Every finding on record at Avir at Camp Wood

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility reviewed for safe and functioning equipment. 1. The facility failed to maintain 2 of 2 vans used for resident transportation with one van in the shop and the other one not having adequate air conditioning.2. The facility failed to maintain 1 of 2 reach in refrigerators in the kitchen for an unknown period and used it for dry goods storage.3. The facility failed to maintain hot water for 1 of 1 hand washing stations in the kitchen.These failures could place residents who require transportation services at risk of heat stroke by not having transportation with air conditioning and residents who eat meals from the kitchen at risk for food contamination, and food borne illness. 1. Record review of Resident #12's admission Record dated 9/12/2026 reflected she was admitted on [DATE]. Resident #12 had diagnoses of end stage renal disease, diabetes II, and chronic obstructive pulmonary disease. Record review of Resident #12's Quarterly MDS dated [DATE] reflected she was moderately cognitively impaired, she used a walker to mobilize, required set-up and supervision for ADLs. Record review of Resident #12's care plan dated 9/1/2026 reflected resident had potential fluid volume overload related to kidney failure related to Dialysis, diabetes II, resident needs dialysis related to renal failure, COPD. Observation on 9/11/2026 at 2:30 PM of the gray van that was left running for a bit revealed the back blower was blowing hot air, and the front of the van did not have air conditioning. The residents' seats were in the front of van, the 2nd seat was in the middle of van, but near the front. The back vents were blowing on the 2nd set of seats, but hot air was coming out. The temperature outside was about 100 Degrees Fahrenheit and was getting hotter. During interview on 9/11/2026 at 11:13 AM with Resident #12 stated that when she must go to Dialysis on Monday, Wednesday and Friday the van is hot. Resident #12 stated the van air conditioner had not worked for a while. So, Resident #12 sometimes asked her family to come pick her up and take her back to the facility from the Dialysis Center, which is about 45 minutes away. During an interview on 09/10/2026 at 1:40 p.m., the Maintenance Director revealed the facility had two vans, one was in the shop and the other the air conditioning blower was not working, but the back of the van does provide cold air. The Maintenance Director was unsure of how long the vans required repairs. During interview on 9/11/2026 at 2:29 PM with Transportation CNA D stated Resident #12 goes to Dialysis on Monday, Wednesday and Friday from 11 AM-5:15 PM. Transportation CNA D stated the white van was in the shop and used the grey van to transport residents for appointments. Transportation CNA D stated the grey van's air conditioner did not work in the front, and the blower works in the back. Transportation CNA D stated the grey van was an older van and the back side of the van blew out hot air. Transportation CNA D stated Resident #12 and other residents have complained of the van not having Air conditioner when it was hot outside. During interview on 9/11/2026 at 2:32 PM with Transportation CNA D stated there was a day that Resident #12's family had to pick her up from dialysis, due to the heat and the air conditioner did not work in the van. Transportation CNA D stated the white van has been in shop for about 2 weeks. During interview on 9/11/2026 at 2:45 PM with Maintenance Director stated the white van was in the shop, so they are using the grey van to transport residents to appointments. Maintenance Director stated the back blower of the van works and was blowing cool air when he used the van last. Maintenance Director stated the white van has been in shop for 2 weeks. During interview on 9/12/2026 at 12:53 pm with ADM stated the van's air conditioner was not working. The ADM stated she was made aware yesterday that the back of van blower was not working. ADM stated last month when she drove the grey van the air conditioner was working. ADM stated this could affect residents by residents passing out and residents health could decline and dehydration due to air conditioning not working in the van. Record review of Monthly Weather Forecast for town where the facility was located - weather.com reflected 100 Degrees Fahrenheit dated on 9/11/2026. 2. During an observation and interview on 09/08/2026 at 10:32 a.m. revealed 1 of 2 reach in refrigerators in the kitchen had an error code reading for temperature. The Dietary Manager said the reach in refrigerator located near the main kitchen entrance had been down for an unknown period and was only used for dry goods food storage. During an observation and interview on 09/10/2026 at 10:00 a.m. revealed 1 of 1 wash station in the kitchen was not functioning with hot water. The Dietary Manager said the hot water had been turned off a week ago by the maintenance director for safety as the water was too hot to wash hands under. She said she was unsure when the maintenance director would be repairing it and dietary staff are washing hands with cool water at this time. During an interview on 09/10/2026 at 12:12 p.m., the Maintenance Director revealed that the reach in refrigerator had been inoperable for a while and dry goods like oatmeal and cream of wheat were being stored in it. He said the refrigerator was old and management did not want to repair it. He said there was a functioning walk in and reach in refrigerator in good working condition. He said the equipment could be seen as abandoned in the kitchen. He said he could have the inoperable refrigerator removed and trashed. During an interview on 09/10/2026 at 3:21 p.m., the Maintenance Director revealed that he had shut off the hot water valve to the hand-washing station in the kitchen as it was getting extremely hot. He stated that he shut off the hot water sometime last week per management's directions. He said that he was instructed to purchase a part that would help reduce the water temperature. He said he had not had time to go to the hardware store to pick up the necessary valve to repair the hot water. He said not having hot water to wash hands in the kitchen could affect infection control and negatively affect the residents. During an interview on 09/12/2026 at 1:20 p.m., the Administrator revealed that all equipment in the facility needs to be maintained in a safe operating status. She said not maintaining equipment in a safe operating status could negatively impact residents. She said that the refrigerator being used for dry goods storage was not necessary and would work with the Maintenance Director to have it removed and would follow up on the repairs required for the two vans and hand-washing station hot water. Record review of facility policy titled, Maintenance Service revised December 2009, revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. f. establishing priorities in providing repair service. j. others that may become necessary or appropriate. 7. Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 of 2 medication carts (100 and 300 hall nurse carts) reviewed for medication storage and labeling. The facility failed to ensure all insulins were properly labeled and expired insulin discarded from carts. This failure could place residents who receive medications at risk of not receiving the intended therapeutic effects of their prescribed medications. The findings included:During an observation of the 300-hall nurse medication cart on 09/09/2026 at 8:30am, revealed two opened insulin vials which had not been dated when opened: Insulin Glargine 100u/ml vial was opened but not dated; label instructed to discard 28 days after opening and Insulin Lispro 100u/ml vial opened and not dated; label instructed to discard 28 days after opening. During an interview with LVN E on 09/09/2026 at 8:30am, LVN E stated that nurses should be dating insulins when they are opened, and she does not know why these were not dated and that this was her first time working with this medication cart. LVN stated that the risk of administering an expired insulin could be the medication not being as effective as it should be.During an observation of the 100-hall nurse medication cart on 09/09/2026 at 8:45 a.m., revealed an opened insulin vial which had not been dated when opened: Insulin Glargine 100u/ml vial was open but not dated; label instructed to discard 28 days after opening and an undated insulin pens: Lantus Solostar 100u/ml; label instructed to discard 28 days after opening.During an interview with LVN H on 09/09/2026 at 8:45 a.m. she stated that everyone was responsible for checking medication carts to check for expired medication and open dates but does not know why the insulins were not dated. LVN H stated that the risk of administering an expired medication could be the medication not working like it was supposed to.During an interview with DON on 09/11/2026 at 8:34 a.m. she stated medications should be dated when opened, especially insulins are only good for 28 days. The DON stated medication carts should be audited at least once a month to catch undated and expired medications and providing education will raise awareness. The DON stated that if an expired medication is administered to a resident, it may be ineffective.A record review of facility policy Medication Labeling and Storage dated February 2023, revealed: Medication Labeling: 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview and record review the facility failed to follow the menu for 1 of 2 days (09/10/2026) reviewed for the breakfast and lunch meal service.1. Dietary staff failed to follow the breakfast menu on 09/10/2026 and served biscuits and sausage gravy, oatmeal and dry cereal and lunch menu on 09/10/2026 and served steamed red potatoes, salad with dressing mixed in, hot dog bun with steak patty and sauteed onions, sauteed bell peppers, and lemon pudding on graham cracker crumbs.2. Dietary staff failed to maintain and document menu substitutions. 3. Dietary staff failed to discuss menu substitutions and gain approval to change menus with the Dietitian.These deficient practices could contribute to resident dissatisfaction.The findings included: Record review of the weekly calendar, Week 1 dated Summer 2026, revealed the breakfast menu being used was for Day: 5 - Thursday for Wednesday, 09/10/2026 the regular diet included assorted juice, cereal of choice, sausage patty, scrambled egg, breakfast bread of choice, margarine, jelly, milk, and beverage. Record review of the weekly calendar, Week 1 dated Summer 2026, revealed the lunch menu being used was for Day: 5 - Thursday for Wednesday, 09/10/2026 the regular diet included grilled Philly steak sandwich, potato wedges, tossed salad, dressing of choice, ketchup, cheesecake with dessert sauce, and beverage.During an observation on 09/10/2026 at 12:41 p.m., [NAME] K delivered a lunch test tray that consisted of Salsbury steak meat, with cooked bell peppers and cooked onions on a hotdog bun, no cheese, salad with lettuce, tomatoes, cheese and mixed salad ranch dressing, red steamed potatoes, and graham cracker crumbs with lemon pudding on top, iced tea, and water.During an observation and interview on 09/10/2026 at 10:29 a.m., [NAME] K revealed that she changed the breakfast menu of cereal of choice, sausage patty, scrambled egg, and breakfast bread of choice to biscuits and sausage gravy, oatmeal and dry cereal and excluded scrambled eggs because she knows her residents and they would not like to eat eggs two days in a row. She stated that other days due to administration budget she was required to substitute food items for the last several months. She said prior to company changes she would follow the menu and said the Dietary Manager was aware of the substitutions needed. She said she documents substitutions daily and the Dietary Manager keeps these logs. She said that she did not notify the Dietary Manager that she would be excluding scrambled eggs from this morning's breakfast and she made that decision on her own. She was observed documenting the blank Menu Substitution Log in the Dietary Manager's office. She said she had forgotten to document 09/09/2026 and 09/10/2026 breakfast substitutions. [NAME] K was observed documenting 09/09/2026 and 09/10/2026 planned menu item, item substituted and reason documented listed the food item substituted for and did not specify reason for substitution. She said residents' diets could be affected by substitutions and she should have notified the Dietary Manager of menu substitutions and should have documented these substitutions. Observation of [NAME] K preparing 09/10/2026 lunch. She was observed preparing steamed red potatoes, salad with dressing mixed in, hot dog bun with steak patty and sauteed onions, sauteed bell peppers, and lemon pudding on graham cracker crumbs.During an interview on 09/10/2026 at 10:42 a.m. the Dietary Manager said she had given [NAME] K directions to make substitutions to the menu and substitutions would be documented in the Menu Substitution Log. She said she was aware of substitutions to the menu for the last 30 days due to the facility budget. She said that she can recall that on 09/08/2026 the menu called for pot roast, and she had substituted the meat to pork loin. She said that lunch and dinner menus are followed. She said at times sausage was substituted for bacon as not everyone can have bacon. She said she was not aware that scrambled eggs were left off this morning's breakfast menu and was not sure of the reason the cook made this decision and that the facility had enough eggs to serve. She said bacon was not often ordered as breakfast menu was not often followed. She said she did not keep menu substitution logs and could not produce any for the last 60 days. She said the dietitian was remote and she had not notified the dietitian of menu substitutions. She said making changes to the menu should have been discussed with the dietitian as it could affect resident diets. She said there was no specific reason why she had not reached out to the dietitian.During an interview on 09/12/2026 at 1:20 p.m., the Administrator revealed that the Dietary Manager was required to follow any recommendations made by the Dietitian regarding menus and menu substitutions. She said that the Dietary Manager should consult with the Dietitian prior to making changes to the menus including substitutions. She said not following menus and making substitutions to the menu without the Dietitian's approval could impact the residents' health and nutrition. During a phone interview on 09/15/2026 at 10:29 a.m. the Dietician revealed that she has been assigned to the facility for the last two months and she provides consultations remotely. She said the Dietitian was contracted to work with the Dietary Manager on menus and substitutions. She said that menus would be reviewed and signed off on. She said menus are created, reviewing and making sure in line with policy. She said the Dietary Manager and cooks should be following the menus as is, which are approved by the Dietitian. She said any substitutions should be documented, Dietitian should be notified and signed off on for them to take place. She said the Dietary Manager had her direct contact information and there were no notifications of substitution changes received.Record review of facility document titled, Standardized Recipes dated 2023 and approved 08/31/2026, revealed 5. Cooks/chefs should discuss problems or concerns about recipes with the director of food and nutrition services so that issues can be resolved.Record review of facility document titled, Menu Substitutions dated 2023 and approved 08/31/2026, revealed Menu substitutions will be made after discussion with the director of food and nutrition services whenever possible . 1. Kitchen staff will consult with the director of food and nutrition services or designee on any needed menu substitutions . 3. All changes to the menu (including the date, menu item substitution and reason for the substitution) will be recorded. 4. The registered dietician nutritionist (RDN) or designee will periodically evaluate menu changes and if needed, an appropriate plan of action will be made to correct any concerns. 5. Records of menu substitutions should be retained for a reasonable period of time.

