened, he stated they had a man in my room that wouldn't leave. He then started a confused conversation regarding being chased in a car. Record review of Resident #87's progress note dated 06/05/2025 at 1:10 p.m. authored by Psych NP F indicated assessed patient due to incident this morning, and upon arrival he was pacing in room with aide present. Pt is confused with a BIMS of 3 (severe cognitive impairment). Pt is able to follow directions but does have times of delusions and is delusional currently about a car and police chase. Patient has a history of traumatic brain injury from years ago and schizoaffective. Patient has disorganized thought process and speech. I plan to send patient out for monitoring of delusions. I do not think he is a harm to others. Nursing staff are closely monitoring for any changes. Record review of Resident #87's clinical record indicated he was placed on 1:1 monitoring by staff from 06/05/2025 at 3:30 a.m. until transferred to behavioral center on 06/05/2025 at 1:30 p.m. Record review of the facility's Provider Investigation Report, dated 06/05/25, incident categorized as abuse and incident signed by the Administrator on 06/12/25. PIR indicated the incident occurred 06/05/25 at 3:20 a.m. on the secure unit. PIR indicated Resident #87, and Resident #106 had an un-witnessed resident-to-resident incident, both on the secure unit. Description of the Allegation: [Resident #106] was noted in the hallway by LVN M and stated that someone had come into his room. DON asked if the other patient hit him, and he stated: no, he swung first so I have a right to defend myself. So, I hit him. [Resident #87] would not give a statement at this time. PIR indicated LVN M provided head to toe assessment to Resident #87 and Resident #106 on 06/05/25 indicating Resident #87 had raised area noted to forehead and small laceration to upper lip, reddened nose and Resident #106 no visible injuries. PIR indicated Provider Response: patients were immediately separated, both patients were placed on one-on-one, roommate of Resident #106 was immediately removed, Neuro-checks initiated on Resident #87, both Residents immediately assessed for injuries and treated, MD/ RP/ PD/ Psych were notified, In-services, Safe surveys and Staff interviews initiated. PIR indicated Investigation Summary: Upon receipt investigation was immediately initiated. Admin interviewed Resident #106 on the incident. Mr. (Resident #106) stated, I was lying in bed, and he came into my room mumbling to himself. I screamed at him to leave, and he sat down in my wheelchair. So, I got up and hit him so he would leave. Admin asked if Mr. (Resident #87) hit him, Mr. (Resident #106) stated no. Admin asked him if he would go to the psych hospital, he stated no, there is no reason for me to go, I just want to go home and you can't keep me here. Admin went to get DON, and Social Worker in regard to possible discharge. Administrator, DON and Social Worker went back to speak with (Resident #106). Resident at this time has changed his statement to Mr. (Resident #87) came in his room, stood over his bed and would not leave then sat down in his wheelchair. Then proceeded to change statement again that he came in yelling and drug me out of the bed, while I was screaming, so I had to defend myself and I hit him, and I just want to go home now. Re-educated at this time it is not appropriate to touch other residents and psych would come see him and further explain the benefit of a behavioral hospital. Resident stated F**k you. I am not going anywhere but home and I want to go today, you cannot hold me here. Social worker asked how he would have care at home, and he said his friend is a caregiver and they live together. Explained we would notify MD for discharge orders and set up home health, but would take a little time, and he stated I am not waiting, I am leaving today. Friend was notified. Resident #106 discharged AMA home with Friend. APS was contacted. Admin went to interview Mr. (Resident #87) about what happened last night. Mr. (Resident #87) stated that he was in a car wreck in the middle of the night. I asked him if he was hurting or if he felt safe, Mr. (Resident #87) said yea, I am ok, but my car isn't. It's broke now. Admin reported the statement to charge nurse. Mr. (Resident #87) was sent out later for delusions per MD/ Psych. Admin then interviewed (Resident #106) roommate in regard to incident. Admin asked if he saw or heard anything. Roommate stated, I didn't hear or see anything, he couldn't have been too loud. Roommate BIMS of 10. Safe surveys completed with no negative findings. Staff interviews completed with no negative findings. In-servicing completed. Record review of Resident #87's 1:1 monitoring record indicated on 06/05/2025 at 3:30 a.m., he was placed on 1:1 monitoring until approximately 2:15 p.m. when he was transferred to the behavioral center for evaluation. Record review of Resident #106's 1:1 monitoring record indicated on 06/05/2025 at 3:30 a.m., he was placed on 1:1 monitoring until approximately 1:30 p.m. Resident #106's progress notes indicated multi entries of Resident #106 continuing with 1:1 monitoring by staff in his room. Record review of Resident #106's progress notes dated 06/05/2025 at approximately 10:50 a.m., Resident #106 had stated to staff that he understood he was leaving facility AMA and signed the form. Review of progress notes indicated Resident #106 left facility at approximately 1:40 p.m. with a friend. PIR indicated Provider investigation findings: Unconfirmed. PIR indicated Provider action taken post-investigation: Safe surveys completed with no negative findings, staff interviews completed with no negative findings and In-servicing completed. During an interview on 6/18/2025 at 10:00 a.m., LVN N and LVN O said the incident occurred on the night shift and were told during report at shift change the following morning. She said this was in Resident #87's previous room and speculate due to his dementia, he thought he was in his room. During an interview at on 06/18/2025 at 10:30 a.m., the Administrator said Resident #106 had changed his story several times. He said Resident #87 had come in and sat down, then that he was standing over him, also that he felt threatened and was defending himself, etc. He became upset and said he wanted to leave and go back to a motel and get stoned. During an interview on 06/19/25 at 8:39 a.m., LVN N said she worked the 6a to 2p shift on the memory care unit on 06/05/25. LVN N said Resident #87 had a history of delusions, self-propelled wheelchair, pacing and often wandered into other residents' (on the memory care) rooms because he thought they were his room, and he would start undressing himself to get in the bed. LVN N said staff would often re-direct Resident #87 out of other resident's rooms and to his own room. LVN N said on the morning of 06/05/25, Resident #87 did not know what happened and that he thought the police or Nazis were after him. LVN N said she notified the Resident's physician of the incident and was given orders to send him to a behavior hospital. LVN N said Resident #87 was not acting any different from his baseline, because he always had delusions and wandered. During an interview on 06/19/25 at 6:13 p.m., the Administrator said she was the Abuse Coordinator and was the one responsible for the investigation of the 06/05/25 altercation between Resident #87 and #106. The Administrator said Resident #106 had changed his statement multiple times. She stated one story was a man came into his room, stood over his bed, and hit him. Then later Resident #106 claimed he had to protect himself because Resident #87 tried to drag him out of bed and so he hit him. The Administrator said Resident #106 was mad, and refused to be transferred to the behavioral center for treatment. When he went to hospital, there were no medication changes. He was mad the police did not talk to him after incident. She stated the roommate [Resident #87] was interviewed and unaware of the incident until the resident screamed. Negative sex offender. UTI/ labs were off before the incident. The Administrator said there was nothing she would have done differently. She stated Resident #106 had no history of aggression and no issues with abuse. During a phone interview on 06/19/25 at 11:25 a.m., CNA QQ said she worked the 10p to 6a shift on the Memory Care unit female hall, and on 06/05/25 CNA RR, on the men's side of the hall, called her to come help. CNA QQ said that Resident #87 was in Resident #106's room and Resident #87 was standing over Resident #106's, who was in bed. CNA QQ said she removed Resident #87 from the room and hollered for a nurse. CNA QQ said Resident #87 was bleeding from his face, lip and hands. CNA QQ said she could tell because there was blood coming from both his hands and his face. CNA QQ said they could use some help or use more help if they could get one more CNA to help monitor the residents because a lot of them wander into rooms. CNA QQ said that there's only two CNA's and one nurse working on the night shift. She said there's many residents that wander into other residents' rooms. She stated they redirected them and take them back to their room, they offer snacks, they may even get extra blankets if they're cold. During a phone interview on 06/19/25 at 1:43 p.m. LVN M said she was the nurse on duty 10p to 6a on 06/05/25 on the Memory Care unit. LVN M said she was leaving the nurses station and Resident #106 was coming towards the nurses' station from his room in a wheelchair with blood on his hands saying he had the right to defend himself. LVN M said Resident #106 told her Resident #87 came in his room swinging at him, he had the right to defend himself. LVN M said Resident #87 had a raised area on his head, skin tears on both arms, and had a small cut on the upper lip. LVN M said Memory Care unit staffing at night was one CNA for each hall and one nurse for the entire unit. LVN M said there is enough help to provide care with only one CNA, and when they must go to lunch, another staff from 200 hall would come to help. LVN M said Resident #87 had been in his room most of the night, and no one saw when he left his room and entered Resident #106's room. LVN M said after the altercation, Resident #106 and Resident #87 had been on one-to-one monitoring, but she could not remember which staff did the 1 to 1 monitoring. LVN M said at night, the LVN must do frequent rounds and frequent redirection of the residents who wander. During a phone interview on 06/19/25 at 12:45 p.m. CNA RR said she was working the floor 10p to 6a on 06/05/25 on the Memory Care unit, men's hall. CNA RR said she left her men's hall to go assist CNA QQ (women's hall) with care and LVN M came and got them to assist Resident #87 who was standing in the hall bleeding but not bad back to his room. CNA RR said Resident #106 was sitting in a wheelchair in the hall outside the door. She stated Resident #87 had said someone was in his room; Resident #106. CNA RR said Resident #106 told her Resident #87 was standing over him and he needed to defend himself, so he hit Resident #87. CNA RR said they helped put Resident #87 back in the wheelchair and put him in his room. CNA RR said Resident #87 had been in bed most of the night, but must had gotten up, and usually when Resident #87 does wander into someone else's room, they redirect him back to his room or they'll sit with them. CNA RR said she thought Resident #87 got up to use the bathroom and lost his way back to the bed, went to his old room where Resident #106 was. CNA RR said Resident #106 had never had contact or an altercation that she knew of with any other resident. CNA RR said she did the 1 to 1 monitoring and CNA QQ sat with Resident #106. The Administrator was notified a past non-compliance situation had been identified due to the above failures. It was determined these failures placed residents in an IJ situation on 05/28/2025 through 06/05/2025. The facility had implemented the following interventions: -Resident #47 immediately removed from the smoking area away from Resident #106 -Resident #47 skin assessment performed -Resident #106 was monitored 1:1 on 05/28/25 from 09:00 a.m. until transferred to behavioral center at around 6:00 p.m. -Physician, Responsible Party, Police Department and Psych Services notified. -Resident #47 and Resident #106 were seen by psych services on 05/28/2025 -Resident #106 was sent to behavioral center for evaluation and admission on [DATE] - safe surveys were initiated by SW -staff interviews initiated -On 05/28/2025, all staff were educated by DON on Resident Rights, Abuse, Neglect, Exploitation, and Abuse Reporting. -On 06/05/2025, Resident #87 was placed on 1:1 monitoring until approximately 2:15 p.m. when he was transferred to the behavioral center for evaluation. -On 06/05/25, Resident #106 was placed on 1:1 monitoring by staff in his room until he discharged . -On 06/05/2025, Resident #106 left the facility AMA at approximately 1:40 p.m. with a friend. Record review indicated on 06/05/2025, the DON held an in-service on the following with 46 employees in attendance: -resident rights; -abuse, neglect, and abuse reporting; and -managing behaviors and de-escalation. Attendees included 2 RNs, 6 LVNs, 1 MA, 21 CNAs, 4 rehabilitation staff, 4 dietary staff, 5 housekeepers, 1 AD, 1 SW, and 1 receptionist. Interviews conducted on 06/16/2025 from 09:00 a.m. through 06/20/2025 at 4:15 p.m., with the following staff through various shifts (6a-6p, 6p-6a, 6a-2p, 2p-10p, and 10p-6a) i floor tech T, ADON/ICP, LVN U, LVN ADON E, CNA V, CNA J, LVN W, CNA X, CNA L, CNA Y, RNA H, AD Z, DON, housekeeper AA, housekeeper BB, CNA V, Housekeeper CC, Housekeeper DD, Housekeeper EE, LVN FF, CNA GG, Environmental supervisor, Admissions, LVN HH, Housekeeper AA, LVN O, LVN KK, CNA LL, CNA MM, LVN N, CNA NN, Housekeeping OO, CNA PP, LVN M, CNA QQ and CNA RR, CNA SS, CNA PP, CNA WW, CNA K, CNA AA, CNA BB, CNA CC, CNA LL , LVN MMM, LVN M, LVN TT, LVN, R, LVN VV, MDS LVN JJJ, MDS LVN FF, RN UU, ADON E, ADON/ IP, Environmental supervisor, HK BB, HK XX, DM, Maintenance Assistant ZZ, Laundry DD, dietary aide EEE, Staffing, ST NNN, ST KKK, ABOM, Receptionist GG, Medical Records HH, PTA, and SW. The staff said they had been trained on abuse/neglect, abuse reporting, resident rights on hire and at least annually. The staff said they were retrained following the incidents that occurred on 05/28/2025 and 06/05/2025. The were able to voice what to do first such as separate the residents and get help as needed. They said they would report to nurses then report to the Abuse preventionist. They were able to identify different types of abuse i.e. verbal, sexual and physical. The noncompliance was identified as PNC. The IJ began on 05/28/2025 and ended on 06/05/2025. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 resident (Residents #87 & #106) reviewed for accidents hazards and supervision. 1. The facility failed to provide adequate supervision on the facility's memory care unit, to prevent Resident #87, who had severe cognitive impairment from wandering into Resident #106 room at approximately 4:00 a.m. on 06/05/25. 2. The facility did not implement interventions to include adequate supervision prior to the incident or following the incident for all residents at risk for injuries related to wandering behaviors. An Immediate Jeopardy (IJ) was identified on 06/19/25 at 4:50 p.m. The IJ template was provided to the facility on [DATE] at 5:08 p.m While the IJ was removed on 06/20/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of emotional distress, fear, severe injury, hospitalization, and decline in quality of life. Findings included: Resident #87 Record review of Resident #87's face sheet, dated 06/21/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #87 had diagnoses which included Alzheimer (loss of cognitive functioning), schizoaffective disorder bi-polar type(mental health condition combination impacting a person's thoughts, emotions and behavior), cognitive communication deficit(difficulty communicating, understanding, speaking reading, writing and social interaction), psychosis(mental health condition characterized by a disconnection from reality) and anxiety(intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #87's quarterly MDS assessment dated [DATE] indicated Resident #87 was understood and had the ability to understand others. He had a BIMS score of 3 of 15 indicating his cognition was severely impaired for daily decision making, and had disorganized thinking. Resident #87 had minimal difficulty hearing, impaired vision, and clear speech. Resident #87 used a wheelchair and exhibited behavior of wandering 1 to 3 days. Record review of Resident #87's care plan, revised 03/12/2025, reflected the following: Focus: The resident is/has potential to be physically aggressive r/t Anger, . Interventions: COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated .Focus: Resident to resident altercation; physical altercation became agitated with a confused resident and hit them. Interventions: counsel resident on acceptable vs unacceptable behaviors, monitor for potential altercation between residents . Refer to psych care as needed. Record review of Resident #87's Progress Notes reflected the following: 06/05/2025 03:30 AM- approached room [ROOM NUMBER] resident was standing near door skin tear noted to left and right hand when asked what happened resident didn't respond resident cooperated and exited this room, sites cleaned and dressed head to toe eval done resident nose appeared to be red no blood noted. Family member OOO was notified 1st contact no answer DON notified of situation, EMS was call to transport resident to ER for eval neuoro checks iniated. This entry was written by LVN M. 06/05/2025 04:40 AM- raised area noted to forehead and small laceration to upper lip, when ems arrived resident refused to go to er, this nurse asked resident what happened this time he stated they had a man in my room that wouldn't leave then he started a confused conversation re being chased in a car. one on one staff with resident at this time neuro checks in progress. This entry was written by LVN M. 06/05/2025 12:57 PM- Resident Remains 1:1, is pacing with CNA at side and having delusions saying he was in a car wreck last night, then the germans are attacking, NP notified and is on way to round on resident. This entry was written by LVN N. 06/05/2025 2:24 PM- res transferred to behavioral hospital by their facility van called and gave report to the nurse there This entry was written by LVN N. Record review of Resident #87's Provider Notes reflected the following: 06/05/2025 1:10 PM- I assessed pt due to incident this am, and upon arrival he was pacing in room with aid present. I went into room and greeted me with kindness. pt is pleasant. pt denied any problems. pt denies any suicidal or homicidal thoughts, pt is confused with a BIMs of 3. pt is able to follow directions but does have times of delusions and is delusional currently about a car and police chase. Pt has a history of traumatic brain injury from years ago and schizoaffective. pt has disorganized thought process and speech. I plan to send resident out for monitoring of delusions. I do not think he is a harm to others, Nursing staff are closely monitoring pt for any changes. This entry was written by Psych NP F. Record review of the facility Incidents/Accidents reports reviewed for to June 2025 revealed there was no incident report regarding Resident #87's injuries, wandering or altercation. Resident #106 Record review of Resident #106's face sheet, dated 06/21/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #106 had diagnoses which included adjustment disorder with depressed mood(mental health condition characterized by emotional and behavioral symptoms) and personality disorder(mental health condition characterized by inflexible and unhealthy patterns of behavior and thinking that differ from cultural norms). Record review of Resident #106's admission MDS assessment dated [DATE] indicated Resident #106 was understood and had the ability to understand others. He had a BIMS score of 12 of 15 indicating his cogntition was moderately impaired for daily decision making, and had disorganized thinking. Resident #106 had adequate hearing, vision, and clear speech. Resident #106 used a wheelchair and exhibited no behavior of wandering. Record review of Resident #106's care plan, initiated 05/28/25, reflected the following: Focus: RESIDENT HAD AN EPISODIC BEHAVIOR OF GRABBING, SUICIADAL IDEALATIONS, AGGRESSION, Interventions: .NEW ORDER NOTED FOR EVALUATION AND ADMIT. Record review of Resident #87's Progress Notes reflected the following: 06/05/2025 3:21 AM- this nurse was leaving nurses station to make round this resident was coming down hall stated that another resident was in his room and swung at him so he hit him he continued screaming [NAME] have the right to defend myself man or woman i will knock the f out of them, this nurse ensured he was safe and could calm down small ampount of bllod was noted on his right hand . don was notified of situation and gave orders for this nurse to call the police to come out. This entry was written by LVN M. 06/05/2025 5:05 AM- Spoke with resident in regard to refusing to go to Hospital and he stated there was no need to, he was never touched by other resident and did not need psych services. Asked him again what happened, he stated, He came in my room, so I felt the need to defend myself so I did and will do again Asked what (Res #87) said to him, and he said he didn't say anything just came in here in the middle of the night. Denies any pain at this time, will continue with 1:1 monitoring and Psych to see today. This entry was written by DON. 06/05/2025 9:34 AM- Went to interview/assess resident with Administrator and social worker. Resident in room, with CNA FOR 1:1 monitoring. Resident at this time has changed his statement to Resident #87 came in his room, stood over his bed and would not leave then sat down in his wheelchair. Then proceeded to change statement again that he came in yelling and drug me out of the bed, while I was screaming, so I had to defend myself and I hit him, and I just want to go home now. Re-educated at this time it is not appropriate to touch other residents and psych would come see him and further explain the benefit of a behavioral hospital. Resident stated F. you, I am not going anywhere but home and want to go today, you cannot hold me here. Social worker asked how he would have care at home, and he said his friend is a caregiver and they live together. Explained we would notify MD for discharge orders and set up home health, but would take a little time, and he stated I am not waiting, I am leaving today. This entry was written by DON. 06/05/2025 10:09 AM- res in room no aggression noted res on 1:1 monitoring. This entry was written by LVN N. 06/05/2025 1:16 PM- Pt seen at this time r/t incident this am. He would not speak to me about it, no visible distress noted. When I asked what happened he said I don't have to answer you because I am going home now and no longer under your care. pt denies any suicidal or homicidal thoughts, I attempted to re-question/re-assess and he told me to get out. I exited the room, aid remained in room, and pt was ok with aid in room. This entry was written by Psych NP F. 06/05/2025 3:46 PM- SW made report to statewide intake as resident left AMA today. This entry was written by Social Worker. Record review of the facility Incidents/Accidents reports reviewed for to June 2025 revealed there was no incident report regarding Resident #106's altercation or leaving AMA. Record review of the facility's Provider Investigation Report, dated 06/05/25, incident category as abuse and incident signed by the Administrator on 06/12/25. PIR indicated the incident occurred 06/05/25 at 3:20 a.m. on the secure unit. PIR indicated Resident #87 and Resident #106 had a un-witnessed resident-to-resident incident, both on the secure unit. Description of the Allegation: Resident #106 was noted in the hallway by [LVN M] and stated that someone had come into his room. DON asked if the other patient hit him, and he stated: no, he swung first so I have a right to defend myself. So I hit him. Resident #87 would not give a statement at this time. PIR indicated LVN M provided head to toe assessment to Resident #87 and Resident #106 on 06/05/25 indicating Resident #87 had raised area noted to forehead and small laceration to upper lip, reddened nose and Resident #106 no visible injuries. PIR indicated Provider Response: patients were immediately separated, both patients were placed on one-on-one, roommate of Resident #106 was immediately removed, Neuro-checks initiated on Resident #87, both Residents immediately assessed for injuries and treated, MD/ RP/ PD/ Psych were notified, In-services, Safe surveys and Staff interviews initiated. PIR indicated Investigation Summary:Upon receipt investigation was immediately initiated. Admininistrator interviewed Resident #106 on the incident. Mr. (Resident #106) stated, I was lying in bed and he came into my room mumbling to himself. I screamed at him to leave and he sat down in my wheelchair. So I got up and hit him so he would leave. Administrator asked if Mr. (Resident #87) hit him, Mr. (Resident #106) stated no. Admin asked him if he would go to the psych hospital, he stated no, there is no reason for me to go, I just want to go home and you can't keep me here. Administrator went to get DON, and Social Worker in regards to possible discharge. Administrator, DON and Social Worker went back to speak with (Resident #106). Resident at this time has changed his statement to Mr. (Resident #87) came in his room, stood over his bed and would not leave then sat down in his wheelchair. Then proceeded to change statement again that he (Resident #106) came in yelling and drug me out of the bed, while I was screaming, so I had to defend myself and I hit him, and I just want to go home now. Re-educated at this time it is not appropriate to touch other residents and psych would come see him and further explain the benefit of a behavioral hospital. Resident stated Fuck you. I am not going anywhere but home and I want to go today, you cannot hold me here.Social worker asked how he would have care at home, and he said his friend is a caregiver and they live together. Explained we would notify MD for discharge orders and set up home health, but would take a little time, and he stated I am not waiting, I am leaving today. Friend was notified. Resident #106 discharged AMA home with Friend. APS was contacted. Administrator went to interview Mr. (Resident #87) about what happened last night. Mr. (Resident #87) stated that he was in a car wreck in the middle of the night. I asked him if he was hurting or if he felt safe, Mr. (Resident #87) said yea, I am ok, but my car isn't. It's broke now. Admin reported the statement to charge nurse. Mr. (Resident #87) was sent out later for delusions per MD/ Psych. Admin then interviewed (Resident #106) roommate in regards to incident. Admin asked if he saw or heard anything. Roommate stated I didn't hear or see anything, he couldn't have been too loud. Roommate BIMS of 10. Safe surveys completed with no negative findings. Staff interviews completed with no negative findings. In-servicing completed, Provider investigation findings: Unconfirmed, action taken post-investigation: Safe surveys completed with no negative findings, staff interviews completed with no negative findings and In-servicing completed. Record review of the facility's employee sign-in sheet for the Memory Care Unit dated 06/04/25 indicated LVN M, CNA QQ, and CNA RR worked the 10p to 6a shift when the altercation between Resident #87 and Resident #106 to place. Record review of facility's census report dated 06/18/25 indicated the Memory Care unit had a census of 19 males and 16 females. The DON highlighted and identified 18 residents on the Memory Care unit who wander. During an interview on 06/19/25 at 8:39 a.m., LVN N said she worked the 6a to 2p shift on the memory care unit on 06/05/25. LVN N said Resident #87 had a history of delusions, self-propelled wheelchair pacing and often wandered into other resident's (on the memory care) rooms because he thought they were his room and he would start undressing himself to get in the bed. LVN N said staff would often re-direct Resident #87 out of other resident's rooms and to his own room. LVN N said on the morning of 06/05/25 Resident #87 did not know what happened and that he thought the police or Nazis were after him. LVN N said she notified the Resident's physician of the incident and was given orders to send him to behavior hospital. LVN N said Resident #87 was not acting any different from his baseline, because he always had delusions and wandered. During an interview on 06/19/25 at 6:13 p.m., the Administrator said she was the Abuse Coordinator and was the one responsible for investigation of the 06/05/25 altercation between Resident #87 and #106. The Administrator said Resident #106 had changed his statement multiple times, one story was a man came into his room stood over his bed and hit him, then later Resident #106 claimed he had to protect myself because Resident #87 tried to drag him out of bed and so he hit him. The Administrator said Resident #106 was mad, refused behavior center. When he went to hospital no medication changes. He was mad the police did not talk to him after incident. Roommate was interviewed and unaware of incident until resident screamed. Negative sex offender. UTI/ labs were off before the incident. Admin said there was nothing she would have done differently Resident #106 had no history of aggression and no issues with abuse. During a phone interview on 06/19/25 at 11:25 a.m. CNA QQ said she worked the 10p to 6a shift on the Memory Care unit female hall and on 06/05/25 CNA RR on the men's side of the hall called her to come help, which left the women hall unattended. CNA QQ said that Resident #87 was in Resident #106's room and said Resident #87 was standing over Resident #106's who was in bed. CNA QQ said she removed Resident #87 from the room and hollered for a nurse. CNA QQ said Resident #87 was bleeding from his face, lip and hands. CNA QQ said she could tell because there was blood coming from both his hands and his face. CNA QQ said they could use some help or use more help if they could get one more CNA to help monitor the residents because a lot of them wander into rooms. CNA QQ said that there's only two CNA's and one nurse working on the night shift she said there's a large amount of residents that wander into other residents rooms they redirect them and take them back to their room, they offer snacks, they may even get extra blankets if they're cold. CNA QQ said on 06/05/25, 2 CNAs came from unit 100 to help until after the police and EMS had been there and then they went back to their hall and she went back to the women's side and she says no one sat with Resident #87 or Resident #106. During a phone interview on 06/19/25 at 1:43 p.m. LVN M said she was the nurse on duty 10p to 6a on 06/05/25 on the Memory Care unit. LVN M said she was leaving the nurses station and Resident #106 was coming towards nurses station from his room in a wheelchair with blood on his hands saying he had the right to defend himself. LVN M said Resident #106 told her Resident #87 came in his room swinging at him, he had the right to defend himself. LVN M said Resident #87 had a raised area on his head, skin tears on both arms, and had a small cut on the upper lip. LVN M said Memory Care unit staffing at night was one CNA for each hall and one nurse for the entire unit. LVN M said there is enough help to provide care with only one CNA, and when they have to go to lunch another staff from 200 hall would come to help. LVN M said Resident #87 had been in his room most of the night, and no one saw when he left his room and entered Resident #106's room. LVN M said after the altercation Resident #106 and Resident #87 had been on one to one but she could not remember which staff did the 1 to 1 monitoring. LVN M said at night the LVN has to do frequent rounds and frequent redirection of the residents who wander. During a phone interview on 06/19/25 at 12:45 p.m. CNA RR said she was working the floor 10p to 6a on 06/05/25 on the Memory Care unit, men's hall. CNA RR said she left her men's hall to go assist CNA QQ (women's hall) with care and LVN M came and got them to assist Resident #87 who was standing in the hall bleeding but not bad back to his room. CNA RR said Resident #106 was sitting in a wheelchair in the hall outside the door, and Resident #87 had said someone was in his room Resident #106. CNA RR said Resident #106 told her Resident #87 was standing over him and he needed to defend himself so he hit Resident #87. CNA RR said they helped put Resident #87 back in the wheelchair and put him in his room. CNA RR said Resident #87 had been in bed most of the night but must have gotten up, and usually when Resident #87 does wander into someone else's room they redirect him back to his room or they'll sit with them. CNA RR said she thinks Resident #87 got up to use the bathroom and lost his way back to the bed, went to his old room where Resident #106 was. CNA RR said Resident #106 had never had contact or an altercation that she knows of with any other resident. CNA RR said she did the 1 to 1 and CNA QQ sat with Resident #106 and they didn't call for extra staff. Interview on 06/19/25 at 5:30 p.m., the DON said that one nurse and two CNAs was sufficient because they had 35 residents in the Memory Care unit. She stated that they try to have additional staff on the day shift, the transportation person, when she is not doing transportation, is back there or hospitality aides. She stated that on the evening shift the nurses from hall 200 or 100 will go back there to help but it wasn't assigned to any particular person. The charge nurses were responsible to ensure the Memory Care unit was covered and if they couldn't get any one to help out they let me know. It was always one nurse and two CNAs, one for female side and other for male side. The DON said she was notified that Resident #87 had wandered into Resident #106 room and there was an altercation where Resident #106 hot Resident #87. The DON said LVN M was rounding and saw Resident #106 come out of his room saying he had to protect himself from Resident #87.The DON said LVN called the CNAs for Help and separated the residents She said Resident #106 had only been on the Memory Care unit for 2 days when the incident occurred. She said as an intervention, they placed both Resident #87 and #106 on 1:1 supervision until Resident #87 was sent to the hospital and #106 left AMA that same day. Record review of the facility's Abuse Neglect and Exploitation policy, revised dated April 2021, read in part, . 