Based on observation, interview, and record review, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for 3 of 3 (lunch on 09/08/2026, 09/09/2026, and 09/10/2026) meals observed for dietary services.The facility failed to serve the 09/08/2026, 09/09/2026, and 09/10/2026 lunch meals on time at the scheduled time based on the meal postings.This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medications given without food, and diminished quality of life.The findings included:Observation on 09/08/2026 at 12:00 p.m. in the main dining room of meal times posting revealed lunch 12:00 PM.Observation on 09/08/2026 at 12:58 p.m. revealed the first hall tray was passed to residents on 400 hall. Observation on 09/09/2026 at 12:44 p.m. revealed the first hall tray was passed to residents on 400 hall.Observation on 09/10/2026 at 12:44 p.m. revealed the first hall tray was passed to residents on 400 hall.During an interview on 09/10/2026 at 10:20 a.m. the DA L said that meals are consistently late. She said that the meals are not normally late so she would not know for sure how having late meals would affect residents.During an interview on 09/10/2026 at 10:42 a.m. the Dietary Manager denied meals being served late and denied complaints from residents regarding late meals. She said that meals are typically served to the halls 15-20 minutes following the scheduled time of 7 a.m., 12 p.m., and 5 p.m. She said that by not serving meals according to the schedule could cause concerns with residents' health, their blood sugar, and they could become upset. During a confidential interview at an undisclosed date and time, four anonymous residents stated that the meals are normally late.During an interview on 09/11/2026 at 1:04 p.m., CNA G revealed that depending on how fast staff serve meals in the dining room the meals served to the halls could be late. She said sometimes there are resident complaints about meals being 30-45 minutes late. She said the facility procedures are to deliver meals on time. She said that when meals are not delivered as scheduled or at a decent time some residents will refuse the meal and will refuse to eat all together. She said she could not recall which residents had declined their meal because of it being late.During an interview on 09/12/2026 at 1:20 p.m., the Administrator revealed that there are some very vocal residents who have voiced that meals are constantly late. She said that residents have grown used to having meals late. She said that the facility's policy was to deliver meals timely and according to schedule. She said by not delivering meals as scheduled could have an impact on residents' rights. Record review of untitled and undated document revealed meal times for the facility, Breakfast: 7 AM, Lunch: 12 PM, and Dinner: 5 PM.Record review of policy titled, Meal Times and Frequency dated 2023, revealed The facility will provide at least three meals daily at regular times comparable to standard meal times in the community.Meals will be served in a timely manner.

Based on observation, interview and record review the facility failed to ensure the assessment accurately reflected the residents' status for 1 of 9 (Resident #37) residents whose records were reviewed for assessments.1. Nursing staff failed to accurately code Resident #37's assessment of mental status, daily preferences, activity preferences, and that he had behavioral symptoms on his MDS assessment to reflect progress notes being documented.2. This deficient practice could place residents at risk of not identifying care areas and result in residents not receiving needed care and services.The findings included:Record review of Resident #37's admission Record, dated 09/10/2026, revealed a [AGE] year-old male admitted [DATE], he was listed as his own responsible party. Record review of Resident #37's Medical Diagnoses, undated and accessed 09/10/2026 at 4:46 p.m., revealed diagnoses including neuromyelitis optica (central nervous system disorder that causes inflammation in nerves of the eye and the spinal cord, type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as fuel), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), polyneuropathy (refers to the breakdown of peripheral nerves that typically affects multiple nerves symmetrically throughout the body) paraplegia (paralysis of the legs and lower body caused by a problem with the spinal cord or nerves), acquired absence of right leg above knee, palliative care (specialized form of care that provides symptom relief, comfort and support to people living with serious or chronic illnesses), Human Immunodeficiency Virus (HIV) Disease (virus that attacks the body), neuromuscular dysfunction of bladder (occurs when nervous system issues affect bladder control), and pressure ulcer (injuries to the skin and underlying tissue caused by prolonged pressure on the skin) of sacral region (lower part of the spine). Record review of Resident #37's Modification MDS, dated [DATE] and signed as completed 09/08/2026, reflected no BIMS score coded and coded yes, staff assessment for mental status be conducted and coded and no response for Resident Mood Interview. Resident #37 was documented as having not exhibited any behavioral symptoms, including physical, verbal, and other behavioral symptoms directed toward others. Resident #37 was documented for rejection of care with this behavior of this type occurred 4 to 6 days, but less than daily, Section F -Interview for Daily Preferences was documented as no response or non-responsive, Interview for Activity Preferences was documented as no response or non-responsive, and Daily and Activity Preferences Primary Respondent was documented as Interview could not be completed by resident. Resident #37's Staff Assessment of Daily and Activity Preferences was documented as Resident Prefers: F. Receiving sponge bath. Resident #37's functional limitation in range of motion was documented as having an impairment on both sides to lower extremity, functional abilities of self-care were documented as requiring substantial/maximal to setup or clean-up assistance and functional abilities of mobility were documented as 09. Not applicable - Not attempted to 01. Dependent assistance for walk 10 feet and tub/shower transfer. Resident #37 was documented as having special treatments and was on hospice care. Record review of Resident #37's Care Plan, updated and accessed on 09/10/2026 at 5:47 p.m., revealed Resident #37 had potential to be physically aggressive r/t Anger, History of harm to others, Poor impulse control, history of throwing items at staff and others, and breaking holes in walls and facility property destruction. initiated: 08/14/2026 and revised 09/09/2026 with interventions of documenting observed behavior and attempted interventions in behavior log. [monitoring/documenting/reporting] PRN any s/sx of resident posing danger to self and others. [and when Resident #37] becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. initiated 08/14/2026 and revised 09/03/2026. During an observation and interview on 09/08/2026 at 10:50 a.m., revealed Resident #37 was lying down in bed watching television and playing with his cell phone. He engaged in conversation and shared his experiences while at the facility. Resident #37 was fixated on discussing his dissatisfaction with services, the food, and the former SNF he transferred from. Resident #37 was alert, had full awareness and oriented to person, place, time, and situation, and his cognition was intact. Resident #37 said that it had been rough here, when given services staff use EBP, not sure of medications administered as staff will not speak with him and the ones that do make comments that he had AIDS. He said if it was not for the Administrator, he was not sure what would happen. He said that he will record every staff member that enters his room. He said he knew his rights and he had fears and thus for recording every interaction. He said that nursing staff will tell him he had AIDS, he was racist, so he does not talk to the staff or call for help other than when he needs pain medication. During an interview on 09/11/2026 at 4:10 p.m., the Regional MDS Coordinator revealed that the current MDS Coordinator was new and in training and currently was responsible for inputting MDS assessments. She said the Administrator was responsible for overseeing the MDS assessments until the position had been filled and had the ability to reach out to other region to review, look over, or to input MDS assessments and she was responsible for signing off on them. She said on a PRN basis she would review medical records, the DON would sign MDS as complete, but when it was vacant the RNC was responsible for signing off on them. She said that if an MDS assessment was not accurate or not completed within the required timeframes that it could impact the residents and it would not give a true picture of the care they require. She referred to the position being vacant and staff in training for reason Resident #37's MDS assessment had been inaccurately coded. During an interview on 09/12/2026 at 11:13 a.m., the ADON revealed that Resident #37 had only been verbally aggressive with staff and had not been physically aggressive. She said that the facility did not have an MDS Coordinator from June - September 2026 and current one was in training. She said that regional office works on the MDS remotely. She said regional staff will review the resident's electronic medical record for diagnoses, care plan, progress notes when completing the MDS assessments. She said that electronic medical records may be missing or not present in the medical record and that can impact how the MDS assessment was coded. She said inaccurate MDS assessments negatively impact a resident's care. The ADON said that Resident #37 could be challenging to work with, but that he did not refuse direct care from her, and she had not experienced physical aggressive behaviors towards her. During an interview on 09/12/2026 at 12:19 p.m., Human Resources revealed that she had not witnessed Resident #37's physical or verbal behaviors. She said that during the morning meeting she had been informed that he was verbally aggressive towards the MDS Coordinator but was unable to provide additional details. Record review of policy titled, Comprehensive Assessments revised February 2025, revealed Comprehensive assessments are conducted to assist in developing person-centered care plans. 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. 2. admission Assessment - The admission assessment is a comprehensive assessment for a new resident.that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1; if a. this is the resident's first time in this facility. Record review of policy titled, Care Plans, Comprehensive Person-Centered revised March 2022, revealed .2. The comprehensive, person-centered care plan is developed within (7) days of the completion of the required MDS assessment (Admission/Annual or Significant Change in Status), and no more than 21 days after admission. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; g. receive the services and/or items included in the plan of care. 11. Assessments of residents are ongoing. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 9 residents (Residents #17, #34) reviewed for dignity in 1 of 4 hallways and 1 of 1 dining room reviewed for resident rights. 