3. Ensure adequate staffing and oversight/support to prevent burnout stressful working situations and high turnover rates . Record review of the facility's Behavioral Assessment Intervention and monitoring policy dated revised dated March 2019, read in part, .11. The Director of Nursing or Designee will evaluate whether the staffing needs have changed based on acuity of the residents and their plans of care additional staff and our staff training will be provided if determined that the needs of the residents cannot be met with the current level of staff or staff training . An Immediate Jeopardy/Immediate Threat was identified on 06/19/25 at 4:50 p.m. The Administrator was notified of the Immediate Jeopardy on 06/19/25 at 5:08 p.m. The IJ template was provided to the facility on [DATE] at 5:18 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 06/19/25 at 9:29 p.m. and reflected the following: Plan to Remove Immediate Jeopardy The facility failed to adequately supervise residents to implement interventions to protect residents from injuries from resident-to-resident abuse. The facility did not implement interventions to include adequate supervision prior to the incident or following the incident for all residents at risk for injuries related to wandering behaviors. On 6/5/25, resident #87 was discharged to the behavioral hospital for evaluation. On 6/5/25, a full assessment and prompt medical attention was provided to resident #87 by the assigned LVN. On 6/5/25, resident #10 refused a full assessment by the nurse. Resident #87 and Resident #106 were immediately separated by the charge nurse and certified nursing assistants on 6/5/25. Resident #106 and resident #87 immediately had a staff member monitoring them one on one until resident #87 was discharged to the behavioral center for delusions/hallucinations, on 6/5/25. Resident #87 remains at the behavioral center at this time. On 6/19/25 the Director of Nursing, Regional Nurse Consultant, and Nursing Facility Administrator began conducting all staff in-service's for Abuse and Neglect, de-escalating resident behaviors, and monitoring residents while they wander, including residents who pace and potentially would wander into another resident's space. All staff will be in-serviced prior to the beginning of their next shift. Any new hires and/or agency staff will be in-serviced prior to their first shift on the floor, by the Director of Nurses or designee. The Director of Nursing or designee will question 3 random staff members weekly X4 weeks to ensure comprehension of the new procedures. On 6/19/25 an in-service was initiated by the Director of Nursing, Regional Nurse Consultant, and Nursing Facility Administrator to ensure staffing patterns are increased to ensure that there are two staff members present on each hall of the facility secured unit at all times. If there are two staff required to perform care on a resident, there will be another staff member called in to the secured unit to supervise while two are performing care. When one staff member steps out for any reason, another staff member will take their place in the secured unit, to ensure adequate supervision of wandering residents. Any new hires and/or agency staff will be in-serviced prior to their first shift on the floor, by the Director of Nurses or designee. The Director of Nursing or designee will question 3 random staff members weekly X4 weeks to ensure comprehension of the new procedures. On 06/19/2025 Ad-Hoc QAPI Held with Medical Director, Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant to review the alleged deficiency, policy and procedure and the plan of removal of immediacy. The Nursing Home Administrator will be responsible for ensuring the plan is completed on 06/19/2025. The RDO/Designee will provide oversight of Nursing Home Administrator and Director of Nurses, to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the facility's Plan of Removal included the following: Observation and interview on the secure unit on 06/20/25 at 2:15 p.m. indicated Resident #87 and #106 no longer resided in the facility. Observed and interview 06/20/25 at 2:15 p.m. with the RDO/Designee indicated she was in the facility rounding and providing oversight to Nursing Home Administrator and Director of Nurses, ensuring that the items on the plan of removal are reviewed and completed. Inservice sign-in sheet reviewed with 66 staff signatures indicating participation , and included staff to ensure staffing patterns are increased to ensure that there are two staff members present on each hall of the facility secured unit at all times. If there are two staff required to perform care on a resident, there will be another staff member called in to the secured unit to supervise while two are performing care. When one staff member steps out for any reason, another staff member will take their place in the secured unit, to ensure adequate supervision of wandering residents Interviews conducted on 06/20/2025 from 2:15 p.m. through 4:00 p.m. and 9:45 p.m. through 11:30 p.m. representing staff from various shifts (6a.m.-2p.m., 2p.m.-10p.m.,& 10p.m. -6a.m.) included the following staff: CNA SS, CNA PP, CNA RR, CNA WW, CNA K, CNA QQ, CNA AAA, CNA BBB, CNA CCC, CNA LLL, LVN MMM, LVN N, LVN M, LVN TT, LVN, R, LVN VV, MDS LVN JJJ, MDS LVN FFF, RN UU, ADON E, ADON/ IP, Environmental supervisor, HK BB, HK XX, DM, Maintenance Assistant ZZ, Laundry DDD, dietary aide EEE, Staffing, ST NNN, ST KKK, ABOM, Receptionist GGG, Medical Records HHH, PTA, SW. All staff were able to identify the different types of abuse, who to report any incidents of abuse de-escalating resident behaviors, and monitoring residents while they wander, including residents who pace and potentially would wander into another resident's space, what to do if they witness resident to resident abuse, what signs to watch for in residents to prevent resident to resident abuse,. Examples were given. To remove from reach of others, increase supervision of wandering by monitoring while they are wandering, and/or engaging in activity. Staff indicated they were to be aware of resident behaviors, monitor for behaviors, and how to de-escalate behaviors. Staff knew they were to separate residents immediately and ensure residents were safe. Staffing patterns were increased to ensure that there are two staff members present on each hall of the facility secured unit at all times. If there are two staff required to perform care on a resident, there will be another staff member called in to the secured unit to supervise while two are performing care. When one staff member steps out for any reason, another staff member will take their place in the secured unit, to ensure adequate supervision of wandering residents. All staff were able to identify the responsibilities for supervision and monitoring residents. Nursing staff identified that effective immediately 2 CNA were to be assigned to female hall and 2 CNAs to male hall of the Memory Care during the 10p to 6a shift due to increased amount patients with wandering. Staff interviewed said they had to be relieved before going on break/meal. All staff aware of supervising and monitoring is a preventive or proactive intervention. During an interview on 06/20/2025 at 10:05 p.m., the Administrator and DON said the corporate office approved to have 2 CNAs for each hall (male and female hall) assigned to the Memory Care unit 10:00 p.m. to 6:00 a.m., on the unit at night as a permanent change in scheduling. She said all staff had received the additional training as outlined on the POR except for a couple of staff that were out on leave and would receive the required training before returning to work. She stated next week she would start the questioning of 3 random staff members weekly X4 weeks to ensure comprehension of the new procedures and in-service information. Record review of the POR binder included: Record review of Ad-Hoc QAPI agenda sign in page dated 06/19/25 held with Medical Director, Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant to review the alleged deficiency, policy and procedure and the plan of removal of immediacy. Training records of 82 staff with completion dates ranging from 06/19/25-06/20/25 to identify the different types of abuse, who to report any incidents of abuse de-escalating resident behaviors, and monitoring residents while they wander, including residents who pace and potentially would wander into another resident's space, what to do if they witness resident to resident abuse, what signs to watch for in residents to prevent resident to resident abuse. Training records of 66 staff with completion dates ranging from 06/19/25-06/20/25 for staffing patterns being increased to ensure that there are two staff members present on each hall of the facility secured unit at all times. If there are two staff required to perform care on a resident, there will be another staff member called in to the secured unit to supervise while two are performing care. Responsibilities for supervision and monitoring residents. When one staff member steps out for any reason, another staff member will take their place in the secured unit, to ensure adequate supervision of wandering residents. An Immediate Jeopardy (IJ) was identified on 06/19/25 at 4:50 p.m. The IJ template was provided to the facility on [DATE] at 5:18 p.m. While the IJ was removed on 06/20/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interview and record review the facility failed promptly notify the ordering physician or nurse practitioner of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 of 10 residents (Resident #1) reviewed for laboratory services. The facility did not immediately report to Resident #1's physician when a STAT lab was ordered in response to a reported change in condition noted by a family member and facility nursing staff and lab results showed high Na (sodium). The critical high out-of-range laboratory results were not reported to the physician or NP for more than 8 hours after they were resulted causing a delay in treatment. Resident #1 was transferred to the hospital on 11/29/22 at 1:50 a.m., 9 hours after the labs were received and he was diagnosed with dehydration (loss of body fluid caused by illness, sweating, or inadequate intake), hyperosmolality (a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's other organs, including the brain), and hypernatremia (having too much sodium in the blood). This failure could place residents at risk of delayed treatment/intervention and decline in health. Record review of a face sheet dated 12/08/22 indicated Resident #1 was an [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), severe protein-calorie malnutrition (not consuming enough protein and calories), dysphagia (difficulty swallowing), and Alzheimer's (brain disorder that slowly destroys memory and thinking skills). Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 00 (severe cognitive impairment) and was able to eat with supervision. Record review of care plan dated 07/27/22 indicated Resident #1's diet as regular/dysphagia/purred/thin liquids. Goals included consume >75% of meals and adequate fluid intake to help prevent dehydration. Interventions included monitor and record food intake at each meal and notify MD if there was a change in baseline level of orientation/alertness. Record review of physician order dated 09/24/20 indicated Resident #1's diet as regular diet, pureed texture, and regular consistency. There were no orders for monitoring input or output. Record review of physician order dated 08/06/21 indicated Resident #1 was to receive 2Cal 90 ml by mouth three times a day for supplement. Review of a progress noted dated 11/28/22 at 9:24 a.m., completed by LVN F, indicated Resident #1 was alert with arousal, he ate 0% of his breakfast and was unable to swallow foods, liquids, or crushed medications. The speech therapist and MD A were notified. Record review of physician orders dated 11/28/22 indicated MD A ordered STAT CBC, CMP, lipid, and A1C for Resident #1. Record review of Resident #1's lab results dated 11/28/22 indicated the lab specimen was collected on 11/28/22 at 11:39 a.m. and reported to the facility on [DATE] at 4:48 p.m. The results indicated Na (sodium) was high! at 182 (verified by repeat analysis) with reference range 135-146 mmol/L. Record review of hospital records dated 11/29/22 indicated Resident #1 had elevated Na levels which led to dehydration. Resident #1 was in ICU and not observed during the investigation. Record review of a MAR dated 11/22 indicated Resident #1 received 2Cal as ordered. Resident #1 did not receive a supplement on 11/28/22 at 9:00 a.m. He received a supplement at 1:00 p.m. and 5:00 p.m. Record review of meal intake documentation dated 11-2022 indicated Resident #1's intake as the following: *11/25/22: three meals- 76%-100%, *11/26/22: two meals- 76%-100%, one meal- 51%-75%, *11/27/22: one meals- 76%-100%, two meals- 51%-75%, and *11/28/22: one meal- 26%-50%, two meals- 0%-25%, Record review of progress note dated 11/27/22 at 4:00 p.m., completed by LVN E, indicated Resident #1 was not easily aroused. His BP was 140/82, pulse was 93, temperature was 98.4 F, O2 SAT on room air was 98%, RR was 20, and blood glucose was 178. Redness was noted to his right eye. Resident was stable and in bed. On call for MD A (NP B) was notified and new orders for head CT without contrast and warm compress to right eye. Record review of progress note dated 11/28/22 at 2:29 a.m., completed by LVN K, indicated Resident #1 as awake and alert and responded to touch and verbal stimuli. Would continue to monitor and report any changes. Review of progress note/SBAR dated 11/28/22 at 9:29 a.m., completed by LVN F indicated Resident #1 was unresponsive, seemed different, talked less, and was tired. His BP was 149/80, pulse was 103, RR was 18, temp was 98.2. He had altered level of consciousness and increased confusion and required more assistance with ADLS, had general weakness, and swallowing difficulty. His resting pulse was greater than 100. He was difficult to arouse. Primary care recommended CT scan of head without contrast, CBC, CMP, A1C and lipid. Record review of progress note dated 11/28/22 at 5:24 p.m., completed by LVN D, indicated she was not able to schedule the CT scan and a hospital automated message indicated to between hours of 8:00 a.m. and 5:00 p.m. She tried to feed Resident #1 and he was not able to swallow. Resident #1 drank 8 oz of 2Cal. Record review of laboratory results dated [DATE] indicated Resident #2's critical results were called in to the facility Receptionist at 4:47 p.m. and the verbal results of Na (sodium) and verified /read back. During an interview on 12/08/22 at 9:32 a.m., LVN E said Resident #1 was not talking and calling staff to his room on 11/27/22 like he usually did. She said she took his vitals and they were within normal limits. She said his family member mentioned he appeared sleepy. She said she told Resident #1's family member she would call the on-call doctor. She said Resident #1 ate and drank a little bit and drank all of the supplement when she held the cup. She said she advised NP B of Resident #1's vitals and NP B ordered a CT and a warm compress for his eye. She said Resident #1 was provided ice water between meals and a glass of water was included on all meal trays. During an interview on 12/08/22 at 9:54 a.m., LVN F indicated Resident #1 was not eating or drinking on 11/28/22. She said the labs were called in as STAT labs. She said the CT scan was not scheduled because she could not get through and she passed on the information for the next nurse to try to schedule. She said Resident #1 was provided ice water between meals and a glass of water was included on all meal trays. During an interview on 12/08/22 at 9:58 a.m., LVN G said LVN F told her of Resident #1's change of condition and the results were sent to MD A. She said Resident #1 had some sores in his mouth and there was some medication to apply. She said she completed her rounds and other residents' breathing treatments and looked over Resident #1's labs. She said she was not satisfied the previous nurse (LVN D) sent the results to MD A via fax. She said the labs were critical and she called the doctor on call (NP B). She said NP B said to send Resident #1 to the hospital for evaluation and treatment. She said Resident #1 was provided ice water between meals and a glass of water was included on all meal trays. Record review of progress note dated 11/29/22 at 1:54 a.m., completed by LVN G indicated Resident #1 was transferred to the hospital at 1:50 a.m. related to critical labs. During an interview on 12/08/22 at 2:04 p.m., Laboratory Director C said Resident #1's critical labs were repeated to ensure accuracy. She said the critical lab was called in to the facility through the phone and then faxed over to the facility. She said the facility was to notify the physician. Record review of the facility fax records indicated there was no fax cover sheet available for review. During an interview on 12/08/22 at 2:41 p.m., LVN D said Resident #1's labs were faxed to MD A on 11/28/22. She said she did not recall what time she faxed the results. She said she was waiting for a response. She said she called the hospital to arrange the CT scan and there was a message to call between 8:00 a.m. and 5:00 p.m. She said she observed Resident #1 was not eating. She said she gave him 4 oz. of 2Cal and he started talking. She said she wanted to observed Resident #1 eating but he would not swallow. She said she gave Resident #1 an additional 8 oz. of 2Cal and he drank all of the 8 oz. She said she cleaned his mouth. She said Resident #1 was provided ice water between meals and a glass of water was included on all meal trays. She said she could not recall if she called MD A or NP B regarding Resident #1's critical labs. She said the results came in on nurse station #2's fax machine and she faxed the results over to MD A/NP B. During an interview on 12/08/22 at 3:07 p.m., MD A said NP B admitted Resident #1 to the hospital on 11/29/22. He said the lab results were faxed to the office after hours on 11/28/22. He said he saw the lab results the next day. He said although facility staff should have notified him or NP A immediately of the critical labs, the 5 or 6 hours of delay for Resident #1's critical lab results being communicated to NP B would not change Resident #1's diagnoses. He said Resident #1 had stopped eating and drinking and had adult failure to thrive. He said he talked to the family about hospice and they were not interested. He said Resident #1's condition was unavoidable and would occur again. The surveyor sent a text message to NP B on 12/09/22 at 9:22 a.m. to call the surveyor. NP B did not respond to the text message prior to the survey exit . During an interview on 12/09/22 at 1:43 p.m., ST L said she screened Resident #1 on 11/28/22 and noted his tongue was swollen and told the nurse (she could not recall the name of the nurse) it looked like thrush. She said the nurse and aide were feeding Resident #1. She said he had delayed onset of swallow and reflex. She said he was able to tolerate puree diet with modifications. She said Resident #1 was on regular liquids. Record review of a swallowing screening dated 11/28/22, completed by ST L, indicated Resident #1 was a laborious swallower with delayed onset/slow reflex, and aspiration risk. During an interview on 12/09/22 at 3:55 p.m., the DON said critical labs should be called in to the doctor or the NP immediately. She said physician notification was monitored during review of incident and transfer documentation. She said staff should follow the INTERACT Care Path. She said all nursing staff were trained to notify the physician or NP of critical labs. She said Resident #1 was provided ice water between meals and a glass of water was included on all meal trays. Record review of the facility policy Lab, Radiology and other Diagnostic Testing Services Standards of Practice dated 03/13/22 indicated The facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents in accordance with State and Federal guidelines. It is the practice of this facility to timely notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of lab, radiology and other diagnostic testing findings. Standard of Practice Explanation and Compliance Guidelines: .2. Facility must promptly notify the attending physician or physician extender of lab, radiology and other diagnostic results. 3. Qualified nursing personnel will receive and review the diagnostic test reports and communicate the results to the ordering physician per physician orders. Physician orders should contain parameters for notification and the absence of specific parameters. The nurse will refer to the INTERACT Change of Condition file cards for notification time frames. If the report results fall outside of the clinical reference ranges and require immediate attention, the physician will be notified upon receipt. Record review of the form dated 2011 INTERACT Change of Condition: When to report to the MD/NP/PA . Report Immediately .Sodium (Na) <125, >155 mg/dl .

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility did not prevent Resident #1 who had a history of elopement prior to admission from leaving the facility unsupervised. Resident #1 was founf one road over from facility in a neighborhood area. The facility was not aware the resident was missing until time for medications. An Immediate Jeopardy (IJ) situation was determined to have existed on 8/8/22 to 8/9/22. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of accidents, injury, or death. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia and diabetes. Upon admission the resident was noted to have bruising to the left elbow and old scabs to right hand. Record review of Resident #1's admission BIMS screening form dated 7/27/22 revealed a BIMS score of 5 out of 15, which indicated his cognition was severely impaired. The admission MDS was noted to be in process and was incomplete. Record review of Resident #1's care plan, initiated on admission 7/29/22, indicated Resident #1 was a high risk for elopement. He was to be admitted to the secure unit. Interventions included to assist and monitor the resident for off unit activities if able. Record review of Resident #1's progress notes dated 7/26/22 - 8/16/22, revealed an Elopement Evaluation completed on admission, 7/26/22. Resident #1 had a history of elopement while at home. Resident #1 ambulated independently. Record review of Resident #1's progress notes, dated 8/8/22 at 6:45 p.m. by LVN A, stated Resident unable to be located at this time. Code Orange initiated. Code Orange was the facility emergency code used to describe a missing resident. It is announced over loudspeaker and alerts staff of situation. An entry entered at 10:40 p.m. indicated Resident #1 returned to facility accompanied by facility social worker and went to his room. Record review of Missing Resident Checklist included initial actions for staff which included activate facility's emergency operation plan; search the facility grounds for resident including closets, storage rooms, under beds and behind furniture. If not found after expedient search, notify law enforcement. Notify responsible party, etc. (etcetera indicates there is additional steps necessary to take) Interview on 8/17/22 at 9:00 a.m., the DON said Resident #1 resided on the secure unit. She said the residents from the secure unit were escorted to the main dining area for meals. The residents were assigned to one area in the dining room along with the general population. All staff were responsible for passing meal trays and supervising and/or assisting residents with meals. She said on 8/8/22 during the evening meal (served usually 5-6 p.m.), there were 2 LVNs and 3 CNAs present in the main dining area. She said Resident #1 had been served his meal. At end of the meal, Resident #1 apparently exited the main dining room through a side exit door, entered the courtyard and proceeded through an open gate and was located about a block from the facility by police. There were no busy streets nearby. During meal service in main dining area, 2 LVNs and 3 CNAs are designated to supervise residents, pass trays, and assist with eating. Resident #1 had not attempted to elope from facility since admission. Upon return, Resident #1 had a small abrasion noted to right elbow. Observation and interview on 8/17/22 at 11:30 a.m., revealed Resident #1 on the secure unit watching TV in the activity area. Resident #1 smiled when greeted but could not recall the incident of elopement from the facility. Interview on 8/17/22 at 11:45 a.m., LVN A said she was coming on duty at the time of Resident #1's elopement on 8/8/22. She said he was due for medications and CMA was unable to locate him on the secure unit. She informed LVN A whom then initiated Code Orange (elopement). She said all staff immediately began to search for Resident #1 throughout the interior of the facility as well as outside the property. She notified local authorities within 10-15 minutes of missing resident. She said she spoke to an officer who said they had located a male fitting Resident #1's description near the facility, and he was being transported to the local emergency room for evaluation since he could not tell them where he lived. During an observation on 8/17/22 at 12:15 p.m., the residents residing on the secure unit were not being escorted to main dining room for meals. The noon meal was taken in the dining areas prepared for the secure unit residents. Interview on 8/18/22 at 8:00 a.m., the Administrator said the exit doors and outside gates were not locked. The administrator said she believed Resident #1 walked through the exit gate and into the large parking lot at side of building and kept walking to next block. The Administrator said the facility had accepted bids to upgrade gates at exits and to equip with keypads and to integrate into fire alarm system to prevent elopements. She added staff had been in-serviced on elopement, resident rights, Code Orange procedures, and high risk residents. Phone interview on 8/18/22 at 3:25 p.m., the LMSW said she had been notified by the facility of Resident #1's elopement on the evening of 8/8/22. She was informed he was at the local emergency room for evaluation. She said she arrived at the emergency room to assess the situation. She said she stayed with the resident for approximately an hour. He was dressed in a short-sleeved shirt and jeans and seemed happy and cheerful and had no complaints of pain or injury. She said Resident #1 had told her he was going to store to buy groceries for his wife. She said he was discharged back to the facility, and she transported him in the facility van. He was returned to the secure unit where he was assessed by nursing staff and left in their care. Phone interview on 8/18/22 at 3:45 p.m., CNA B said she had been on duty on 8/8/22 at the time of Resident#1's elopement. She was on the secure unit when she discovered Resident #1 was unaccounted for by the CMA. She said all residents returned from the main dining area except for Resident #1. She added a search of the facility was immediately initiated. All staff on each hall searched their halls, she heard another staff member used their personal vehicle to search the nearby area for the resident. She said Resident #1 was returned to facility around the end of her shift. She said Resident #1 was located approximately 20-25 minutes after facility alerted by Code Orange. She said the staff were re-trained on missing resident protocols, elopement, and abuse/neglect. She said they had Code Orange drills every 3-4 months. The administrator was notified a past non-compliance situation had been identified due to the above failures. It was determined these failures placed residents in an IJ situation on 8/8/22 to 8/9/22. The facility implemented the following interventions: -assessment of Resident #1. - completion of in-services regarding elopement investigation. - identified all residents at risk for wandering/exit seeking. - complete chart audit implemented to assure risk assessments completed on all new admissions and quarterly. - Staff re-educated as to interventions to keep residents safe, abuse/neglect, resident rights and elopement. These interventions were completed based on 5 staff (Administrator, DON, 1 LVN, 1 CNA, and social worker) interviews to ensure these interventions had been completed. Staff were able to appropriately define neglect, identify the abuse coordinator, and said they would immediately notify the administrator or DON of any neglect allegations or elopements.

Based on interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and failed to ensure each resident received adequate supervision and assistance to prevent accidents for 2 of 8 residents (Resident #1 and CR #2) reviewed for accidents and supervision. The facility failed to ensure Resident#1 and CR#2 who had a history of physical altercations with each other, were supervised and remained separated to prevent an altercation between them in less than 24 hours where CR #2 entered the smoking area and slapped Resident #1 in the face. These failures could place residents at risk of physical harm, injury, or emotional distress. Findings included: Resident #1 Record review of Resident #1's facesheet revealed [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included [CONDITION(S)] (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated her cognition was intact . Further review of the MDS indicated she had no behavioral or mood concerns and she ambulated with a walker. Record review of Resident #1's undated care plan revealed she had a potential to demonstrate verbally abusive behaviors by evidence of negative verbalization to other residents. The interventions included were to analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document . Assess and anticipate the resident's needs such as: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Assess resident understanding of the situation and allow time for the residents to express self and feelings towards situation. Evaluate for side effects of medications. Give the resident as many choices as possible about care and activities. Notify the charge nurse of any abusive behaviors. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: intervene before escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, ensure all resident involved are safe and staff to walk calmly away, and approach later. Record review of Resident #1's progress notes dated 9/23/21 at 5:27PM written by LVN A revealed, Nurse was notified by activities director that the resident in room 135A (CR #2) kicked resident very lightly on her left leg. Activity Director immediately separated and redirected both residents and brought Resident #1 to the nurse. Nurse immediately assessed resident head to toe, no injuries noted upon assessment. Resident informed nurse that, He kicked me in my left leg, resident denies pain, you can ask other people that were outside, he kicked me on my leg. Nurse assessed resident head to toe, no injuries noted upon assessment, no bruising, swelling or injuries noted on resident left leg. Vital signs obtained, both residents redirected away from each other, and on Q-15 mins (every 15 minutes) behavior monitoring. Resident denies pain at this time. RP, NP, psych NP, and DON notified. Will continue to monitor resident. Record review of Resident #1's progress notes dated 9/23/21 at 6:00PM written by the previous DON revealed, DON assessed resident who is alert and awake sitting up in chair in room, no sign of distress/discomfort notes, no complain of pain at this time. DON asked resident about the incident, resident said the male resident room 135A (CR #2) kicked her on her left leg while out in the courtyard during the smoke break. Resident denies pain to left leg and also denies hitting or kicking the other resident. DON asked resident she was cursing out at the other resident and resident replied, we both exchanged words back and forth. Resident educated to always report to nurse/staff if the other resident takes her soda or stuff, so the staff members can intervein. Upon assessment no injuries noted on resident, no bruising or swelling, noted to left leg, Q-15 minutes behavior monitoring initiated on resident. MD, NP with psych and RP notified, will continue to monitor. Record review of Resident #1's progress notes dated 9/25/21 at 10:00AM revealed, Called to outside door to smoking area by residents stating that this resident was fighting with another resident. When I approached the smoking area, noted resident seated on rollator, continues with verbal insults to other resident who is seated in wheelchair across yard with other residents in area between the two. Resident states that __ slapped me, redirected and removed from area. Assessed for injuries, noted slight swelling to right cheek and outer right eyebrow area. Record review of Resident #1's progress notes dated 9/27/21 at 4:00AM revealed, Resident monitored closely this shift related to continuation of argument with another resident who has been moved to another hall. Slept all night with no noted behaviors. Record review of Resident #1's progress notes dated 9/27/21 at 2:31PM revealed, Resident noted with no behaviors on day shift. Resident walked around facility with walker freely and participated in activity services. Psych NP came to visit with resident due to the 2 recent incidents that occurred. Psych NP reported to this nurse that resident is very assertive and makes false statements to put the blame on other people and does not take responsibility for her actions. No medications changes received at this time will continue to monitor. Record review of Resident #1's progress notes dated 4/29/22 at 7:19PM by LVN B revealed, Notified by other charge nurse that another resident (CR #2) hit Resident #1 while sitting outside in smoking area. After investigating the incident. The resident and other resident was arguing and began exchanging licks to one another. No injuries noted at this time. Vital signs: 156/65, 108, 20, 96.8. Record review of Resident #1's progress notes dated 4/30/22 at 6:32PM by LVN A revealed, This nurse was alerted by CNA that the resident had been slapped by another resident. As I walked outside to bring my resident inside, I could hear the two residents were upset and engaged in a heated exchange. I brought the resident back to her room to do an initial skin assessment. No signs/symptoms of bruising or open areas. No complaints of pain. RP notified. Awaiting call back. DON notified. Will continue to monitor. Record review of Resident #1's progress notes dated 4/30/22 at 8:13PM revealed, Resident family member returned call and after the situation was explained decided they wanted police involved. Police arrived and interviewed the resident. Resident did decide to press charges . The residents are separated, DON notified. Social worker notified. Will continue to monitor and keep residents separated at all times. CR #2 Record review of CR #2's facesheet revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged to other nursing home on 5/4/22. His diagnoses included major depressive disorder, [CONDITION(S)] (A disorder that affects a person's ability to think, feel, and behave clearly), lack of coordination, and dementia. Record review of CR #2's annual MDS dated [DATE] revealed a BIMS score of 5 out of 15 which indicated his cognition was severely impaired. Further review of the MDS revealed he had no issues with his mood or behavior, and he ambulated with a wheelchair. Record review of CR #2's care plan initiated on 9/28/21 revealed he had potential to demonstrate physical behaviors related to diagnoses [CONDITION(S)] and dementia and secondary poor impulse control by kicking other residents, hitting other residents, and slapping other resident. His interventions included, 4/30/22 1:1 monitoring continued, 9/23/21 q15 monitoring 1:1 , labs drawn, transferred to unit 2, hospital evaluation, 9/25/21 q15 monitoring 1:1 continuing, Analyze key times, places, circumstance, triggers, and what de-escalated behavior and document, provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Evaluate for side effects of medications, if the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately, Medication review requested with pharmacy, CBC, CMP, UA ordered (3/11/22), Monitor/document/report to MD of danger to self and others. Notify the charge nurse of any physical behaviors, psychiatric consult as needed, send to hospital for evaluation for hitting/slapping another resident. Record review of CR #2's progress notes dated 9/23/21 at 5:27PM by LVN A revealed, Nurse was informed by the Activity Director that during the smoke break CR#2 kicked the resident in room 106B (Resident #1) in her leg. Activity Director immediately intervened moving both residents away from each other. Nurse asked resident what happened and resident informed nurse that, They said I kicked her, but I don't remember kicking her and I didn't kick her, and I won't do it again Nurse assessed resident head to toe, no injuries noted upon assessment. Resident immediately placed on q15 minute behavior monitoring for 72 hours, resident denies pain at this time, resident denies kicking other resident on the leg. RP, NP, psych NP and DON notified. Will continue to monitor resident. Record review of CR #2's progress notes dated 9/23/21 at 6:15PM by previous DON revealed, DON assessed resident who is alert and awake sitting in wheelchair in the courtyard, no sign of distress/discomfort noted, no complain of pain at this time. DON asked resident about the incident he was seen kicking another resident on the leg in the courtyard during the smoke break. Resident denies kicking the other resident on the leg. DON informed resident that staff member and other residents saw resident kicking another resident on the leg, resident then replied, If I did, I promise I won't do it again, but she was cursing out to me while in the courtyard, I wont kick her again, I promise. Resident educated to always report to nurse/staff if the other resident is cursing out at him, so staff members can intervein and put a stop to it. Resident replied, ok I'll do that, thank you. Upon assessment no injuries noted on resident. Q-15-minute behavior monitoring initiated on resident. MD, NP with psych and RP notified, will continue to monitor resident. Record review of CR #2's progress notes dated 9/25/21 at 9:50AM revealed, Called to outside area by resident stating that this resident was involved in an altercation with another resident. Resident observed outside in the smoke area, involved at this time in a verbal aggressive altercation with another resident (Resident #1). He was seated in wheelchair, other residents between them. No physical activity noted. However, the other resident accused the resident of slapping her. Removed resident from area, reported to supervisor. One on one behavior monitoring initiated. 