1. The facility failed to promote Resident #17's dignity and privacy during lunch when staff checked his blood pressure and administered medications to him in the dining room around other residents on 09/08/2026.2. The facility failed to promote Resident #34's dignity when staff failed to respond in a timely manner to residents' request for incontinence care assistance on 09/08/2026. These failures could place residents at risk of diminished dignity and affect their quality of life.The findings included:1. Record review of Resident #17's admission Record, dated 09/09/2026, revealed a [AGE] year-old male admitted on [DATE]. Resident #17 was listed as his own responsible party with his [family member] listed as Emergency Contact #1.Record review of Resident #17's Medical Diagnoses, undated and accessed 09/09/2026 at 4:00 p.m., revealed diagnoses including peripheral vascular disease (condition characterized by narrowed arteries that reduce blood flow to the limbs, primarily the legs), absence of right leg below knee, anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest), and type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as fuel).Record review of Resident #17's Quarterly MDS assessment, dated 07/01/2026 and signed 07/10/2026 as completed, revealed no BIMS score was documented for Resident #17. Resident #17 was documented as taking antidepressants and hypoglycemics. Resident #17's functional abilities were documented as requiring partial/moderate to setup or clean-up assistance.Record review of Resident #17's Care plan, updated and accessed 09/12/2026 at 9:22 a.m., revealed Resident #17 was at risk for anxious behaviors r/t [related to] Anxiety. [Goal] overall comfort, safety, sense of well-being, and self sufficiency will be support by lessening/elimination of causes of Anxiety. dated 10/18/2024 and revised 10/28/2025. Resident #17 was documented has having impaired cognitive function or impaired thought process r/t confusion at times, Anxiety, Depression. dated 10/18/2024.Record review of Resident #17's electronic medical record reflected that there was no update to the care plan to allow for blood pressure checks and medication administration to occur during lunch time.During an observation on 09/08/2026 at 12:16 p.m., Resident #17 was observed sitting in his wheelchair in the dining room preparing to eat lunch. Other residents were observed sitting at his table. The ADON was observed checking Resident #17's blood pressure at the dining table and administering him medication.During an observation and interview on 09/08/2026 at 12:45 p.m., Resident #17 was observed sitting near the front door of the facility. His cognition was moderately impaired, and he was unable to appropriately answer a few questions. Resident stated that he does not like it when the nursing staff check his blood pressure and administer his medications during lunch as this interrupts his lunch time and disturbs him from eating his meal.2. Record review of Resident #34's admission Record, dated 09/09/2026, revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Resident #34 was not listed as her own responsible party with her [family member] listed as Emergency Contact #1.Record review of Resident #34's Medical Diagnoses, undated and accessed 09/09/2026 at 6:26 p.m., revealed diagnoses including schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), pressure ulcer of left buttock, unstageable, pressure ulcer of other site, stage 4, unspecified open wound, right lower leg, unspecified open wound, right foot, anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), and mood disorder (mental health condition that primarily affects your emotional state).Record review of Resident #34's Quarterly MDS, dated [DATE] and signed 08/24/2026 as completed, reflected a BIMS score of 11, indicating moderate cognitive impairment. Resident #34 was documented as having Little interest or pleasure in doing things. with frequency of several days and Feeling down, depressed, or hopeless with frequency of several days. Resident #34's functional abilities were documented as requiring substantial/maximal to setup or clean-up assistance and mobility requiring dependent assistance. Resident #34 was documented as always having urinary and bowel continence. Resident #34 was documented as being at risk of developing pressure ulcers/injuries and required the use of pressure reducing device for bed and was taking antipsychotics, antidepressants, and hypoglycemics.Record review of Resident #34's Care Plan, undated and accessed 09/09/2026 6:33 p.m., revealed Resident #34 was dependent on staff for meeting emotional, intellectual, physical and social needs.[and] has a potential for pressure ulcer development r/t Immobility, Incontinence, Poor nutritional intake, Anemia, HIGH RISK SKIN Resident is unavoidable for Skin breakdown. dated 01/23/2025. Observation and interview on 09/08/2026 at 4:40 p.m., revealed that Resident #34 was lying in bed and stated that she had been waiting for over two hours to have incontinence care performed on her. She stated that she requires two staff assistance to meet her needs due to her functional ability and that call light responses can exceed 5-10 minutes before someone responds and turns the light off and longer than two hours before she was provided with incontinence care. She stated that she pressed the call light to request assistance with incontinence care earlier today and she was still waiting. She stated that has no choice but to wait for the nursing staff but sometimes it will make her angry. She was observed pressing the call light and requesting assistance. The call light remained blinking for seven minutes. LVN B walked by Resident #34's room past the blinking call light until the MDS Coordinator answered the call light at 4:47 p.m. The MDS Coordinator stopped CNA F and notified her that Resident #34 was requesting assistance with incontinence care. CNA F asked aides for assistance with providing Resident #34 with incontinence care. CNA F returned to Resident #34's room at 5:10 p.m. along with additional aid to provide her with incontinence care. During an interview on 09/10/2026 at 7:20 p.m., CNA H revealed that that she had been trained on resident rights and dignity. She said that the call lights should be responded to within 3 minutes and that any staff member can answer them. She said that not responding to call lights in a timely manner could lead to falls or unanswered resident emergency.During an interview on 09/12/2026 at 10:24 a.m., LVN B revealed that the last face-to-face in-service on resident rights was in October 2025 and all other trainings were online or a sheet of paper that was circulated during shifts. She said that call light response should be within 3 beeps, roughly less than a minute and any staff can answer. She said that incontinence care should not take any longer than 10-15 minutes to provide a resident with care and anything after 15 minutes would be too long. She stated that if residents were waiting 30 minutes or more, they would feel like nobody cares, would feel hurt, nasty, and humiliated. She said long waiting periods for incontinence care could cause wounds. She said she did not recall walking past Resident #34's room when her call light was on.During an interview on 09/12/2026 at 11:13 a.m., the ADON revealed the nursing staff were constantly provided training on resident rights and dignity. She stated the policy for resident rights was that residents have all the rights. She said if a resident did not have their rights honored could affect them emotionally, physically, mentally, and could change their eating habits and cause them to become depressed or to isolate themselves. She said that all staff can answer call lights within 3-5 minutes. She said the emergency light should be answered in less than 3 minutes. She stated that waiting more than 7 minutes to answer a call light was unacceptable. She said if staff were providing care to another resident they need to communicate with the resident who needs assistance or find another staff to assist with request. The ADON said that 30 minutes for incontinence care would be too long and it could impact the residents and cause skin problems and dignity issues. She said that some residents have their care planned documented to administer medications and check their blood pressure during their lunch, but she could not recall which residents were care planned. During an interview on 09/12/2026 at 1:20 p.m., the Administrator revealed that the nursing staff have been educated on resident rights and on privacy and dignity. She said the nursing staff were required to ensure that residents get the highest quality of care and dignity when providing care regardless of their behavior. She stated that if the residents' rights were not being honored that their health could decline and could cause them to become depressed. She said if a resident did not have their rights honored it could impact their care and cause their health to diminish. She said all staff were responsible for answering call lights timely and within 3 minutes. She said there were more than enough staff to answer call lights timely. She said that if call lights were not answered timely this could leave a resident with unmet needs and safety concerns. She said a resident could be using the call light because their life was in jeopardy or something simple like needing a remote control. She said that staff were required to follow resident rights policy and ensure their dignity and needs are being met. The Administrator said that if the nursing staff were not following policy that it could have an impact on the residents' dignity and privacy and could cause them to become depressed. She stated that residents were expected to have time for their meal during lunch and that medication administration and blood pressure checks should be performed before or after meals. The Administrator said that if the nursing staff were not following policy that it could have an impact on the residents' dignity and privacy, and that it was a HIPPA violation and could cause them to become depressed. She added that residents want to enjoy their meals in peace. Record review of policy titled, Resident Rights date revised February 2021, revealed Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. Record review of policy titled, Dignity, revised February 2021, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: b. promptly responding to a resident's request for toileting assistance. e. provided with a dignified dining experience . Record review of policy titled, Homelike Environment, revised February 2021, revealed Residents are provided with a safe, clean, comfortable and homelike environment. 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. Record review of policy titled, Call System, Residents date revised January 2025, revealed Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 6. Calls for assistance are answered timely.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 4 residents reviewed (Resident #20 and Resident #73) for infection control. 1. CNA C turned Resident #20 onto a soiled brief after cleaning the resident during catheter and incontinent care. 2. CNA G failed to change gloves and perform hand hygiene after cleaning and removing a soiled brief while providing incontinence care to Resident #73.These failures could place residents at risk of cross contamination and infection.The findings include:1. A record review of Resident #20's Face Sheet, dated 09/10/2026, revealed the resident was a [AGE] year-old male, initially admitted to the facility on [DATE], readmitted on [DATE], with diagnosis of neuromuscular dysfunction of bladder (loss of bladder control due to brain, spinal cord, or nerve problems).A record review of Resident #20's Quarterly MDS assessment, dated 06/23/2026, revealed the resident had a BIMS score of 05, indicating severe cognitive impairment; resident had an indwelling catheter, and was always incontinent of bowel.A record review of Resident #20's Care Plan Report, reviewed on 09/10/2026, revealed focus: bowel and bladder incontinence, with intervention: INCONTINENT: Check FREQ and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Date Initiated: 4/26/2022.During an observation on 09/10/2026 at 10:35 a.m. CNA C and CNA D provided catheter and incontinence care to Resident #20. CNA C turned Resident #20 to left side, cleaned the resident's buttocks, but failed to remove soiled brief and turned Resident #20 back onto the soiled brief.During an interview on 09/10/2026 at 10:50 a.m., CNA C stated he forgot to remove the soiled brief before turning Resident #20 because he was a new CNA. He stated failing to remove the soiled brief could cause cross contamination and infection by exposing the resident to bacteria.During an interview on 09/10/2026 at 10:55 a.m., CNA D stated that cleaning a resident's skin and then placing them back on a soiled brief should not occur because it is infection control and can cause infections.2. A record review of Resident #73's Face Sheet, dated 09/10/2026 revealed a [AGE] year-old female with diagnoses of metabolic encephalopathy (when problems with metabolism cause brain dysfunction) schizophrenia (a mental disorder that causes altered thought processes, perceptions and emotional responsiveness) and dementia (loss of mental functions affecting memory and the ability to perform daily activities).A record review of Resident #73's Quarterly MDS assessment, dated 06/08/2026, revealed the resident is rarely/never understood, and was always incontinent of bladder and bowel.A record review of Resident #73's Care Plan Report, reviewed on 09/10/2026, revealed focus: The resident has bladder incontinence r/t Confusion, Dementia, schizophrenia, with intervention: INCONTINENT: Check every two hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Date Initiated: 12/13/2023.During an observation of incontinence care for Resident #73 on 09/10/2026 at 2:00 p.m. CNA G failed to remove her gloves and perform hand hygiene after cleaning the resident and before applying the clean brief.During an interview with CNA G on 09/10/2026 at 2:15 p.m. she stated she forgot to change her gloves, use hand sanitizer, and put on clean gloves before applying the clean brief because she was nervous. CNA G stated that hand washing and changing gloves is important for the safety of the resident.During an interview with the DON on 09/11/2026 at 8:34 a.m., she stated hand hygiene and changing gloves should be performed at the correct times during incontinent care and failing to do so may result in cross contamination and infection. The DON stated she has begun educating the staff on hand hygiene.Record review of facility policy titled, Perineal Care, dated February 2018, revealed: Purpose: the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Male and Female: 4. Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens/adult brief.

Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 (Resident #20) of 2 residents reviewed for incontinent care and indwelling urinary catheters. The facility failed to ensure Resident #20's indwelling urinary catheter tubing was secured during personal care to prevent dislodgement and injury.This failure could place residents at risk of accidental pulling of the catheter tubing and/or injury.Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 (Resident #20) of 2 residents reviewed for incontinent care and indwelling urinary catheters.The facility failed to ensure Resident #20's indwelling urinary catheter tubing was secured during personal care to prevent dislodgement and injury.This failure could place residents at risk of accidental pulling of the catheter tubing and/or injury.The findings were:A record review of Resident #20's Face Sheet, dated 09/10/2026, revealed the resident was a [AGE] year-old male, initially admitted to the facility on [DATE], readmitted on [DATE], with diagnosis of neuromuscular dysfunction of bladder (loss of bladder control due to brain, spinal cord, or nerve problems).A record review of Resident #20's Quarterly MDS assessment, dated 06/23/2026 revealed the resident had a BIMS score of 05, indicating severe cognitive impairment and resident had an indwelling catheter.Record review of Resident #20's Order Summary Report dated 09/10/2026 revealed an active order: Secure catheter with leg strap every shift, dated 03/13/2026.During an observation on 09/10/2026 at 10:35 a.m. CNA C and CNA D provided catheter and incontinence care to Resident #20 and there was no leg strap or securement device in place. Neither CNA acknowledged the absence of a securement device to the resident's catheter tubing.During an interview on 09/10/2026 at 10:50 a.m. CNA C stated he did not notice that Resident #20's catheter tubing was not anchored to the resident's leg. CNA C stated that failing to secure the tubing may cause tension and the possibility of pulling the catheter out and that the nurse should be notified to replace the leg strap.During an interview on 09/10/2026 at 10:55 a.m., CNA D stated that Resident #20 did not have his catheter tubing secured with a leg strap which can cause it to be pulled. CNA D stated that there are leg straps available, and the nurse was responsible for replacing them.During an interview with DON on 09/11/2026 at 8:34 a.m. she stated her expectation was that urinary catheter tubing is secured to the resident's leg for all residents with a catheter and the CNA staff should notify the nurse if the leg strap was missing.During an interview with LVN B on 09/12/2026 at 11:40am, she stated that CNA's and nurses are responsible for checking catheter securement devices are in place and there is an order in the MAR for the nurse to check off every shift that the leg strap was present because failing to have the catheter tubing anchored may cause pulling or injury if the catheter becomes dislodged.A record review of facility policy titled Catheter Care, Urinary dated July 2024, revealed: Steps in the Procedure: 18. Secure catheter utilizing a leg band.

Based on observation, interview, and record review the facility failed to provide a resident who is unable to carry out activities of daily living the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 9 residents (Residents #34 and #37) reviewed for Activities of Daily Living.1. The facility failed to ensure that Resident #34 was provided with incontinent care and ADL assistance in a timely manner.2. The facility failed to ensure Resident #37 received showers frequently from 08/13/2026 (admission date) to 09/11/2026.These failures could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.The findings included:1. Record review of Resident #34's admission Record, dated 09/09/2026, revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Resident #34 was not listed as her own responsible party with her [family member] listed as Emergency Contact #1.Record review of Resident #34's Medical Diagnoses, undated and accessed 09/09/2026 at 6:26 p.m., revealed diagnoses including schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), pressure ulcer of left buttock, unstageable, pressure ulcer of other site, stage 4, unspecified open wound, right lower leg, unspecified open wound, right foot, anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), and mood disorder (mental health condition that primarily affects your emotional state).Record review of Resident #34's Quarterly MDS, dated [DATE] and signed 08/24/2026 as completed, reflected a BIMS score of 11, indicating moderate cognitive impairment. Resident #34 was documented as having Little interest or pleasure in doing things. with frequency of several days and Feeling down, depressed, or hopeless with frequency of several days. Resident #34's functional abilities were documented as requiring substantial/maximal to setup or clean-up assistance and mobility requiring dependent assistance. Resident #34 was documented as always having urinary and bowel continence. Resident #34 was documented as being at risk of developing pressure ulcers/injuries and required the use of pressure reducing device for bed and was taking antipsychotics, antidepressants, and hypoglycemics.Record review of Resident #34's Care Plan, undated and accessed 09/09/2026 at 6:33 p.m., revealed Resident #34 was dependent on staff for meeting emotional, intellectual, physical and social needs.[and] has a potential for pressure ulcer development r/t Immobility, Incontinence, Poor nutritional intake, Anemia, HIGH RISK SKIN Resident is unavoidable for Skin breakdown. dated 01/23/2025. Observation and interview on 09/08/2026 at 4:40 p.m., revealed that Resident #34 was lying in bed and stated that she had been waiting for over two hours to have incontinence care performed on her. She stated that she required two staff assistance to meet her needs due to her functional ability. She stated that call light responses can exceed 5-10 minutes before someone responds and turns the light off. She said that she can wait up to two hours before she would be provided with incontinence care. She stated that she pressed the call light to request assistance with incontinence care earlier today and she was still waiting. She stated that she had no choice but to wait for the nursing staff but sometimes it would make her angry. She was observed pressing the call light at 4:40 p.m. and requesting assistance. The call light remained blinking for seven minutes. LVN B walked by Resident #34's room past the blinking call light until the MDS Coordinator answered the call light at 4:47 p.m. The MDS Coordinator stopped CNA F and notified her that Resident #34 was requesting assistance with incontinence care. CNA F asked aides for assistance with providing Resident #34 with incontinence care. CNA F returned to Resident #34's room at 5:10 p.m. along with an additional aide to provide her with incontinence care. 2. Record review of Resident #37's admission Record, dated 09/10/2026, revealed a [AGE] year-old male admitted [DATE]. Resident was listed as his own responsible party.Record review of Resident #37's Medical Diagnoses, undated and accessed 09/10/2026 at 4:46 p.m., revealed diagnoses including neuromyelitis optica (central nervous system disorder that causes inflammation in nerves of the eye and the spinal cord, polyneuropathy (refers to the breakdown of peripheral nerves that typically affects multiple nerves symmetrically throughout the body) paraplegia (paralysis of the legs and lower body caused by a problem with the spinal cord or nerves), acquired absence of right leg above knee, palliative care (specialized form of care that provides symptom relief, comfort and support to people living with serious or chronic illnesses), Human Immunodeficiency Virus (HIV) Disease (virus that attacks the body), neuromuscular dysfunction of bladder (occurs when nervous system issues affect bladder control), and pressure ulcer (injuries to the skin and underlying tissue caused by prolonged pressure on the skin) of sacral region (lower part of the spine).Record review of Resident #37's Modification MDS, dated [DATE] and signed as completed 09/08/2026. Resident #37's Staff Assessment of Daily and Activity Preferences was documented as Resident Prefers: F. Receiving sponge bath. Resident #37's functional limitation in range of motion was documented as having an impairment on both sides to lower extremity, functional abilities of self-care were documented as requiring substantial/maximal to setup or clean-up assistance and functional abilities of mobility were documented as 09. Not applicable - Not attempted to 01. Dependent assistance for walk 10 feet and tub/shower transfer. Resident #37 was documented as having an indwelling catheter [suprapubic catheter] and ostomy for bladder and bowel. Resident #37 was documented as having a condition or chronic disease that may result in a life expectancy of less than 6 months. Resident #37 was documented as having a pressure ulcer/injury, was at risk of developing pressure ulcers/injuries, and having one or more unhealed pressure ulcers/injuries with (1) stage 3 pressure ulcer and (2) unstageable pressure injuries presenting as deep tissue injury that were present upon admission. Resident #37 was documented as having special treatments and was on hospice care.Record review of Resident #37's Care Plan, updated and accessed 09/10/2026 at 5:47 p.m., revealed Resident #37 had an ADL self-care performance deficit r/t Paraplegia and frequent refusal of care and interventions of BATHING/SHOWERING: [Resident #37's] USUAL ability to wash, rinse, and dry self. needs Substantial/Maximal by 1-2 staff with (bathing or showering) .Report any changes to the nurse initiated 09/03/2026 and revised 09/09/2026.Record review of Resident #37's Palliative Care Plan, dated 08/13/2026, revealed that Resident #37 was admitted to palliative care for diagnosis of neuromyelitis optica.Record review of Resident #37's Transfer/Discharge Report dated 08/12/2026 from Former SNF, revealed he was admitted [DATE] and discharged [DATE]. Resident #37's admission record was documented as not having behaviors; Administration Progress Note dated 08/06/2026 at 4:16 a.m. documented that [Resident #37] PREFERS WOUND CARE AT NIGHT AFTER SHOWER. Record review of Resident #37's Care Sheet undated and accessed 09/12/2026 at 11:35 a.m. revealed Resident #37's Intervention Shower/Bathing: Prefers (SPECIFY) . QShift [every shift] documented that staff had provided resident #37 with a shower two times a day from September 01 - September 11, 2026. Care Sheet did not document when the resident was to receive showers. Record review of In-Services from 08/13/2026 [admission date] to 09/12/2026 did not reveal the Administrator provided education to the staff on how to care for Resident #37's ADLs. During an observation and interview on 09/08/2026 at 10:50 a.m. revealed Resident #37 was alert, had full awareness and oriented to person, place, time, and situation, and his cognition was intact. Resident #37 said that it had been rough here as staff will not speak with him and the ones that do make comments that he had AIDS was racist, so he does not talk to the staff or call for help other than when he needs pain medication.During an observation and interview on 09/10/2026 at 7:26 p.m., Resident #37 was observed lying down in bed. He said that he only had one shower since he arrived at the facility more than three weeks back. He said staff had offered him a bed bath and he had declined as he could do on his own, which was how he stayed clean. He said he had made it clear that he wanted a shower. He said that staff have denied him showers because they do not have additional staff to help him transfer to a shower chair. He said that the hospice nurse could not provide him with a shower as she said she would require nursing staff help to transfer him and they informed her that they did not have enough staff members to provide a shower. During an interview on 09/09/2026 at 11:23 a.m., CNA J revealed that they are short staffed today, she worked Monday - Friday and she showered a bunch of residents yesterday. She said she came in a little late today and she had not started showers yet. She said residents are provided with showers roughly every other day and a shower sheet documenting showers would be turned in daily for residents provided with showers. She said that not providing residents with showers often could cause skin conditions, infections, make them uncomfortable and cause them to have behaviors. She said since Resident #37's admission [DATE]] she had not provided him with a shower.During an interview on 09/10/2026 at 6:13 p.m., CNA I revealed that when working the previous day, she completed 3 resident showers and left 1 shower incomplete. She said she was not sure if it got passed on to the next shift. She said she tries to do as much as she can for the residents during her shift. She said she will do her best to get all residents who ambulate with walkers completed first and 1 resident who requires a Hoyer lift. She said if a staff member comes in to help her then she will provide a shower to a resident requiring a Hoyer lift or offers bed bath. She said she documents all showers and bed baths provided to residents on a shower sheet. She said that when residents do not receive showers frequently, they could feel dirty. She said that when they are short staffed some residents will miss showers. She said she recalled that when she did not have a second staff or floater staff assigned to her hall with her, she would be unable to provide showers, but she could not recall the date or the residents that were not showered. She said she had not been assigned to provide Resident #37 with a shower.During an