10:40AM notified doctor of incident, received orders to send to ER for evaluation. 11:00AM notified guardian of incident and discharge to hospital ER for evaluation. Record review of CR #2's progress notes dated 4/29/22 at 7:55PM written by LVN C revealed, At 7:05PM, this nurse was notified by CMA that resident had hit another resident, she stated nurse from another unit told her and she then relayed message to this nurse and pointed that resident back on unit and pointed towards door at resident sitting in wheelchair on sidewalk outside unit 2 door. This went to resident and asked about the incident and he did answer initial question, I asked if he hit another resident and he replied yes and I asked why, he replied because (Resident #1) cussed at him. I told resident he cannot hit anyone for cussing him and that he should have removed himself from that situation if he did not like her cussing at him and the return to his unit. Resident responded yes ma'am; I understand. Resident then made aware he is not to go outside to the common area between unit 2 and unit 1. He said yes ma'am. This nurse notified unit manager, who notified DON and Administrator. Resident returned to room. Vitals obtained 98.0, 120/50, 52, 18, 98% and started behavior monitoring every 15 minutes. Skin assessed and no obvious injuries and resident denies any pain at this time. Resident has laid down to go to sleep. Witness reports taken from 2 resident witnesses and from resident that was fighting (Resident #1). Doctor notified. Called guardian and notified her of the incident. Pending CBC, CMP, UA with C&S due to behavior. Record review of CR #2's progress notes dated 4/30/22 at 4:00PM by LVN E revealed, Resident was outside witness by CNA D that resident was the aggressor and pulled on and slapped another resident. CNA reported it to Weekend RN and LVN A on unit 1. Weekend RN notified myself (LVN E) of incident and resident was assessed and placed with LVN (LVN E) while LVN did rounds and also with CNA at nurses station to be watched. Record review of CR #2's progress notes dated 4/30/22 at 4:00PM by LVN E revealed, On 4/20/22 CR #2 was the aggressor nursing outside activity. CR #2 attacked another resident by pulling her leg and slapped the resident. CR #2 was seen by a CNA (CNA D). CNA D reported it to Weekend RN and LVN A on unit 1. The Weekend RN came and notified me (LVN E) on the incident. CR #2 was assessed and evaluated for any bruising or wounds. CR #2's vitals were withing normal limits BP: 140/66 HR: 70 O2: 96. Record review of CR #2's progress notes dated 4/30/22 at 4:28PM by the DON revealed CR #2 was sent to the hospital for aggressive behavior. Record review of CR #2's progress notes dated 5/1/22 at 8:10AM by LVN B revealed CR #2 returned from the hospital with no report or new orders. CR #2 was placed on one-on-one staff monitoring. Record review of CR #2's progress notes dated 5/1/22 - 5/4/22 revealed he remained on one-on-one staff monitoring. Record review of CR #2's progress note dated 5/4/22 at 6:30PM revealed CR #2 was discharged to another facility. Record review of CR #2's every 15-minute behavior monitoring sheet started on 4/29/22 revealed the resident was being observed every 15 minutes from 4/29/22 - 5/4/22. Further review of sheet revealed every 15-minute time slots for nurse to put code of resident's behavior. Interview and observation on 6/1/22 at 12:30PM, Resident #1 was sitting in the smoking area outside between unit 1 and 2 talking with two other residents. No staff was present outside with residents. Resident #1 said she was sitting outside to get warm while she waited on lunch. Resident #1 said she had a lot of problems with CR #2 at the facility and said he was no longer at the facility which she was happy about. Resident #1 said her, and CR #2 would always argue so they would stay away from each other. Resident #1 said they would always argue because, he was a mean old fart. Resident #1 could not recall how many times her and CR #2 had altercations, but she said it was a couple times. Resident #1 said their last altercation happened where she was sitting in the smoke area and said CR #2 came outside to the area and called her a [OBSCENITY] which made her angry and told him his mother was a [OBSCENITY] . Resident #1 said CR #2 was angered by what she said and grabbed her and slapped her in the face. Resident #1 said CR #2 had slapped her in the face before but could not say specifically when. Resident #1 said CR #2 was supposed to smoke in another area , but he would still try and come to the area between unit 1 and 2 to smoke. Resident #1 said CR #2 was always the one who took things to another level by physically hitting her first. Interview on 6/2/22 at 2:23PM, LVN B said on 4/29/22 another nurse came told her Resident #1 and CR #2 were fighting outside. LVN B said Resident #1 was already back inside when she was informed, and Resident #1 said CR #2 hit her. LVN B said she did not witness the incident but there were other residents who were outside who told them what happened and confirmed CR #2 hit Resident #1 on the leg, and she hit him back. Interview on 6/2/22 at 2:25PM, LVN A said Resident #1 and CR #2 were always going at it and had a history of altercations. LVN A said after Resident #1 and CR #2 first set of altercations CR #2 was moved to a different unit and they used different smoking areas, but CR #2 would forget and still go sit outside in the smoking area between unit 1 and 2. LVN A said on 4/30/22 she did not witness the altercation between Resident #1 and CR #2 but was told by a CNA Resident #1 had been slapped by CR #2. She went outside and the 2 residents were arguing back and forth and said Resident #1 was upset saying CR #2 slapped her. She brought Resident #1 inside and assessed her with no injuries noted. LVN A said Resident #1's family were informed, and they wanted the police called so they did call the police and they came to the facility and took statements. LVN A said they kept the residents separated until CR #2 was discharged from the facility. LVN A did not know how CR #2 got to the smoking area between unit 1 and unit 2 and said she was not assigned to CR #2. Interview on 6/2/22 at 3:31PM, CNA D said she was clocking in on 4/30/22 around 2:30PM when she looked out and saw CR #2 pull Resident #1's legs and pulled her towards him. CR #2 then slapped Resident #1 in the face. CNA D said she immediately went outside and redirected CR #2 and told them she was going to get the nurse. CNA D said she told LVN D about observing CR #2 slapping Resident #1 and LVN D went outside to the residents. Interview on 6/2/22 at 4:00PM, LVN C said she was working on 4/29/22 when a CMA informed her around 7:30PM - 8:00PM that Resident #1 and CR #2 were fighting. LVN C said she did not witness the incident but other residents in the smoking area reported Resident #1 and CR #2 were hitting each other on the legs. LVN C said when she was informed of incident CR #2 was already back on unit 2 and CR #2 reported he hit Resident #1 because she was cursing at him. LVN C said she redirected CR #2 to not hit other residents and CR #2 was placed on every 15-minute monitoring. LVN C said she informed CR #2 not go to the smoking area between unit 1 and 2 and staff would bring him to the other smoking area. LVN C said staff were aware to take CR #2 to the other smoking area between unit 2 and 3 and to keep him away from smoking area between unit 1 and 2 to keep him and Resident #1 separated. LVN C said she had no issues with monitoring CR #2 every 15 minutes on 4/29/22. Interview on 6/2/22 at 4:45PM, LVN F said she worked on unit 2 on 4/29/22 but was not assigned to CR #2. LVN F said there was every 15-minute monitoring sheet in process for CR #2 for an altercation he had with Resident #1 on 4/29/22 and everyone on the unit assisted with keeping an eye on CR #2. LVN F said they kept CR #2 and Resident #1 separated and took him to the smoking area away from Resident #1 when he wanted to smoke. LVN F said CR #2 would try to go to the smoking area between unit 1 and 2 and staff would have to remind him he could not go out there because he would forget. LVN F said CR #2 would mostly sit and watch TV in front the nurse's station, so they were able to easily monitor him. Interview on 6/2/22 at 4:50PM, the Activity Director said during the week she would usually take the residents out on their smoke breaks. The Activity Director said Resident #1 and CR #2 had a history of always getting into it so they tried to keep them separated. The Activity Director said CR #2 smoked in a separate smoking area between unit 2 and 3 so he could be away from Resident #1. The Activity Director said the residents did go outside on their own in the smoking area to just sit outside but said they were always supervised during smoking times. Interview on 6/2/22 at 5:09PM, LVN E said she worked on 4/30/22 from 2pm - 10pm. LVN E said when she came in for her shift she was informed by a nurse (could not recall which nurse) that CR #2 was on every 15-minute monitoring because he was acting up the day before. LVN E said she was not told CR #2 was in a physical altercation with Resident #1 or that they should be kept separate. LVN E said she was told if CR #2 needed to smoke he should go to the smoking area between unit 2 and 3. LVN E said she was not told CR #2 could not go outside into the smoking area between unit 1 and 2. LVN E said she was CR #2's assigned nurse when the altercation happened on 4/30/22 between CR #2 and Resident #1. LVN E said all the staff on unit 2 were assisting with watching CR #2 and checking him every 15 minutes. LVN E said at the time CR #2 got out to the smoking area she had left the nurses station and was doing medication pass and said the CNA were busy moving around gathering their things because shift change had just happened. LVN E said around 2:30PM the Weekend RN came told her CR #2 had gotten outside and slapped Resident #1. She then found out about them (Resident #1 and CR #2) having a previous altercation the day before and was then told to keep them away from each other. LVN E said CR #2 was put on one-on-one monitoring with a CNA after the altercation on 4/30/22. LVN E said staff were checking CR #2 every 15 minutes before the altercation on 4/30/22 and he was able to have the unwitnessed altercation within the 15-minute checks because CR #2 was very quick. LVN E was not sure who else was on the unit to watch CR #2 when he was able to get outside and assault Resident #1. Record review of the facility's unit 2 staffing sheet dated 4/30/22 for unit 2 revealed 2 nurses (LVN E and LVN G), 1 CMA (CMA H), and 4 CNA's (CNA I, CNA J, CNA K, and CNA L) were assigned to work 2pm - 10 pm. Record review of the facility time sheets dated 4/30/22 revealed the following clock in times for staff: CNA D clocked in at 2:36PM, LVN E clocked in at 2:00PM, LVN G clocked in at 1:00PM, CMA H clocked in at 6:32AM, CNA I clocked in at 2:03PM, CNA J clocked in at 2:01PM, CNA K clocked in at 2:03PM, and CNA L clocked in at 2:45PM. Interview on 6/2/22 at 5:21PM, CMA I said on 4/29/22 Resident #1 told her CR #2 had hit her. CMA I said she reported what Resident #1 told her to the nurse, but she did not witness the altercation. CMA I said Resident #1 and CR#2 had a history of getting into it and everyone tried to watch him to keep them separated but said CR #2 was very quick and always tried going to the smoking area between unit 1 and 2 and they would have to redirect him to keep him away from Resident #1. CMA I said she did not witness the incident on 4/30/22 but she was assisting with monitoring him every 15 minutes. CMA I said the staff were able to monitor him every 15 minutes, but he was quick and able to get outside within the 15-minute checks when everyone was busy. An attempted telephone on 6/3/22 at 10:50AM with CNA I who worked unit 2 from 2pm - 10pm on 4/30/22 was unsuccessful. In a telephone interview on 6/3/22 at 11:09AM, CNA L said she worked 4/30/22 from 2pm - 10pm on unit 2 but said the altercation between CR #2 and Resident #1 had already happened when she arrived to work and said when she made it to the floor to work CR#2 was already on one-on-one supervision. In a telephone interview on 6/3/22 at 11:30AM, CNA K said when she got into work at 2pm on 4/30/22 and she was told CR #2 slapped Resident #1 for the second time CR #2 was already on one-on-one supervision when she started working. CNA K said she did not think she was present at work when the altercation happened on 4/30/22 between CR #2 and Resident #1. In a telephone interview on 6/3/22 at 2:01PM, LVN G said she worked on 4/30/22 from 6am - 10pm on unit 2. LVN G said she was not the assigned nurse to CR #2 but was told some time in the middle of her shift by the Weekend RN that CR #2 needed to be taken to the smoking area between unit 2 and 3 to smoke but was not told why. LVN G said she was not sure if it was before or after his incident on 4/30/22 she was told about where CR #2 needed to smoke. LVN G said she found out about Resident #1 and CR #2 having an altercation because the cops showed up on 4/30/22 but she did not know about the altercation prior to that. In an attempted telephone interview with CNA J on 6/3/22 at 10:56AM was unsuccessful. In attempted telephone interviews with CNA J on 6/3/22 at 2:23PM, was unsuccessful. Interview on 6/3/22 at 3:15PM, the DON said she just started working at the facility in March of 2022 and did not know of Resident #1 and CR #2's history of physical altercations. The DON said she learned of Resident #1 and CR #2's history after their altercation on 4/30/22. The DON said she could not recall who but said a nurse called her on 4/29/22 to report Resident #1 and CR #2 had gotten into a physical altercation and at the time they only knew that CR #2 had hit Resident #1. The DON said she called the Administrator and decided to initiate the q 15-minute monitoring for CR #2 since he was the aggressor. The DON said she made her expectations known to the staff which was to make sure CR #2 was within his unit and supervised, CR #2 was to smoke in a separate smoking area to keep Resident #1 and CR #2 apart. The DON said she communicated what she wanted done to the nurse on unit 2 on 4/29/22 but could not recall the name of the nurse she spoke to. The DON said she got another phone call the following day on 4/30/22 that CR #2 and Resident #1 had another altercation. The DON said she questioned staff who worked on 4/30/22 how CR #2 was able to make unsupervised contact with Resident #1 and the staff reported he was quick and slipped right by them. The DON said she contacted the physician to have an order to send CR #2 to the hospital to have him evaluated but he came right back to the facility within a few hours. The DON said after the second altercation on 4/30/22 CR #2 was on one-on-one supervision until he was discharged to another facility. The DON said she was not aware her directives to keep CR #2 and Resident #1 separated was not communicated to all staff including LVN E. The DON said the nurses should be communicating at shift change giving verbal report and documenting on the 24-hour report. The DON said if she knew about the history between CR #2 and Resident #1, she could have gotten him out a little sooner. The DON said she felt the staff were keeping up with the q 15-minute checks on CR #2 and said she learned a lot can happen within 14 minutes. Record review of the facility's Behavior Health Care Management policy (review date 10/2021) revealed in part, .Staff will observe for and monitor target behaviors, such as pacing, wandering in other resident room, disrobing, inappropriate response to verbal communications, displays of violent/aggressive behaviors towards staff and/or other residents, or other symptoms identified on the care plan as part of the behavior . 5. Review of the care plan to determine resident specific protocol and clarify any deviations from or revisions, based on the goals, needs and strengths specific to the resident. Identify the type of assistance required. 6. Review of interventions other than medication to address behavior .

Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 12 residents reviewed for accidents. (Resident #1) CNA B failed to prevent Resident #1 from falling off the bed during incontinent care resulting in a [CONDITION(S)]. This failure could place residents at risk for falls and not receiving proper treatment resulting in injury, pain, and hospitalization . Findings included: Record review of physician orders dated 09/15/21 indicated Resident #1 was a [AGE] year-old female readmitted on [DATE]. Her initial admission was 11/05/19. Her diagnoses included [CONDITION(S)], cerebral infarction (also called ischemic stroke), [CONDITION(S)] (any diffuse disease of the brain that alters brain function or structure), muscle wasting and atrophy, cognitive communication deficit, flaccid [CONDITION(S)] affecting right dominant side, and [CONDITION(S)]. Record review of the Minimum Data Set, (MDS) dated [DATE] indicated Resident #1 had severely impaired cognition, was rarely understood, usually comprehends most conversation, and required total assistance of 1 staff for bed mobility and total assist of 2 staff for transfers. She was not able to focus and had disorganized thinking. She was incontinent of bladder and bowel. Record review of care plan dated 10/01/20 indicated Resident #1 had [CONDITION(S)] due to CVA and the interventions included assist with ADLS as needed and pain management as needed. Record review of care plan dated 10/19/20 (revised 07/26/21) indicated Resident #1 had ADLS deficit and interventions included 1-person total assist for bed mobility, 2-person total assist for all transfers, 1-person total assist with toileting, and 1-person total assist with bathing and hygiene. Record review of the care plan dated 10/27/20 indicated Resident #1 was at risk for falls and interventions included two staff to assist with transfers. Record review of a nurses note dated 07/11/21 at 6:30 a.m., completed by LVN A indicated Resident #1 was in isolation related to possible COVID-19 exposure. She was resting in bed with no signs or symptoms of respiratory distress. Resident #1 did not complain of pain or discomfort. All orders were followed as prescribed and all safety needs were met. The nurse note did not include documentation of Resident #1's fall, post fall assessment, or notification to the physician, responsible party (RP), or the DON. Record review of a weekly skin assessment dated [DATE], completed by LVN C indicated Resident #1 had no bruises or injuries. Record review of a weekly skin assessment dated [DATE], completed by LVN G indicated Resident #1's groin area was assessed and there was no knot, redness or bruising. There was no facial grimaces or signs of pain. Record review of physician orders dated 07/20/21 indicated Resident #1 had an order to obtain STAT x-ray to right thigh due to pain. Record review of nurse note dated 07/20/21 at 11:27 a.m., completed by LVN C indicated NP E ordered x-ray to right thigh due to right thigh pain. Record review of Resident #1's x-ray report dated 07/20/21 indicated an acute appearing distal right femur fracture. Record review of nurse note dated 07/20/21 at 4:00 p.m., completed by LVN D indicated Resident #1's femur x-ray showed an acute appearing distal right femur fracture. The RP had notified LVN D of a bump in Resident #1's groin area on 07/19/21. LVN D had assessed and did not fell a bump and Resident #1 did not moan or grimace. LVN D notified NP E. NP E assessed Resident #1 and stated she did not feel a bump but Resident #1 yelled out in pain and had facial grimacing when NP E massaged the hip area. Resident #1 was not able to say what happened. NP E was notified. Resident #1 was transported by EMS to the hospital for evaluation and treatment. The RP was notified. Record review of emergency medical services (EMS) records dated 07/20/21 indicated Resident #1 was able to communicate right leg pain to the facility on [DATE]. X-ray indicated a distal fracture of the right femur. Nurses denied Resident #1 had a fall and were unsure of how she fractured her leg. An inspection of Resident #1's right leg indicated a shortening but no rotation. Record review of hospital records dated 07/20/21 indicated Resident #1 had moderate pain with little movement on 07/19/21. Resident #1's admitting diagnosis was right femur fracture. Record review of hospital records dated 07/22/21 indicated Resident #1's right femur fracture was surgically repaired. During an interview on 09/13/21 at 10:50 a.m., the DON said during the facility's investigation of Resident #1's femur fracture, the facility determined Resident #1 fell during incontinent care on 07/10-11/21 during the 10:00 p.m. - 6:00 a.m. shift at approximately 12 midnight. He said CNA B was providing incontinent care and Resident #1 fell off the bed. The DON said CNA B was trained, her skills were checked, and she was competent in her skills. He said CNA B reported the fall immediately to LVN A. He said the facility was not aware of the fall from 07/11/21 until 07/20/21. He said all staff were expected to follow the facility policy related to falls and accidents. He said staff are expected to report all falls, chart all falls, assess all residents after a fall, and notify the DON, the physician, and the RP. He said LVN A admitted she was aware of the fall and CNA B had reported the fall to her. He said LVN A admitted she did not report the fall. He said LVN A admitted she did not chart the fall or notify the DON, the physician, or the RP. During an interview on 09/15/21 at 8:31 a.m., CNA B said she was completing Resident #1's incontinent care on 07/11/21 at approximately 12 midnight during first rounds. She said Resident #1 was a 1-person assist for incontinent care. She said she turned Resident #1 on to her right side facing away from her (CNA B). She said Resident #1's left leg went over the side off the bed and then the rest of her body followed. She said Resident #1 was wet with soap and water from being cleaned and slipped of the bed. She said Resident #1 flipped over and hit her head on the nightstand as she fell out of the bed. She said she put a pillow between Resident #1's head and the nightstand. CNA B said yelled for LVN A. She said LVN A said Resident #1 was fine and placed a bedsheet under Resident #1 to lift her back into her bed. CNA B said she told LVN A Resident #1 was too heavy to transfer from the floor. She said LVN A said they could do it and they proceeded to lift Resident #1 back into bed. She said she asked for the witness form to complete and LVN A told her she did not need to do a witness form because it was a witnessed fall. CNA B said LVN A said she would complete the report. She said she told LVN A of Resident #1 hitting her head on the bedside table. She said LVN A left Resident #1's room and did not check Resident #1 for injuries. CNA B said she completed Resident #1's incontinent care and Resident #1 was groaning in pain. She said LVN A was not in the room. She said LVN A appeared to have no interest in Resident #1's fall or condition. CNA B said she was trained in resident care, including incontinent care and the facility conducted random skills competency checks. During an interview on 09/16/21 at 2:12 p.m., LVN A said CNA B asked for her help. She said Resident #1 was on the floor. She said CNA B said Resident #1 fell off the bed during incontinent care but did not hit her head. She said she got a sheet and placed it under Resident #1. LVN A said she put a sheet under Resident #1, then she and CNA B transferred Resident #1 from the floor back to her bed. She said she looked Resident #1 over and moved all her limbs. She said she did not see any injuries and Resident #1 had no signs of pain. She said Resident #1 made no sounds of pain and had no grimacing. She said she did not she did not report the fall, did not chart the fall or notify the DON, the physician, or the RP and did not complete an incident report regarding Resident #1's fall. She said she was trained and knew she should have followed the facility's policy regarding falls. She said she was really busy and confused what she should have done on that particular night. She said it was no excuse, but she had no other explanation. Record review of the facility's undated Incidents &Accidents Standards of Care indicated each resident receives adequate supervision and assistive devices to prevent avoidable accidents . Record review of the undated Facility's Perineal Care policy indicated .If the perineum is grossly soiled, turn resident on side, remove any fecal material .reposition resident in supine position Record review of the undated Facility's Perineal Care policy indicated .If the perineum is grossly soiled, turn resident on side, remove any fecal material .reposition resident in supine position

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 23 residents reviewed for neglect. (Resident #44) The facility did not ensure nursing staff conducted a thorough assessment on Resident #44 after he was found in a vacant room with a skin tear to his left hand, and he could no longer walk without pain; and waited for the hospice nurse to assess the resident the following day. The resident was later diagnosed with a left [CONDITION(S)]. This failure could place residents residing on the secure unit at risk of not receiving needed goods and services. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #44 was admitted to hospice services on 11/7/18. The most recent MDS dated [DATE] indicated Resident #44 walked on the unit independently with supervision, due to his unsteady balance. The assessment noted Resident #44 had no impairment with upper or lower extremities range of motion. Resident #44's comprehensive plan of care dated 11/20/18 indicated he was at risk for injury/falls related to his poor safety awareness secondary to Alzheimer's disease. The goal was Resident #44 would have no significant injury related to falls in the next 90 days. Nursing notes dated 1/27/19 at 10:11 p.m., indicated LVN O documented an incident that occurred on 1/27/19 at 8:40 p.m LVN O said a CNA called her to a vacant room where Resident #44 was sitting on the side of the bed. He could not stand alone. LVN O documented the resident limped when he took 1 or 2 steps and she assisted Resident #44 back to his room with a wheelchair. The note indicated the resident was able to stand two steps away from his bed and get in bed. LVN O documented that during peri-care, Resident #44 was rolled to his side, but complained of pain to his left leg. LVN O indicated she called and spoke with hospice nurse N who sent an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated Hospice nurse M called at 9:30 p.m. and said he would follow up with Resident #44 at the facility the following day. A nursing note dated 1/28/19 at 4:54 a.m., documented LVN O had Resident #44 bend his left leg, and noted he complained of some pain when his leg was bent. During a phone interview on 2/5/19 at 8:10 a.m., LVN O said on 1/27/19, CNA P called her to a vacant room. LVN O said Resident #44 was sitting on side of the bed attempting to stand but he needed assistance. She said the resident would take 1-2 steps and limp. She used a wheelchair to assist the resident to his own room. She said the resident was able to stand and take 2 steps to get in his own bed. She said during peri-care, Resident #44 was able to roll over but complained of pain and said ouch. She said she then placed a call to hospice to request pain medication, and an order was given for Tylenol 500 mg tablet along with Ibuprofen 200 mg as needed. She said around 5:30 a.m., on 1/28/19, she observed Resident #44 had some puffiness to left knee, but he could bend the knee. She said when he was turned by staff, he had said ouch. LVN O said she had told both Hospice nurses M and N that resident had pain when taking steps. During an interview on 2/5/19 at 8:55 a.m., CNA P said on 1/27/19, Resident #44 had been walking about the unit all during her shift without any problems. CNA P said around 8 - 8:15 p.m., she found Resident #44 in a vacant room and she summoned LVN O. She said they tried to stand the resident and he was able to take one step, but unable to walk on his own anymore and she then got a wheelchair to transport him to his room and bed. CNA P said after finding Resident #44 in the vacant room, he was unable to walk. During a phone interview on 2/5/19 at 9:54 a.m., Hospice nurse N said on 1/27/19, LVN O called him because Resident #44 did not have any pain medications. Hospice nurse N said LVN O told him Resident #44 maybe had some joint pain and was not specific and said it was generalized pain and Tylenol would help. Hospice nurse N said if he had known or suspected a fractured hip, he would have gone immediately to the facility to assess the resident. A nursing note dated 1/29/19 at 7:55 a.m., indicated LVN E on 1/28/19 at 10:00 a.m., the hospice nurse assessed Resident #44 regarding a change in condition (approximately 13 hours after he was found in the vacant room). The hospice nurse ordered [MEDICATION(S)] 50 mg for the resident's pain, and ordered an x-ray of the resident's left hip and knee. During a phone interview on 2/5/19 at 9:54 a.m., Hospice nurse N said on 1/27/19, LVN O called him because Resident #44 did not have any pain medications. Hospice nurse N said LVN O told him Resident #44 maybe had some joint pain and was not specific and said it was generalized pain and Tylenol would help. Hospice nurse N said if he had known or suspected a fractured hip, he would have gone immediately to the facility to assess the resident. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A Provider Investigation Report dated 1/27/19 indicated Resident #44 was found in a vacant room on the secure unit at approximately 8:40 p.m. on 1/27/19 and noted the resident was unable to ambulate as he had been. The report indicated LVN O assessed the resident and found a skin tear to the top of his left hand with some bleeding, but noted he could move all fingers. The report indicated on 1/28/19, DON and the hospice nurse performed a head to toe assessment on Resident #44 and found signs and symptoms of a fractured hip. A Resident Incident Report dated 1/27/19 for Resident #44 indicated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44 had a bleeding skin tear on the top of his left hand, and the note indicated was blood on the floor. The resident's skin tear was cleaned and dressing was applied. The resident was able to move all his fingers. A Complaint/Grievance Report dated 1/28/19 indicated staff noticed Resident #44 was unable to ambulate as his prior level of function. An SBAR form (Situation, Background, Appearance, Review-form dated 1/27/19 at 9:00 p.m., used to assess a resident prior to calling a physician) indicated LVN O noted Resident #44 had a change in condition, a skin tear to the top of his left hand. During an interview on 2/5/19 at 10:15 a.m., LVN E said she had worked the day shift on 1/28/19. She said when she assessed Resident #44 due to the incident the previous night, Resident #44 was vague about pain but pointed toward his knee/foot when asked about pain. She said she suspected a fractured hip because Resident #44's left leg was a little shorter than the right, but did not call the resident's physician or hospice because the hospice nurse was scheduled to see the resident that morning. A statement completed by the DON dated 1/28/19 at 10:00 a.m. indicated she and the hospice nurse assessed Resident #44 and indicated he continued to exhibit signs of pain. There was an area approximately 0.1 cm x 4 cm petechia (tiny purple or red spots that resembled a rash) noted to the resident's left upper thigh area. The statement noted the resident's left foot was slightly shorter in length than the right with left foot rotated outward, and indicated the .resident responded with ouch when the hospice RN touched his left leg and attempted ROM. A report from the X-ray of Resident #44's left hip indicated the following: Significant Findings. left hip . Grossly displaced fracture of the left femoral neck. Impression. Acute femoral neck (hip) fracture. Departmental Notes dated 1/28/19 indicated at 4:45 p.m., the facility received results of X-rays and received orders to transfer to local hospital for further evaluation. During an interview on 2/4/19 at 10:45 a.m., Hospice nurse M said he returned a call to facility after the on-call nurse spoke to LVN O. Hospice nurse M said he was not informed Resident #44 was exhibiting signs of pain, but was told the on-call nurse prescribed pain medication, and he told LVN O he would be in facility the next morning to assess the resident. Hospice nurse M said he immediately knew Resident #44 had a fracture to his left hip after his assessment on the morning of 1/28/19. He said the hospice nurses are required to assess residents immediately after reports of major injuries and that they were not informed of the extent of Resident #44's injury when LVN O spoke to the on-call nurse. During an interview on 2/5/19 at 2:10 p.m., the DON said Resident #44 was walking without assistance prior to the incident. She said LVN O notified hospice of Resident #44's change in condition. She acknowledged the SBAR indicated hospice was notified regarding a skin tear to Resident #44's left hand, but was not informed about the discomfort to his left lower extremity. The DON acknowledged Resident #44's clinical record indicated he had generalized pain. She said she assessed Resident #44 along with Hospice nurse M on the morning of 1/28/19. She stated I checked and the left leg was shorter and I knew indicating she realized the hip was fractured. She said we tell staff to call for X-rays when there is any question no matter what hospice orders. She said nursing staff needed another in-service on recognizing hip fractures and injuries. During an interview on 2/5/19 at 2:33 p.m., the administrator said that a change from prior level of function should have been first clue that something was wrong with Resident #44's hip. She said the nursing staff knew enough to check Resident #44's ROM and that should have clued her in that something was wrong. She said Resident #44 should have had an X-ray at the time of the incident. The administrator stated He's our patient under our care and is our responsibility no matter what hospice did. Our people should have been called and facility would have paid for X-rays. We could have done so much better.