interview on 09/10/2026 at 7:20 p.m., CNA H said that when she was tasked with providing residents with showers during her shift, she would do her best to complete them during her shift. She said that not providing residents with showers frequently can cause skin breakdown, cause openings, and pressure sores. She said that she had not been assigned to provide Resident #37 with a shower recently.During an interview on 09/10/2026 at 8:11 p.m., the Administrator revealed that following Resident #37's physical and verbal aggression incident during his admission the nursing staff had refused to provide him with care. She said Resident #37 had informed her that no nurse or aide would assist him because they were fearful of him having AIDS, fearful of him being a sex offender, fearful he would be physical with them. She said that she and two other staff members provided Resident #37 with a shower two days after admission. She said she had built a rapport with Resident #37 and to an extent he would trust her. She said that she understood Resident #37's frustration and agitation combined with hourly morphine for his pain regimen that caused him to be physically and verbally aggressive during his admission and unwanted EMS transfer to the facility. The Administrator said that the nursing staff had been provided education on Resident #37's current medical condition and the care that he required. She said that she had concerns that several of the nursing staff members are not providing Resident #37 with direct care. She was unwilling to provide specific information on which staff members were not providing care to Resident #37.During an interview on 09/11/2026 at 12:36 p.m., CNA M revealed that she had provided Resident #37 with direct care including transferring him into a Geri chair, changing his brief, and rolling him to his side to put new pads underneath him and he had not refused care. She said that Resident #37 had not asked her for a shower, but said if he did, she would provide him with one. She said staff calling out for their shift and not showing up can affect providing residents with showers. She could not recall the last shift she worked or the names of residents who had not received a shower. She said that staff are required to document every shower, every refusal to shower, and every bed bath on a shower sheet that would be turned in to the nurse in charge. She said that if residents were not provided with showers, it could affect their health.During an interview on 09/11/2026 at 1:04 p.m., CNA G revealed that there should be shower sheets completed for each shower provided as well as entries in the resident's electronic medical record. She said that she had concerns with residents getting showers. She said there are staffing issues and currently management does not want agency staff in the building but being understaff it was hard to keep up with all the residents' needs. She said that she was expected to complete 7-8 resident showers during her shift and it becomes more difficult if the resident requires 2 staff members to provide a shower. CNA G said that there are times when staff are unable to complete all showers for residents that are assigned to them. She said she does what she can when on shift. She said if she cannot shower a resident during her shift, she will notify the charge nurse. She said that residents who require a 2-person assist would receive two showers a week or a bed bath. She said that at times if there are not enough staff to help with a 2-person transfer and shower then she will at least provide a bed bath. She said if residents are not provided with showers frequently, they could be made to feel uncomfortable. She said she had not provided Resident #37 with a shower as he had asked that she not provide him with care. She said that Resident #37 did not give the best introduction at admission and scared the night aides, which had caused a few to be fearful of him. She said she was not sure if Resident #37 had been provided with a shower since admission. She said that she recalled an incident last month where a male resident had not received a shower in a few days and he smelled and his family member reported this to the Administrator. She said she was not sure what the outcome was. During an interview on 09/11/2026 at 3:19 p.m., the Hospice Nurse revealed that Resident #37 does not have a hospice aide because he had declined showers during the day because he wanted his showers at night. She said that she would ask Resident #37 periodically if he would want aides to come out and give him a bath and he declined because showers could only be offered during the day. She said that on 08/13/2026 the Administrator informed her that the nursing staff would take care of Resident #37's showers. She said that Resident #37 had not disclosed to her that he was not getting showers and if he had she would have provided him with a bed bath as he had requested showers at night. During a group interview on 09/11/2026 at 7:45 p.m., the DON revealed that there had been a challenge with the retrieval of documentation for specific residents. The RNC revealed that he had not been informed that Resident #37 had not had a shower in more than three weeks. The Administrator revealed that the ADON had discussed with the resident earlier today that if he wanted a shower today it would be after 6:00 p.m. but it would be rushed, but if he agreed to a shower tomorrow morning, he would be provided with 90 minutes to shower and he agreed.During an interview on 09/12/2026 at 10:24 a.m., LVN B revealed that the last face-to-face in-service on resident rights was in October 2025 and all other trainings were online or a sheet of paper that was circulated during shifts. She said that shower sheets are completed when a resident was provided with a shower or if they refused a shower. She said the facility procedures were to provide residents with showers at minimum three times per week. She said if residents are not provided with showers frequently it could cause them mental health issues, they could feel dirty, forgotten, neglected, and physically could cause skin breakdowns. LVN B said that she does not know if it was due to low staff or lack of motivation that residents are not provided with ADL's, such as showers. She said that she can tell that a lot of residents do not get showers because they smell or do not get shower sheets submitted. She said that Resident #37 goes to another nurse for assistance. She said a few residents had gone to her and said they had not been showered in a few days and that she had ensured they received a shower immediately.During an interview on 09/12/2026 at 1:20 p.m., the ADON revealed that the facility protocol for showers was to provide residents with three showers weekly. She said that residents who required a Hoyer transfer with two staff should also receive three showers weekly. She said if residents are not provided with showers frequently that it would impact them mentally and physically as they could develop skin impairments. She said that the nursing staff had notified her that Resident #37 frequently refused showers, he does not want them in his room, or he had kicked them out of his room. She said the nursing staff did not tell her why Resident #37 refused his showers or care only that he had refused them. The ADON said that she had helped Resident #37 with a shower last week but could not recall the day or the staff that helped her with his shower. She said that she did not have the shower sheet for this shower. She said that she did not locate shower sheets or refusal of showers documented for Resident #37. Record review of policy titled, Dignity, revised February 2021, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1.Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.Record review of In-Service Training Report, titled Shower Cleanliness dated 02/10/2026, revealed 1. Shower Schedule Compliance. - Each resident is assigned specific shower days. - CNAs are responsible for checking the assignment sheet at the beginning of their shift. - All scheduled showers must be completed. - If a resident refuses: - Report immediately to the nurse. - Document refusal per policy. - The nurse must be notified before the end of shift. Skipping or delaying assigned showers = non-compliance with care standards. 2. Shower Sheet Documentation Process. After each shower: 1. Complete the shower sheet fully: - Date - Time - Skin observations - Refusals (if applicable) . 2. Turn the completed sheet in to the nurse. 3. The nurse will review and sign off. This process ensures: - Regulatory compliance - Accountability of care provided. Incomplete documentation = incomplete care. 4. Accountability Failure to: - Complete assigned showers - Submit shower sheets properly May result in: - verbal counseling - written warning - Further disciplinary action per facility policy.

Based on interview and record review the facility failed to ensure comprehensive care plans were prepared by an interdisciplinary team, to the extent practicable, the participation of the resident and the resident's representative(s), and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 3 of 8 (Residents #7, #12, and #69) residents reviewed for care plans in that: 1. Resident #7 did not have a care plan conference in her chart for his care needed at the facility.2. Resident #12 did not have a care plan conference in her chart for his care needed at the facility.3. Resident #69 did not have a care plan conference in her chart for his care needed at the facility. This failure could result in a decrease in care for residents. The Findings: 1.Record review of Resident #7's admission record dated 9/12/2026 reflected he was admitted on [DATE] with advanced directive of DNR. Resident #7's diagnoses were major depressive disorder, chronic pain, generalized anxiety, intellectual disabilities, schizophrenia, psychotic disorder with delusions, and hearing loss. Record review of Resident #7's Quarterly MDS dated [DATE] reflected he was moderately cognitively impaired, inattention, disorganized thoughts for behavior, he was ambulatory, and he required set-up for ADLs. Record review of Resident #7's care plan dated 7/23/2026 reflected that he desired to stay in facility, he was a DNR, he had PASRR services, he had anxiety, he was prone to physical aggression, had an ADL self-care performance deficit related to aggressive behaviors, confusion and impaired balance and he was a smoker. Record review of Resident #7's chart from 9/8/20026 to 9/12/2026 revealed no care plan conferences were documented. 2.Record review of Resident #12's admission Record dated 9/12/2026 reflected she was admitted on [DATE] revealed her advanced directive was a DNR (do not resuscitate) Resident #12 had diagnoses of end stage renal disease, diabetes II, and chronic obstructive pulmonary disease. Record review of Resident #12's Quarterly MDS dated [DATE] reflected she was moderately cognitively impaired, she used a walker to mobilize, required set-up and supervision for ADLs, and she had swallowing concerns. Record review of Resident #12's care plan date 9/1/2026 reflected her advanced Directive was DNR, she desired to stay at the facility, she attended activities, ADL self- care performance deficit related to diagnosed, resident had potential fluid volume overload related to kidney failure related to Dialysis, diabetes II, resident needs dialysis related t renal failure, COPD, and resident received renal diet with thin liquids. Interview on 9/11/2026 at 11:14 AM with Resident #12 stated she was not offered to attend a care plan conference at the facility. Record review of Resident #12's chart 9/8/20026 to 9/12/2026 revealed no care plan conference was documented. 3.Record review of Resident #69's admission Record dated 9/10/2026 reflected he was admitted on [DATE] with a full code. Resident #69's diagnoses was major depressive disorder seizures, paranoid schizophrenia, depression, cognitive communication deficit and pain. Record review of Resident #69's Quarterly MDS dated [DATE] reflected he mobilized with a wheelchair, he required set-up and supervision for ADLs, he was moderately cognitively intact. Record review of Resident #69's care plan dated 7/23/2026 reflected he desired to stay in facility, he choose to be a DNR, he was positive for PASRR services, prone to aggression, Adl self-care performance deficit related to aggression, behavior, confusion, and impaired balance, and behavior problem related to poor impulse control, paranoid schizophrenia, sudden changes in mood, and he was a smoker. Record review of Resident #69's chart from 9/8/20026 to 9/12/2026 revealed no care plan conferences were documented. An attempt interview on 9/8/2026 at 12:30 pm revealed Resident #69 was not interviewable. Interview on 9/11/2026 at 7:45 PM with Regional Corporate MDS stated he was not able to find the care plan conferences for Resident #7, Resident #12, and Resident #69. The Regional Corporate MDS nurse stated they have not had an MDS nurse or a social worker. Interview on 9/12/2026 at 12:52 PM with the ADM stated the MDS person was responsible for resident care plan conferences. The ADM stated they had not had an MDS person for 8 months. ADM stated the facility could not provide care to residents without a resident care plan conference and staff would be unsure of the tools to use for residents' care. Record review of Care Planning-Interdisciplinary Team, dated 12/2024 reflected, The disciplinary team is responsible for the development of residence care plans. Policy interpretation and implementation. 1. Resident care plans are developed according to the timeframes and criteria. 2. Comprehensive, person centered care plans are based on residents' assessment and developed by an interdisciplinary team (IDT).