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent an accident for 1 of 23 residents reviewed for accident supervision. (Resident #44) The facility did not ensure nursing staff provided adequate supervision for Resident #44 who was at risk for falls, after he was found in a vacant room with a skin tear to his left hand, and he could no longer walk without pain. The resident sustained a left [CONDITION(S)]. This failure could place residents residing on the secure unit at risk of not receiving adequate supervision to prevent accidents. Findings included: Physician orders dated February 2019 indicated Resident #44, admitted [DATE], was [AGE] years old, with diagnoses of Alzheimer's disease and fractured left hip. The orders indicated Resident #44 was admitted to hospice services on 11/7/18. The most recent MDS dated [DATE] indicated Resident #44 could walk on the unit independently with supervision, due to his unsteady balance. The assessment noted Resident #44 had no impairment with upper or lower extremities range of motion. Resident #44's comprehensive plan of care dated 11/20/18 indicated he was at risk for injury/falls related to his poor safety awareness secondary to Alzheimer's disease. The goal was Resident #44 would have no significant injury related to falls in the next 90 days. Nursing notes dated 1/27/19 at 10:11 p.m., indicated LVN O documented an incident that occurred on 1/27/19 at 8:40 p.m. LVN O said a CNA called her to a vacant room where Resident #44 was sitting on the side of the bed. He could not stand alone. LVN O documented the resident limped when he took 1 or 2 steps and she assisted Resident #44 back to his room with a wheelchair. The note indicated the resident was able to stand two steps away from his bed and get in bed. LVN O documented that during peri-care, Resident #44 was rolled to his side, but complained of pain to his left leg. LVN O indicated she called and spoke with hospice nurse N who sent an order for Resident #44 for Tylenol 500 mg and Ibuprofen 200 mg by mouth every 6 hours as needed for pain. The note indicated Hospice nurse M called at 9:30 p.m. and said he would follow up with Resident #44 at the facility the following day. A nursing note dated 1/28/19 at 4:54 a.m., documented LVN O had Resident #44 bend his left leg, and noted he complained of some pain when his leg was bent. During a phone interview on 2/5/19 at 8:10 a.m., LVN O said on 1/27/19, CNA P called her to a vacant room. LVN O said Resident #44 was sitting on side of the bed attempting to stand but he needed assistance. She said the resident would take 1-2 steps and limp. She used a wheelchair to assist the resident to his own room. She said the resident was able to stand and take 2 steps to get in his own bed. She said during peri-care, Resident #44 was able to roll over but complained of pain and said ouch. She said she then placed a call to hospice to request pain medication, and an order was given for Tylenol 500 mg tablet along with Ibuprofen 200 mg as needed. She said around 5:30 a.m., on 1/28/19, she observed Resident #44 had some puffiness to left knee, but he could bend the knee. She said when he was turned by staff, he had said ouch. LVN O said she had told both Hospice nurses M and N that resident had pain when taking steps. During an interview on 2/5/19 at 8:55 a.m., CNA P said on 1/27/19, Resident #44 had been walking about the unit all during her shift without any problems. CNA P said around 8 - 8:15 p.m., she found Resident #44 in a vacant room and she summoned LVN O. She said they tried to stand the resident and he was able to take one step, but unable to walk on his own anymore and she then got a wheelchair to transport him to his room and bed. CNA P said after finding Resident #44 in the vacant room, he was unable to walk. During a phone interview on 2/5/19 at 9:54 a.m., Hospice nurse N said on 1/27/19, LVN O called him because Resident #44 did not have any pain medications. Hospice nurse N said LVN O told him Resident #44 maybe had some joint pain and was not specific and said it was generalized pain and Tylenol would help. Hospice nurse N said if he had known or suspected a fractured hip, he would have gone immediately to the facility to assess the resident. A nursing note dated 1/29/19 at 7:55 a.m., indicated LVN E on 1/28/19 at 10:00 a.m., the hospice nurse assessed Resident #44 regarding a change in condition (approximately 13 hours after he was found in the vacant room). The hospice nurse ordered [MEDICATION(S)] 50 mg for the resident's pain, and ordered an x-ray of the resident's left hip and knee. During a phone interview on 2/5/19 at 9:54 a.m., Hospice nurse N said on 1/27/19, LVN O called him because Resident #44 did not have any pain medications. Hospice nurse N said LVN O told him Resident #44 maybe had some joint pain and was not specific and said it was generalized pain and Tylenol would help. Hospice nurse N said if he had known or suspected a fractured hip, he would have gone immediately to the facility to assess the resident. The MAR dated January 2019 for Resident #44 indicated Ibuprofen 200 mg tablet and Tylenol 500 mg was administered on 1/27/19 at 10:01 p.m. and on 1/28/19 at 4:59 a.m. Resident #44 was administered the pain medication [MEDICATION(S)] 50 mg on 1/28/19 at 5:46 p.m. A Provider Investigation Report dated 1/27/19 indicated Resident #44 was found in a vacant room on the secure unit at approximately 8:40 p.m. on 1/27/19 and noted the resident was unable to ambulate as he had been. The report indicated LVN O assessed the resident and found a skin tear to the top of his left hand with some bleeding, but noted he could move all fingers. The report indicated on 1/28/19, DON and the hospice nurse performed a head to toe assessment on Resident #44 and found signs and symptoms of a fractured hip. A Resident Incident Report dated 1/27/19 for Resident #44 indicated the resident sustained a superficial skin tear on his left hand on 1/27/19 at 8:40 p.m. The report indicated a CNA found Resident #44 sitting on the side of a bed, and called for assistance. Resident #44 had a bleeding skin tear on the top of his left hand, and the note indicated was blood on the floor. The resident's skin tear was cleaned and dressing was applied. The resident was able to move all his fingers. A Complaint/Grievance Report dated 1/28/19 indicated staff noticed Resident #44 was unable to ambulate as his prior level of function. An SBAR form (Situation, Background, Appearance, Review-form dated 1/27/19 at 9:00 p.m., used to assess a resident prior to calling a physician) indicated LVN O noted Resident #44 had a change in condition, a skin tear to the top of his left hand. During an interview on 2/5/19 at 10:15 a.m., LVN E said she had worked the day shift on 1/28/19. She said when she assessed Resident #44 due to the incident the previous night, Resident #44 was vague about pain but pointed toward his knee/foot when asked about pain. She said she suspected a fractured hip because Resident #44's left leg was a little shorter than the right, but did not call the resident's physician or hospice because the hospice nurse was scheduled to see the resident that morning. A statement completed by the DON dated 1/28/19 at 10:00 a.m. indicated she and the hospice nurse assessed Resident #44 and indicated he continued to exhibit signs of pain. There was an area approximately 0.1 cm x 4 cm petechia (tiny purple or red spots that resembled a rash) noted to the resident's left upper thigh area. The statement noted the resident's left foot was slightly shorter in length than the right with left foot rotated outward, and indicated the .resident responded with ouch when the hospice RN touched his left leg and attempted ROM. A report from the X-ray of Resident #44's left hip indicated the following: Significant Findings. left hip . Grossly displaced fracture of the left femoral neck. Impression. Acute femoral neck (hip) fracture. Departmental Notes dated 1/28/19 indicated at 4:45 p.m., the facility received results of X-rays and received orders to transfer to local hospital for further evaluation. During an interview on 2/4/19 at 10:45 a.m., Hospice nurse M said he returned a call to facility after the on-call nurse spoke to LVN O. Hospice nurse M said he was not informed Resident #44 was exhibiting signs of pain, but was told the on-call nurse prescribed pain medication, and he told LVN O he would be in facility the next morning to assess the resident. Hospice nurse M said he immediately knew Resident #44 had a fracture to his left hip after his assessment on the morning of 1/28/19. He said the hospice nurses are required to assess residents immediately after reports of major injuries and that they were not informed of the extent of Resident #44's injury when LVN O spoke to the on-call nurse. During an interview on 2/5/19 at 2:10 p.m., the DON said Resident #44 was walking without assistance prior to the incident. She said LVN O notified hospice of Resident #44's change in condition. She acknowledged the SBAR indicated hospice was notified regarding a skin tear to Resident #44's left hand, but was not informed about the discomfort to his left lower extremity. The DON acknowledged Resident #44's clinical record indicated he had generalized pain. She said she assessed Resident #44 along with Hospice nurse M on the morning of 1/28/19. She stated I checked and the left leg was shorter and I knew indicating she realized the hip was fractured. She said we tell staff to call for X-rays when there is any question no matter what hospice orders. She said nursing staff needed another in-service on recognizing hip fractures and injuries. During an interview on 2/5/19 at 2:33 p.m., the administrator said that a change from prior level of function should have been first clue that something was wrong with Resident #44's hip. She said the nursing staff knew enough to check Resident #44's ROM and that should have clued her in that something was wrong. She said Resident #44 should have had an X-ray at the time of the incident. The administrator stated He's our patient under our care and is our responsibility no matter what hospice did. Our people should have been called and facility would have paid for X-rays. We could have done so much better.

Based on observation, interview, and record review, the facility failed to develop and implement their written policies and procedures to prohibit the neglect of 1 of 4 residents sampled for neglect by allowing a resident to be missing, locked in an [MEDICATION NAME] closet for 27 1/2 hours. (Resident #1) Resident #1 resided on the secure unit, was confused, and had a history of [REDACTED].? hours. The resident was found laying on the floor on a pallet of diapers. There was urine and feces on the floor. The resident had reddened areas on his back. The resident was sent to the emergency room with a urinary tract infection and dehydration. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 6/5/2012 at 10:20 a.m. The facility remained out of compliance at a pattern of actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 27 residents who resided on the secure unit at risk for elopement, serious injuries, and death. Findings included: Physician orders [REDACTED]. The most resident MDS assessment dated [DATE] indicated Resident #1 had severely impaired cognitive skills for daily decision making and continuous disorganized thinking. Resident #1's nursing notes dated 6/2/2012 indicated the DON was notified of the missing resident at 5:45 a.m. and the police department was notified at 6:00 a.m. According to the nurses notes dated 6/3/2012, Resident #1 "was found in closet laying on floor." "Red mark approximately 3" long x 1" wide to mid spine at back another red mark on lumbar spine 1" diameter. Had incontinent BM and urine episode. No reply when asked if he was ok." Blood pressure was 184/118 and his temperature was 97.7 degrees. A hospital discharge information sheet dated 6/3/12 indicated the resident was dehydrated and had a urinary tract infection. During an interview on 6/3/2012 at 10:30 a.m., the maintenance supervisor and the administrator said the maintenance supervisor had looked for the missing resident by checking behind all of the doors on the secure unit including the locked doors, on the morning of 6/3/2012 and then later that day he conducted a search of all the same doors with the police department. During an interview with the maintenance supervisor on 6/4/12 at 3:30 p.m., he said the only three people with keys to the diaper closet were the two RNA's and the maintenance staff F. During an interview on 6/3/2012 at 10:50 a.m., CNA C said she provided incontinent care to Resident #1 on 6/2/2012 at approximately 2:30 a.m. She saw him again at approximately 4:30 a.m. She said he was in his bed with his covers pulled up. She said there had been an emergency on another unit and she went to assist leaving LVN D on the unit. When she returned around 5:00 a.m., LVN D told her they needed to do a room search because Resident #1 was not in his room. They searched all of the resident rooms, bathrooms, and closets. They then searched all of the locked doors they had keys for. She said they tried all of the handles and knocked on the doors they did not have keys for. She said the nurses did not have a key to the diaper closet where Resident #1 was found. During an interview on 6/3/2012 at 11:00 a.m., LVN D said she had been passing medications around 5:00 a.m. on 6/2/2012. She did not see Resident #1 in his bed, so when CNA C returned to the secure unit, she told her they needed to conduct a room search for the resident. They searched the rooms three times then opened all of the locked doors they had keys for. She said there was not a key to the diaper closet, so it was not opened. During further interview on 6/5/2012 at 10:44 a.m., LVN D said prior to that night, there were two CNAs working on the unit. She had been told that night there would only be one CNA working. She said one CNA was called to assist with an emergency on another unit leaving LVN D alone during the time Resident #1 went missing. During an interview on 6/3/2012 at 11:40 a.m., SNA E said she had been working on the secure unit until the night Resident #1 went missing. She had been told she was being transferred to another unit. She said she told them (the facility) something would happen if there was only one aide. She said prior to that night, there had been two CNAs. She said that the nurses did not have a key to the diaper closet. If the staff needed diapers, they would either borrow from another resident or call the RNA. During an interview on 6/3/2012 at 12:42 p.m., the DON said she would pull staff from the secure unit to work other units if needed. During an observation of the closet on 6/3/2012 at 11:15 a.m., the inside door handle was broken off the door and had been laid on the shelf in the closet. Maintenance staff F said at this time he thought the resident must have broken the handle off of the door trying to get out of the closet. The closet had an over bed table and diapers. There was still an odor in the closet. During an interview on 6/3/2012 at 11:35 a.m., RNA B said she was responsible for passing out diapers to the residents. Sunday morning, she went to the closet and unlocked it. She was not able to open the door all the way and when she looked down, she saw Resident #1's feet. She said she then went to get help. She had left the door unlocked on Thursday because she had been assisting getting other residents to doctor appointments and did not have time to dispense the diapers. She did not know how long the door handle had been broken. During an interview on 6/3/2012 at 12:46 p.m., MA G said she had assisted getting the resident out of the closet. She said he had pulled diapers down off the shelf and made a pallet to lay on. She said there was urine and feces on the floor and wall in the closet. The facility's undated Abuse, Neglect, and Misappropriation of Property indicated: "1) The facility prohibits resident neglect and mental or physical abuse including but not limited to, involuntary seclusion and the misappropriation of property of residents." The administrator and DON were notified on 6/3/2012 at 12:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 6/5/2012 at 10:20 a.m. and included: " I. Resident #1 was reported missing from Unit 1 of the Oaks at Beaumont at about 5:00 am on 6-2-12. He was located at about 8:30 am on 6-3-12. He was given immediate attention and taken to Baptist Hospital emergency room for evaluation. His family reports that he is doing well. They chose to take him home for the time being. If he should return to the facility, he will be cared for in accordance with his physician's orders [REDACTED]. II. The facility recognizes that any resident has the potential to be effected and that resident's with dementia are even more vulnerable. III. The facility will take the following corrective actions: A. The corporate nurse consultant will in-service the administrator, DON and all department head staff on the issues contained in this plan of abatement. In turn, facility management personnel will in-service all staff on the procedures outlined below. Any staff unable to attend the in-service today will be off the work schedule until such time as they have received the in-service. B. Nursing staff will do a resident head-count at the beginning of each shift, and again at the end of each shift. A form to document these checks will be kept. During the course of the shift a search will commence immediately if any resident is missing. C. If at any time a resident cannot be accounted for, staff will be in-serviced to initiate the Missing Resident Protocol immediately. The in-service will include where this policy and procedure can be located. A copy will be readily available at each nurse's station. The in-service will also include notifying the administrator and the DON and/or their designees. Emergency phone list will be readily available with the procedures. D. The facility's wandering- control magnetic lock system will be tested on the same schedule as describe above by the charge nurse or his/her designee. Any malfunction will be reported immediately to the administrator and director of maintenance for corrective action to be initiated. E. In order to carry out the search procedures properly, a set of keys will be made and available to the charge nurse so that they can search behind doors that are normally locked. F. If a resident is missing in the future, and is not immediately located, the DON and/or the Administrator, or their designees, will personally search each locked room even if they have been previously searched. G. Facility staff will be in-serviced on residents with dementia and their unique supervision needs. H. The facility has recently hired a part-time security officer who will also receive the above cited training. IV. To insure ongoing compliance, the Quality Assessment and Assurance Committee will monitor this issue and make recommendations to the administrator as needed for corrective actions. The administrator will be responsible for implementing the recommendations." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two LVNs, 1 medication aide, two CNAs, and two housekeeping staff were interviewed and said that there were keys for all doors kept on a ring in the medication room. If they needed in a room, the nurse was able to get the keys. They each said the keys were coded by hall. They had been in serviced and were able to tell and demonstrate where the emergency/disaster book was kept which contained the missing person policy and phone numbers of key personnel. The LVNs and CNAs said they were to do a head count at the beginning, middle, and end of each shift and document the findings on a form. During an interview on 6/3/12 at 10:20 a.m. the administrator said 27 residents were on the secure unit.

Based on observation, interview, and record review, the facility failed to develop and implement their written policies and procedures to prohibit the neglect of 1 of 4 residents sampled for neglect by allowing a resident to be missing, locked in an [MEDICATION NAME] closet for 27 1/2 hours. (Resident #1) Resident #1 resided on the secure unit, was confused, and had a history of [REDACTED].? hours. The resident was found laying on the floor on a pallet of diapers. There was urine and feces on the floor. The resident had reddened areas on his back. The resident was sent to the emergency room with a urinary tract infection and dehydration. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 6/5/2012 at 10:20 a.m. The facility remained out of compliance at a pattern of actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 26 residents who resided on the secure unit at risk for elopement, serious injuries, and death. Findings included: The facility's undated Abuse, Neglect, and Misappropriation of Property indicated: "1) The facility prohibits resident neglect and mental or physical abuse including but not limited to, involuntary seclusion and the misappropriation of property of residents." Physician orders [REDACTED]. The most resident MDS assessment dated [DATE] indicated Resident #1 had severely impaired cognitive skills for daily decision making and continuous disorganized thinking. Resident #1's nursing notes dated 6/2/2013 indicated the DON was notified of the missing resident at 5:45 a.m. and the police department was notified at 6:00 a.m. According to the nurses notes dated 6/3/2012, Resident #1 "was found in closet laying on floor." "Red mark approximately 3" long x 1" wide to mid spine at back another red mark on lumbar spine 1" diameter. Had incontinent BM and urine episode. No reply when asked if he was ok." Blood pressure was 184/118 and his temperature was 97.7 degrees. A hospital discharge information sheet dated 6/3/12 indicated the resident was dehydrated and had a urinary tract infection. During an interview on 6/3/2012 at 10:30 a.m., the maintenance supervisor and the administrator said the maintenance supervisor had looked for the missing resident by checking behind all of the doors on the secure unit including the locked doors, on the morning of 6/3/2012 and then later that day he conducted a search of all the same doors with the police department. During an interview with the maintenance supervisor on 6/4/12 at 3:30 p.m., he said the only three people with keys to the diaper closet were the two RNA's and the maintenance staff F. During an interview on 6/3/2012 at 10:50 a.m., CNA C said she provided incontinent care to Resident #1 on 6/2/2012 at approximately 2:30 a.m. She saw him again at approximately 4:30 a.m. She said he was in his bed with his covers pulled up. She said there had been an emergency on another unit and she went to assist leaving LVN D on the unit. When she returned around 5:00 a.m., LVN D told her they needed to do a room search because Resident #1 was not in his room. They searched all of the resident rooms, bathrooms, and closets. They then searched all of the locked doors they had keys for. She said they tried all of the handles and knocked on the doors they did not have keys for. She said the nurses did not have a key to the diaper closet where Resident #1 was found. During an interview on 6/3/2012 at 11:00 a.m., LVN D said she had been passing medications around 5:00 a.m. on 6/2/2012. She did not see Resident #1 in his bed, so when CNA C returned to the secure unit, she told her they needed to conduct a room search for the resident. They searched the rooms three times then opened all of the locked doors they had keys for. She said there was not a key to the diaper closet, so it was not opened. During further interview on 6/5/2012 at 10:44 a.m., LVN D said prior to that night, there were two CNAs working on the unit. She had been told that night there would only be one CNA working. She said one CNA was called to assist with an emergency on another unit leaving LVN D alone during the time Resident #1 went missing. During an interview on 6/3/2012 at 11:40 a.m., SNA E said she had been working on the secure unit until the night Resident #1 went missing. She had been told she was being transferred to another unit. She said she told them (the facility) something would happen if there was only one aide. She said prior to that night, there had been two CNAs. She said that the nurses did not have a key to the diaper closet. If the staff needed diapers, they would either borrow from another resident or call the RNA. During an interview on 6/3/2012 at 12:42 p.m., the DON said she would pull staff from the secure unit to work other units if needed. During an observation of the closet on 6/3/2012 at 11:15 a.m., the inside door handle was broken off the door and had been laid on the shelf in the closet. Maintenance staff F said at this time he thought the resident must have broken the handle off of the door trying to get out of the closet. The closet had an over bed table and diapers. There was still an odor in the closet. During an interview on 6/3/2012 at 11:35 a.m., RNA B said she was responsible for passing out diapers to the residents. Sunday morning, she went to the closet and unlocked it. She was not able to open the door all the way and when she looked down, she saw Resident #1's feet. She said she then went to get help. She had left the door unlocked on Thursday because she had been assisting getting other residents to doctor appointments and did not have time to dispense the diapers. She did not know how long the door handle had been broken. During an interview on 6/3/2012 at 12:46 p.m., MA G said she had assisted getting the resident out of the closet. She said he had pulled diapers down off the shelf and made a pallet to lay on. She said there was urine and feces on the floor and wall in the closet. The administrator and DON were notified on 6/3/2012 at 12:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 6/5/2012 at 10:20 a.m. and included: " I. Resident #1 was reported missing from Unit 1 of the Oaks at Beaumont at about 5:00 am on 6-2-12. He was located at about 8:30 am on 6-3-12. He was given immediate attention and taken to Baptist Hospital emergency room for evaluation. His family reports that he is doing well. They chose to take him home for the time being. If he should return to the facility, he will be cared for in accordance with his physician's orders [REDACTED]. II. The facility recognizes that any resident has the potential to be effected and that resident's with dementia are even more vulnerable. III. The facility will take the following corrective actions: A. The corporate nurse consultant will in-service the administrator, DON and all department head staff on the issues contained in this plan of abatement. In turn, facility management personnel will in-service all staff on the procedures outlined below. Any staff unable to attend the in-service today will be off the work schedule until such time as they have received the in-service. B. Nursing staff will do a resident head-count at the beginning of each shift, and again at the end of each shift. A form to document these checks will be kept. During the course of the shift a search will commence immediately if any resident is missing. C. If at any time a resident cannot be accounted for, staff will be in-serviced to initiate the Missing Resident Protocol immediately. The in-service will include where this policy and procedure can be located. A copy will be readily available at each nurse's station. The in-service will also include notifying the administrator and the DON and/or their designees. Emergency phone list will be readily available with the procedures. D. The facility's wandering- control magnetic lock system will be tested on the same schedule as describe above by the charge nurse or his/her designee. Any malfunction will be reported immediately to the administrator and director of maintenance for corrective action to be initiated. E. In order to carry out the search procedures properly, a set of keys will be made and available to the charge nurse so that they can search behind doors that are normally locked. F. If a resident is missing in the future, and is not immediately located, the DON and/or the Administrator, or their designees, will personally search each locked room even if they have been previously searched. G. Facility staff will be in-serviced on residents with dementia and their unique supervision needs. H. The facility has recently hired a part-time security officer who will also receive the above cited training. IV. To insure ongoing compliance, the Quality Assessment and Assurance Committee will monitor this issue and make recommendations to the administrator as needed for corrective actions. The administrator will be responsible for implementing the recommendations." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two LVNs, 1 medication aide, two CNAs, and two housekeeping staff were interviewed and said that there were keys for all doors kept on a ring in the medication room. If they needed in a room, the nurse was able to get the keys. They each said the keys were coded by hall. They had been in serviced and were able to tell and demonstrate where the emergency/disaster book was kept which contained the missing person policy and phone numbers of key personnel. The LVNs and CNAs said they were to do a head count at the beginning, middle, and end of each shift and document the findings on a form. During an interview on 6/3/12 at 10:20 a.m. the administrator said 27 residents were on the secure unit, including Resident #1.

Based on observation, interview and record review, the facility failed to ensure supervision was provided for 1 of 3 residents by allowing a resident to be missing, locked in an unvented closet for 27 1/2 hours. (Resident #1) Resident #1 resided on the secure unit, was confused, and had a history of [REDACTED].? hours. The resident was found laying on the floor on a pallet of diapers. There was urine and feces on the floor. The resident had reddened areas on his back. The resident was sent to the emergency room with a urinary tract infection and dehydration. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 6/5/2012 at 10:20 a.m. The facility remained out of compliance at a pattern of actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 27 residents who resided on the secure unit at risk for elopement, serious injuries, and death. Findings included: Physician orders [REDACTED]. The most resident MDS assessment dated [DATE] indicated Resident #1 had severely impaired cognitive skills for daily decision making and continuous disorganized thinking. Resident #1's nursing notes dated 6/2/2012 indicated the DON was notified of the missing resident at 5:45 a.m. and the police department was notified at 6:00 a.m. According to the nurses notes dated 6/3/2012, Resident #1 "was found in closet laying on floor." "Red mark approximately 3" long x 1" wide to mid spine at back another red mark on lumbar spine 1" diameter. Had incontinent BM and urine episode. No reply when asked if he was ok." Blood pressure was 184/118 and his temperature was 97.7 degrees. A hospital discharge information sheet dated 6/3/12 indicated the resident was dehydrated and had a urinary tract infection. During an interview on 6/3/2012 at 10:30 a.m., the maintenance supervisor and the administrator said the maintenance supervisor had looked for the missing resident by checking behind all of the doors on the secure unit including the locked doors, on the morning of 6/3/2012 and then later that day he conducted a search of all the same doors with the police department. During an interview with the maintenance supervisor on 6/4/12 at 3:30 p.m., he said the only three people with keys to the diaper closet were the two RNA's and the maintenance staff F. During an interview on 6/3/2012 at 10:50 a.m., CNA C said she provided incontinent care to Resident #1 on 6/2/2012 at approximately 2:30 a.m. She saw him again at approximately 4:30 a.m. She said he was in his bed with his covers pulled up. She said there had been an emergency on another unit and she went to assist leaving LVN D on the unit. When she returned around 5:00 a.m., LVN D told her they needed to do a room search because Resident #1 was not in his room. They searched all of the resident rooms, bathrooms, and closets. They then searched all of the locked doors they had keys for. She said they tried all of the handles and knocked on the doors they did not have keys for. She said the nurses did not have a key to the diaper closet where Resident #1 was found. During an interview on 6/3/2012 at 11:00 a.m., LVN D said she had been passing medications around 5:00 a.m. on 6/2/2012. She did not see Resident #1 in his bed, so when CNA C returned to the secure unit, she told her they needed to conduct a room search for the resident. They searched the rooms three times then opened all of the locked doors they had keys for. She said there was not a key to the diaper closet, so it was not opened. During further interview on 6/5/2012 at 10:44 a.m., LVN D said prior to that night, there were two CNAs working on the unit. She had been told that night there would only be one CNA working. She said one CNA was called to assist with an emergency on another unit leaving LVN D alone during the time Resident #1 went missing. During an interview on 6/3/2012 at 11:40 a.m., SNA E said she had been working on the secure unit until the night Resident #1 went missing. She had been told she was being transferred to another unit. She said she told them (the facility) something would happen if there was only one aide. She said prior to that night, there had been two CNAs. She said that the nurses did not have a key to the diaper closet. If the staff needed diapers, they would either borrow from another resident or call the RNA. During an interview on 6/3/2012 at 12:42 p.m., the DON said she would pull staff from the secure unit to work other units if needed. During an observation of the closet on 6/3/2012 at 11:15 a.m., the inside door handle was broken off the door and had been laid on the shelf in the closet. Maintenance staff F said at this time he thought the resident must have broken the handle off of the door trying to get out of the closet. The closet had an over bed table and diapers. There was still an odor in the closet. During an interview on 6/3/2012 at 11:35 a.m., RNA B said she was responsible for passing out diapers to the residents. Sunday morning, she went to the closet and unlocked it. She was not able to open the door all the way and when she looked down, she saw Resident #1's feet. She said she then went to get help. She had left the door unlocked on Thursday because she had been assisting getting other residents to doctor appointments and did not have time to dispense the diapers. She did not know how long the door handle had been broken. During an interview on 6/3/2012 at 12:46 p.m., MA G said she had assisted getting the resident out of the closet. She said he had pulled diapers down off the shelf and made a pallet to lay on. She said there was urine and feces on the floor and wall in the closet. The administrator and DON were notified on 6/3/2012 at 12:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 6/5/2012 at 10:20 a.m. and included: " I. Resident #1 was reported missing from Unit 1 of the Oaks at Beaumont at about 5:00 am on 6-2-12. He was located at about 8:30 am on 6-3-12. He was given immediate attention and taken to Baptist Hospital emergency room for evaluation. His family reports that he is doing well. They chose to take him home for the time being. If he should return to the facility, he will be cared for in accordance with his physician's orders [REDACTED]. II. The facility recognizes that any resident has the potential to be effected and that resident's with dementia are even more vulnerable. III. The facility will take the following corrective actions: A. The corporate nurse consultant will in-service the administrator, DON and all department head staff on the issues contained in this plan of abatement. In turn, facility management personnel will in-service all staff on the procedures outlined below. Any staff unable to attend the in-service today will be off the work schedule until such time as they have received the in-service. B. Nursing staff will do a resident head-count at the beginning of each shift, and again at the end of each shift. A form to document these checks will be kept. During the course of the shift a search will commence immediately if any resident is missing. C. If at any time a resident cannot be accounted for, staff will be in-serviced to initiate the Missing Resident Protocol immediately. The in-service will include where this policy and procedure can be located. A copy will be readily available at each nurse's station. The in-service will also include notifying the administrator and the DON and/or their designees. Emergency phone list will be readily available with the procedures. D. The facility's wandering- control magnetic lock system will be tested on the same schedule as describe above by the charge nurse or his/her designee. Any malfunction will be reported immediately to the administrator and director of maintenance for corrective action to be initiated. E. In order to carry out the search procedures properly, a set of keys will be made and available to the charge nurse so that they can search behind doors that are normally locked. F. If a resident is missing in the future, and is not immediately located, the DON and/or the Administrator, or their designees, will personally search each locked room even if they have been previously searched. G. Facility staff will be in-serviced on residents with dementia and their unique supervision needs. H. The facility has recently hired a part-time security officer who will also receive the above cited training. IV. To insure ongoing compliance, the Quality Assessment and Assurance Committee will monitor this issue and make recommendations to the administrator as needed for corrective actions. The administrator will be responsible for implementing the recommendations." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two LVNs, 1 medication aide, two CNAs, and two housekeeping staff were interviewed and said that there were keys for all doors kept on a ring in the medication room. If they needed in a room, the nurse was able to get the keys. They each said the keys were coded by hall. They had been in serviced and were able to tell and demonstrate where the emergency/disaster book was kept which contained the missing person policy and phone numbers of key personnel. The LVNs and CNAs said they were to do a head count at the beginning, middle, and end of each shift and document the findings on a form. During an interview on 6/3/12 at 10:20 a.m. the administrator said 27 residents were on the secure unit.

Based on interview and record review, the facility failed to implement interventions to address pain for 1 of 2 residents who sustained a [MEDICAL CONDITION]. (Resident 1) Resident 1 fell at 7:00 a.m., complained of pain, but did not receive [MEDICATION NAME] (narcotic pain medication) until midnight that was ordered at 6:30 p.m. This failure could place all 122 residents at risk for uncontrolled pain should this practice continue. Findings include: 1. An incident report dated 12/02/2010 at 7:00 a.m. indicated Resident 1 said she attempted to transfer and fell landing on her left side. The resident was administered [MEDICATION NAME] (an antiflammatory pain medication for daily use) 50 mg (milligrams) two tablets at 7:40 a.m. The "Pain" assessment completed at the time of the fall stated her pain level was a 10, indicating severe pain. Her follow-up assessment an hour after the [MEDICATION NAME] was administered stated her pain was still at an "8." A telephone order dated 12/2/10 at 6:30 p.m. was written for [MEDICATION NAME] 5/500, a narcotic pain medication. The pain medication was not administered until 12 midnight, 17 hours after her fall and 5.5 hours after the [MEDICATION NAME] was ordered. The resident was not administered any additional [MEDICATION NAME] on the day of the fall. The [MEDICATION NAME] order, dated 11/22/10, indicated she could have one or two tablets every four hours as needed for pain. In interview with Resident #1 on 12/10/10 at 9:15 a.m., she stated it was a long time before she got anything for pain. She stated that she did get relief from the pain after she was finally given the medication that night. In interview with LVN (Licensed Vocational Nurse) A on 12/10/10 at 8:51 a.m., he stated that he took the order for Resident #1's [MEDICATION NAME] on 12/2/10 at approximately 6:30 p.m. He stated he was assisting Resident #1's nurse because she had just gotten a new admission. He stated he did not administer the medication, but informed her nurse of the order and that it was available in the emergency drug box. He was not aware that the medication did not get administered until the next shift at midnight. 2. During the exit conference, the facility was given the opportunity to provide additional information. There was no additional information given. The facility census of 122 was obtained from the facility CMS form 672 dated 12/8/10.