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #20) reviewed for care plans.The facility failed to ensure Resident #20's comprehensive care plan was updated to reflect that resident had an indwelling urinary catheter.These failures could place residents at risk for not having their needs met.The findings were:A record review of Resident #20's Face Sheet, dated 09/10/2026, revealed the resident was a [AGE] year-old male, initially admitted to the facility on [DATE], readmitted on [DATE], with diagnosis of neuromuscular dysfunction of bladder (loss of bladder control due to brain, spinal cord, or nerve problems).A record review of Resident #20's Quarterly MDS assessment, dated 06/23/2026 revealed the resident had a BIMS score of 05, indicating severe cognitive impairment and resident had an indwelling catheter.A record review of Resident #20's Order Summary Report revealed an active order: Urinary Catheter 18 FR, 30CC. Diagnosis: neurogenic bladder every day and evening shift, dated 03/13/2026.A record review of Resident #20's Care Plan Report, reviewed on 09/10/2026, revealed there was not a care plan in place for an indwelling urinary catheter.During an interview with MDS nurse on 09/10/2026 at 11:30 a.m. the MDS nurse stated that she was new to the position but there should be a care plan in place for Resident #20's indwelling catheter. She did not know why there was not, but it would be corrected.During an interview with DON on 09/11/2026 at 8:34 a.m. she stated that MDS was responsible for comprehensive care plans, but there was a new MDS nurse. DON stated that the importance of care plans was to communicate the residents' needs to the nursing staff.A record review of facility policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, revealed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 9 residents (Resident #17) reviewed for abuse. The facility Administrator failed to identify the physical abuse incident against Resident #17 on 09/05/2026 as an alleged violation of resident abuse and report to the State Survey Agency. This deficient practice could place residents at risk of continued abuse. Record review of Resident #17's admission Record, dated 09/09/2026, revealed a [AGE] year-old male admitted on [DATE]. Resident #17 was listed as his own responsible party with his [family member] listed as Emergency Contact #1. Record review of Resident #17's Medical Diagnoses, undated and accessed 09/09/2026 at 4:00 p.m., revealed diagnoses including peripheral vascular disease (condition characterized by narrowed arteries that reduce blood flow to the limbs, primarily the legs), absence of right leg below knee, anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest), and type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as fuel). Record review of Resident #17's Quarterly MDS assessment, dated 07/01/2026 and signed 07/10/2026 as completed, reflected a BIMS score was not documented for Resident #17. Resident #17 was documented as taking antidepressants and hypoglycemics. Resident #17's functional abilities were documented as requiring partial/moderate to setup or clean-up assistance. Record review of Resident #17's Care plan, updated and accessed 09/12/2026 at 9:22 a.m., revealed Resident #17 was at risk for anxious behaviors r/t [related to] Anxiety. [Goal] overall comfort, safety, sense of well-being, and self sufficiency will be support by lessening/elimination of causes of Anxiety. dated 10/18/2024 and revised 10/28/2025. Resident #17 was documented has having impaired cognitive function or impaired thought process r/t confusion at times, Anxiety, Depression. dated 10/18/2024. Record review of the Standard Assessment tab on Resident #17's EMR, undated and accessed on 09/12/2026 at 9:24 a.m., revealed skin check was documented on 09/05/2026 for Incident (Physical Aggression Received) /One Time Only. Review of an incident report titled, #1934 Physical Aggression Received dated 09/05/2026, reflected the following: Person Preparing Report: LVN E documented, Incident Description: CNA [staff name not documented] Informed this nurse [LVN E] this shift that resident stated to another resident In dining area to stop knocking on kitchen door''. The other resident then became upset with [Resident #17's] response, proceeded to walk towards resident and strike him on his L hand with her water cup, causing a skin tear to L hand. Resident stated i told her to stop knocking on the door and she came towards me and hit me with her cup, she always does this and Immediate Action Taken Residents were immediately separated, other resident was escorted back to her room and reminded on the rules/policies. Contacted RP message left. Cleansed skin tear to L hand, no s/s of infection noted at this time. Injuries Report Post Incident: Skin tear. Left hand (back). Record review of Resident #17's progress notes, dated 08/13/2026 to 09/13/2026, indicated no documentation about the physical aggression incident on 09/05/2026. Record review of Resident #17's electronic medical record reflected that no initial progress notes, no risk management record, and no 72-hour monitoring notes following the physical aggression incident on 09/05/2026 were completed by the nursing staff. Record review of Resident #17's electronic medical record reflected that no alleged violation of resident abuse was reported to the State Survey Agency following the physical aggression incident on 09/05/2026. During an observation and interview on 09/08/2026 at 12:45 p.m., Resident #17 revealed small wounds in healing stage to the front of his left hand. Resident #17 stated that a female resident had hit him on his left hand with a water bottle and caused the open wounds. He stated that the staff did tell the female resident to stop and he was given a bandage by the nurse. Resident #17's cognition was severely impaired, and he was unable to provide date of incident and stated that he was okay and that the wounds did not bother him. During an interview on 09/12/2026 at 10:24 a.m., LVN B revealed that she was present for the incident of physical aggression against Resident #17 on 09/05/2026. She said Resident #17 was in the dining room and a female resident was banging on the kitchen door with her water cup and he told her to shut up and she went over to him and struck his hand with the water cup causing small tear to his skin. Residents were separated and Resident #17 was provided with wound care to his hand. During an interview on 09/12/2026 at 11:13 a.m., the ADON revealed that she was notified of the physical aggression incident on 09/05/2026 involving Resident #17, but she could not recall specific details. She stated that residents were separated for their safety. She stated that the aggressor was placed on 1:1 supervision and Resident #17 was placed on 15-minute monitoring for 72 hours. She stated that the nursing staff are required to document the incident in the progress notes, along with monitoring notes, document incident report, risk management report, and 24 hours report. She said the Administrator is the Abuse Coordinator and she would be responsible with reporting ANE to the State. During an interview on 09/12/2026 at 1:20 p.m., the Administrator revealed that she provides the nursing staff with ANE training. She stated that staff are to report ANE to her immediately. She stated that incidents involving injuries are reported to the State within 2 hours. She stated that failure to report to the state could leave residents to continue to experience ANE. The Administrator stated that she was notified of the physical aggression incident towards Resident #17 on 09/05/2026. She stated that the incident occurred on 09/05/2026 and the State arrived shortly thereafter leaving her unable to report to the State. Record review of policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating date revised September 2022, revealed All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). Reporting Allegations to the Administrator and Authorities. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. Record review of policy titled, Resident Rights date revised February 2021, revealed Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b.be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility; 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.

Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for 1 of 9 residents (Resident #49) reviewed for a safe and comfortable environment.The facility failed to provide Resident #49 with a sanitary and clean bed after a bowel movement on 09/08/2026. This failure could place residents at risk of decreased resident satisfaction with their environment and a lack of a homelike environment.The findings included:Record review of Resident #49's admission Record, dated 09/10/2026, revealed a [AGE] year-old female admitted on [DATE]. Resident #49 was not listed as her own responsible party with her [family member] listed as Emergency Contact #1.Record review of Resident #49's Medical Diagnoses, undated and accessed 09/10/2026 at 7:05 p.m., revealed type 2 diabetes type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as fuel), paranoid schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), psychotic disorder with delusions (condition where a person holds fixed false beliefs despite clear evidence to the contrary), major depressive disorder major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest), and local infection of the skin and subcutaneous tissue.Record review of Resident #49's, Quarterly MDS, dated [DATE] and signed 07/14/2026 as completed, reflected a BIMS score of 13, indicating cognition intact. Resident #49's functional abilities were documented as independent, resident completes the activity by themselves with no assistance from a helper and ambulating independently. Resident #49 was documented as being at risk of developing pressure ulcers/injuries and taking antipsychotic and hypoglycemic medications.Record review of Resident #49's Care Plan, undated and accessed 09/10/2026 at 7:12 p.m., revealed Resident #49 was dependent on staff for meeting emotional, intellectual, physical and social needs. dated 01/21/2025 and has an ADL selfcare performance deficit. with interventions of setup or clean-up assistance dated 04/01/2022.During an observation on 09/09/2026 at 11:22 a.m., revealed Resident #49's bed had soiled linens. The linen had dry brown bowel movement stains. Resident #49 was not present in her room.During an observation and interview on 09/10/2026 at 5:59 p.m. revealed Resident #49 was sitting on her bed. She answered yes or no questions but did not answer open-ended questions. Resident #49 presented as being alert to self with confusion. Resident #49 was unable to provide any specific answers to her health condition. Resident #49 looked at the linen with bowel movement and said it was restroom and that she did not know when or how it became dirty. During an interview on 09/09/2026 at 11:23 a.m., CNA J revealed that she had been trained on resident rights. She said replacing soiled linen and clothing was the responsibility of aides assigned to the resident's room. She said the policy for soiled linen was to change the bedding every other day or as needed such as when food spills or when providing incontinence care and bowel movement and urine soil the linen. She said when linen gets a small stain, she was required to change them. She said if soiled linen were not changed the bacteria from urine and bowel movement could impact the residents. She said lying in urine and feces could lead to skin breakdown, diseases and immune system to decline.During an interview on 09/10/2026 at 7:20 p.m., CNA H revealed that that she had been trained on resident rights and dignity. She said that if linen remained soiled for long periods of time it could cause deterioration to mattress, breakdown of resident skin, cause openings or pressure sores. She said all staff were required to help residents maintain clean beds and rooms. During an interview on 09/12/2026 at 10:24 a.m., LVN B revealed that the last face-to-face in-service on resident rights was in October 2025 and all other trainings were online or a sheet of paper that was circulated during shifts. She said that soiled linen procedures required aids and nurses if necessary are responsible for changing soiled linens on resident's bed. She said that by not changing soiled linens could make residents physically and mentally miserable.During an interview on 09/12/2026 at 11:13 a.m., the ADON revealed that the nursing staff were constantly provided training on resident rights and dignity. She stated the policy for resident rights was that residents have all the rights. She said if a resident did not have their rights honored it could affect them emotionally, physically, mentally, and could change their eating habits and cause them to become depressed or to isolate themselves. She said the policy on soiled linens was that the nursing staff change them immediately. She said that the facility had a program in place where staff were assigned to specific halls and were making daily rounds throughout the day. She said that aides assigned to halls were required to observe resident rooms daily and change their bedding or when needed. She said that not changing soiled linens was a dignity concern and could negatively impact resident's care. She said that she was not sure who was assigned to hall 100 and specifically Resident #49's room this week but that she would look into this.During an interview on 09/12/2026 at 1:20 p.m., the Administrator revealed that the nursing staff have been educated on resident rights and on privacy and dignity. She said the nursing staff were required to ensure that residents get the highest quality of care and dignity when providing care regardless of their behavior. She said if a resident was not treated with dignity, it could impact their care and cause their health to diminish. She said that the procedures for soiled linen were to ensure they were changed out immediately when noticed. She said currently staff were rounding every two hours; however, if residents soil their linen often the staff round on them more often. She said that not rounding and changing soiled linen can cause the residents skin issues, decline in health, and impede their dignity. The Administrator said that Resident #49 had mentioned that she does not like anyone to change her sheets and stated she does not believe this was documented in her electronic medical record, but that it should have been documented in her care plan. She said that she would speak to the staff assigned to hall 100 and explain the importance of why sheets need to be changed and provide staff with education.Record review of policy titled, Homelike Environment, revised February 2021, revealed Residents are provided with a safe, clean, comfortable and homelike environment. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; e. clean bed and bath linens that are in good condition.Record review of policy titled, Dignity, revised February 2021, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observations, interviews, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 (Resident #20) of 4 residents reviewed for dignity.The facility failed to ensure Resident #20's privacy curtain was closed during catheter and incontinent care when roommate was present in the room. This failure could cause a decrease in feelings of self-worth by being exposed during care. Findings included:A record review of Resident #20's Face Sheet, dated 09/10/2026, revealed the resident was a [AGE] year-old male, initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses including seizures (abnormal electrical activity in the brain affecting consciousness, muscle control and behavior), major depressive disorder (a mood disorder that causes severe and persistent feelings of sadness and low mood), and neuromuscular dysfunction of bladder (loss of bladder control due to brain, spinal cord, or nerve problems).A record review of Resident #20's Quarterly MDS assessment, dated 06/23/2026 revealed the resident had a BIMS score of 05, indicating severe cognitive impairment.A record review of Resident #20's Order Summary Report revealed an active order: Foley catheter care q shift and PRN, dated 03/13/2026.During an observation on 09/10/2026 at 10:35 a.m. CNA C and CNA D provided catheter and incontinence care to Resident #20 who was lying in bed with a roommate lying in the other bed. CNA C and CNA D failed to pull the resident's privacy curtain while providing care. During an interview on 09/10/2026 at 10:50 a.m., CNA C stated he forgot to close the privacy curtain. CNA C stated the resident should have privacy when care was performed to protect them from being exposed to others.During an interview on 09/10/2026 at 10:55 a.m., CNA D stated Resident #20's privacy curtain should have been closed because it was the resident's right to have privacy during care.During an interview on 09/11/2026 at 8:34 a.m. the DON stated the privacy curtain should have been closed when care was provided because privacy protects a resident's dignity which all residents deserve.Record review of facility policy titled Resident Rights, policy, February 2021, revealed: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: t. privacy and confidentiality.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for 1 of 4 residents (Resident #59) reviewed for reasonable accommodation of needs. The facility failed to ensure Resident #59's call light was in a position accessible to the resident on 09/12/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. The findings included:A record review of Resident #59's Face Sheet, dated 09/08/2026, revealed a [AGE] year-old female admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (a condition caused by damage to the airways and the lungs making breathing difficult) and dementia (loss of mental functioning, thinking, memory, and motor control).A record review of Resident #59's Quarterly MDS, dated [DATE], reflected Resident #59 had a BIMS score of 0.0, indicating she was severely cognitively impaired, requiring substantial/maximal assistance for self-care and dependent for mobility needs.A record review of Resident #59's Care Plan dated 06/02/2023, revealed a focus: The resident has an ADL self-care performance deficit r/t Dementia, confusion, Depression, with intervention Transfer: The resident requires mechanical lift with 2 staff assistance for transfers.During an observation on 09/12/2026 at 8:45 a.m., Resident #59 was observed in the room alone, sitting up in bed, eating breakfast with the head of the bed raised approximately 90 degrees. Her call light was observed to be lying on the floor near the wall behind the head of the bed.During an interview and observation on 09/12/2026 at 8:55 a.m. CNA A stated Resident #59's call light was out of reach as it was located on the floor. She stated Resident #59's call light probably was pulled off the bed when the head of the bed was raised and did not know why it wasn't picked up and placed within reach of the resident. CNA A then placed the call light within reach of Resident #59.During an interview on 09/12/2026 at 11:40 a.m., LVN B stated call lights should be kept in reach so that residents can call for assistance as needed and all staff were responsible for ensuring the call light was in place before leaving the residents' room. LVN B said failing to place the call light in reach may result in a resident not receiving the assistance they need.A record review of facility policy, Call System, Resident, dated as revised September 2022 and updated January 2025, reflected Policy Statement Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation:1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on record review and interview, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 of 9 residents (Resident #5) reviewed for resident rights. The facility failed to obtain informed consent for the use of Haldol Decanoate and Lorazepam (antipsychotic medications) for Resident #5. This failure could place residents who receive psychotropic medications at risk of receiving medications without consent, knowledge of possible side effects of the medications, or other treatment options.The findings included:Record review of Resident #5's admission Record, dated 09/10/2026, revealed an [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Resident #5 was not listed as his own responsible party with his [family member] listed as Emergency Contact #1.Record review of Resident #5's Medical Diagnoses, undated and accessed 09/10/2026 at 3:37 p.m., revealed diagnoses including dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest), insomnia (sleep disorder that can make it hard to fall asleep or stay asleep), and Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills). Record review of Resident #5's, Quarterly MDS, dated [DATE] and signed completed 08/28/2026, reflected a BIMS score was not documented for Resident #5. Resident #5 was documented to have physical behavioral symptoms and have potential indicators of psychosis, hallucinations with physical, verbal, and other behavioral symptoms directed toward others. Resident #5's functional abilities were documented as requiring partial/moderate to setup or clean-up assistance. Resident #5 was documented with active diagnoses of Alzheimer's Disease, Non-Alzheimer's Dementia, anxiety disorder, depression, and psychotic disorder and was taking antianxiety and antidepressant medications. Resident #5 was not documented to be on antipsychotic medications.Record review of Resident #5's Care Plan, undated and accessed 09/10/2026 at 3:48 p.m., revealed Resident #5 has potential to be physically aggressive r/t Anger, Dementia, Poor impulse control dated 11/19/2025 and disrobing, verbal and physical aggression; psych services. dated 08/10/2026 and Resident #5 uses psychotropic medications r/t Behavior management. dated 11/19/2025.Record review of Resident #5's Order Summary Report, dated 09/10/2026, revealed Resident #5 had active orders of Haldol Decanoate Intramuscular Solution 50 MG/ML Verbal (Haloperidol Decanoate) Inject 1.5 ml intramuscularly one time a day every 28 day(s) for give 1.5 ml to equal 75 mg/ml related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION start date 07/03/2026 and LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth three times a day for ANXIETY DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION start date 06/21/2026.Record review of Resident #5's Progress Notes, dated 09/09/2026 at 5:31 p.m., revealed Resident #5 was administered psychotropic medication, LORazepam Oral Tablet 0.5 MG. Give 0.5 mg by mouth three times a day for ANXIETY DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION. Record review of Resident #5's electronic medical record indicated no documentation of Form 3713 NF for Antipsychotic or Neuroleptic Medication Treatment for antipsychotic medications Haldol and Lorazepam.During an interview on 09/11/2026 at 3:14 p.m., RNC stated that the facility staff were searching through boxes of medical records for psychotropic medical consents and Resident #5's consents have not been located.During an interview on 09/11/2026 at 4:10 p.m., the Regional MDS Coordinator stated that the facility policy for when a resident discharges and returns (readmission) to the facility a new consent to administer psychotropic medications was required. She stated that staff were currently searching for psychotropic medication consent forms at the facility.During an interview on 09/12/2026 at 11:13 a.m., the ADON stated there was no consent in Resident #5's medical record regarding the resident's Haldol and Lorazepam and the facility should have obtained the consent from the resident's responsible party before starting the psychotropic medication. The ADON said she did not know why the facility nurses did not obtain the consent. The ADON stated that the DON was responsible for obtaining psychotropic medication consent forms and that by not obtaining the resident's or responsible party consent prior to starting psychotropic medications, the resident would not be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives. During an interview on 09/12/2026 at 1:20 p.m., the Administrator stated that the nursing staff should be obtaining psychotropic medication consent forms before starting medications. The Administrator stated that the nursing staff were searching for psychotropic medication consent forms for Resident #5, but that they have yet to be located.A policy for Form 3713 NF Consent for antipsychotic or Neuroleptic Medication Treatment was requested from the Administrator on 09/11/2026 and 09/12/2026 and no policy was provided.Record Review of policy titled, Psychotropic Medication Use revised July 2022, revealed 1. A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics. 4. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. a. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.

Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program. for 3 of 15 (Residents #40, #10 and #23) residents reviewed for PASARR: 1.Resident #40 had a negative PASARR level 1 on admission and did not include form 1012 from physician. 2. Resident #10 had a negative PASARR level 1 on admission, should be positive PL1. 3. Resident #23's recommendation of Therapy services were not completed. This failure could place residents at risk of not receiving specialized services and could result in loss of PASARR services. The findings: 1.Record review of Resident #40's admission Record dated 9/8/2026 reflected he was admitted on [DATE] and was diagnosed with Bipolar Disorder (3/20/2026) and unspecified dementia (3/20/206). Record review of Resident #40's Quarterly MDS dated [DATE] reflected he was cognitively intact, he mobilized with a manual wheelchair and required set up or clean up assistance for his ADLs. Resident #40 was cognitively intact, (BIMS score 14/15). Record review of Resident #40's care plan dated 8/6/2026 reflected he was care planned for diagnosis of Bipolar Disorder with interventions. The interventions were too administer medications as ordered, monitor for side effects, monitoring labs and report abnormalities to physician Record review of Resident #40's PL1 dated 3/19/2026 reflected he was negative for PASARR services. 2. Record review of Resident #10's admission Record dated 9/11/2026 reflected he was admitted on [DATE] with diagnoses of other schizophrenia and schizoaffective disorder. Record review of Resident #10's Quarterly MDS dated [DATE], indicated he was moderately cognitively impaired, and he was setup and clean up assistance with ADLs. Resident #10 was moderately cognitive impairment (BIMS 12/15). Record review of Resident #10's care plan dated 6/23/2026, reflected he was care planned for Schizophrenia and Schizoaffective disorder with interventions. The interventions were to administer medications as ordered, monitor/document for side effects and effectiveness; anticipate and meet residents needs; assist the resident to develop more appropriate methods of coping and interacting; encourage resident to express feelings and continue to encourage resident to take all medications prescribed by the physician. Record review of Resident #10's PL1 dated 3/19/2026, reflected he was negative for PASARR services. Interview on 9/12/2026 at 1:41 PM, the ADM stated she was not aware of the PL1's not being accurate for Residents #40 and #10. The ADM stated this could affect residents causing a decline in health and would not get the proper care necessary. Interview on 9/12/2026 at 5:10 PM, the Regional Corporate MDS stated Resident #10 had a negative PASARR on 3/19/2026. Resident #10 had diagnoses of other schizophrenia and Schizoaffective disorder with no dementia. The Regional Corporate MDS stated Resident #10 would need a completed a new PL1 and this was inaccurate. 3. Record review of Resident #23's admission Record, dated 09/09/2026, revealed a [AGE] year-old male admitted on [DATE], he was listed as his own responsible party. Record review of Resident #23's Medical Diagnoses, undated and accessed on 09/09/2026 at 4:08 p.m., revealed diagnoses including bipolar disorder (mental health condition characterized by significant mood swings), developmental delays (refers to persistent difficulties in meeting age-expected milestones in areas such as cognitive, language, social, emotional, or motor skills), lack of coordination and moderate intellectual disabilities. Record review of Resident #23's Quarterly MDS dated [DATE] reflected BIMs was 8/15, severely cognitively impaired and has diagnoses of seizure disorder, and bipolar disorder. Record Review of Resident #23's Care plan dated 9/10/2026 reflected he has seizures, bipolar and impaired cognition related to developmental delays, and PASRR positive status related to intellectual development and developmental disability. Record review of a Psychotherapy visit note dated 08/15/2026 revealed, Resident #23's treatment was for generalized anxiety disorder, bipolar disorder, current episode mixed, unspecified, and moderate intellectual disabilities. Record review of Resident #23's electronic medical record, undated, and accessed on 09/12/2026 at 4:08 p.m. indicated no documentation of PASARR for specialized services being provided. Record review of HHS Intake Investigation Worksheet for Complaint received on 09/09/2026 revealed that Resident #23 had a PASARR quarterly meeting on 06/10/2026 and Resident #23 was recommended for specialized services of OT and PT. During an interview on 09/12/2026 at 3:42 p.m., RNC revealed he recalled attending the 06/10/2026 quarterly meeting for Resident #23, but he did not recall the details of the meeting. He said that he understood that the meeting discussed recommendations for OT and PT services and services were not provided and referral for specialized services was not completed by the facility staff. He said that if he did not send the referral then more than likely Resident #23 did not receive the services. He said he would need to follow up with the DOR [Director of Rehabilitation] who was also present for this meeting. He said that the impact of Resident #23 not receiving OT and PT services was that ADLs could decrease or stay the same. He said that Resident #23 did not get services through PASARR and he would need to verify if NF paid for services. During an interview on 09/11/2026 at 4:10 p.m., the Regional MDS Coordinator revealed that Resident #23's PASRR evaluation was completed on 05/14/2026 for ID and DD with no primary diagnoses of dementia, no impatient psych services and he was not eligible for services. During an interview on 09/12/2026 at 3:58 p.m., RNC said that he reached out to the DOR and she confirmed that she picked up Resident #23 for OT and PT services in August 2026 but could not verify the specific date and that Resident #23 did not have OT and PT services for June 2026. Interview on 9/12/2026 at 12:53 pm with ADM stated she was to aware of this situation. ADM stated this could prevent care for #40, #10 and #23. ADM stated residents could decline and not get proper care necessary. Record review of facility policy, PASRR dated 07/29/2025, revealed The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. 1. admission Process: a). Exempted hospital discharge happens when a physician at an acute care hospital (a medicalacute care hospital, not a psychiatric hospital) has determined the person might need a nursing facility stay of 30 days or less for rehabilitation purposes. b). Expedited admission is for those discharged from a medical acute care hospital or a nursing facility transfer. There are seven expedited admission categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite and coma. c). Preadmission happens when a person is coming from the community (psychiatric hospital, home, group home, jail, assisted living, etc.). This includes anywhere other than a medical acute care hospital or another nursing facility. The person, coming from the community with a PASRR Level 1 that indicates suspicion of IDD, and/or mental illness must also have a completed PASRR Evaluation submitted before they can be admitted to a nursing facility. This process must be followed to ensure people coming from a community setting can receive education about other placement alternatives before nursing facility admission. d). Negative indicates the person has a negative PL1 screening, and is not suspected of having an intellectual disability, developmental disability and/or mental illness. 3. Documentation: Facilities must maintain thorough documentation of the PASRR assessments, including the Level I and Level II evaluations, as well as the recommendations made. Care planning: Based on the findings of the Level II evaluation, a care plan is developed that may include specialized services or living arrangements tailored to the individual's needs. Collaboration with mental health professionals and Local Authority to ensure continuity of care.

Based on interview and record review, the facility failed to ensure that alleged violations of abuse, neglect, and exploitation were thoroughly investigated, and the results of the investigation were reported to the State Survey Agency within five working days for 2of 9 residents (Resident #17 and Resident #58) reviewed for abuse, neglect, and exploitation. The facility failed to have evidence of an investigation into alleged abuse of Resident #17 by Resident #58 on 09/05/2026This deficient practice could place residents at risk of continued abuse.The findings included:1. Record review of Resident #17's admission Record, dated 09/09/2026, revealed a [AGE] year-old male admitted on [DATE]. Resident #17 was listed as his own responsible party with his [family member] listed as Emergency Contact #1. Record review of Resident #17's Medical Diagnoses, undated and accessed 09/09/2026 at 4:00 p.m., revealed diagnoses including peripheral vascular disease (condition characterized by narrowed arteries that reduce blood flow to the limbs, primarily the legs), absence of right leg below knee, anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest), and type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as fuel). Record review of Resident #17's Quarterly MDS assessment, dated 07/01/2026 and signed 07/10/2026 as completed, reflected a BIMS score was not documented for Resident #17. Resident #17 was documented as taking antidepressants and hypoglycemics. Resident #17's functional abilities were documented as requiring partial/moderate to setup or clean-up assistance. Record review of Resident #17's Care plan, undated and accessed 09/12/2026 at 9:22 a.m., revealed Resident #17 was at risk for anxious behaviors r/t [related to] Anxiety. [Goal] overall comfort, safety, sense of well-being, and self sufficiency will be support by lessening/elimination of causes of Anxiety. dated 10/18/2024 and revised 10/28/2025. Resident #17 was documented has having impaired cognitive function or impaired thought process r/t confusion at times, Anxiety, Depression. dated 10/18/2024.Record review of Standard Assessment tab on Resident #17's EMR, undated and accessed on 09/12/2026 at 9:24 a.m., revealed skin check was documented on 09/05/2026 for Incident (Physical Aggression Received) /One Time Only. 2. Record review of Resident #58's admission Record, dated 09/12/2026, revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Resident #58 was documented as having a court appointed guardian who was listed as her responsible party. Record review of Resident #58's Medical Diagnoses, undated and accessed 09/12/202 at 9:49 a.m., revealed diagnoses including Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), borderline personality disorder, major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest), and schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking. Record review of Resident #58's Quarterly MDS assessment, dated 06/03/2026 and signed 06/11/2026 as completed, reflected a BIMS score 13 indicating cognition intact. Resident #58 was documented as requiring setup or clean-up assistance. Resident #58 was documented as taking antipsychotic, antianxiety, and antidepressant medications. Record review of Resident #58's Care Plan, undated and accessed 09/12/2026 at 9:55 a.m., revealed Resident #58 had a behavior problem r/t [related to] (specify behavior) 9/5/26 hit another resident with intervention of Resident #58 immediately moved to another safe location and allow to decompress and calm down as tolerated. Record review of Resident #58's psychiatry Visit Note - 99309 Moderate Complexity dated 08/15/2026, revealed Assessment/Plan: active target symptoms of severe anxiety, physical and verbal aggression.Review of an incident report titled, #1934 Physical Aggression Received dated 09/05/2026, reflected the following: Incident Description: CNA [staff name not documented] Informed this nurse [LVN E] this shift that resident stated to another resident In dining area to stop knocking on kitchen door''. The other resident [Resident #58] then became upset with [Resident #17's] response, proceeded to walk towards resident and strike him on his L hand with her water cup, causing a skin tear to L hand. Resident stated i told her to stop knocking on the door and she came towards me and hit me with her cup, she always does this and Immediate Action Taken Residents were immediately separated, other resident [Resident #58] was escorted back to her room and reminded on the rules/policies. Contacted RP message left. Cleansed skin tear to L hand, no s/s of infection noted at this time. Injuries Report Post Incident: Skin tear. Left hand (back). Record review of Resident #17's progress notes, dated 08/13/2026 to 09/13/2026, indicated no documentation about the physical aggression incident on 09/05/2026 was completed. Record review of Resident #17's electronic medical record reflected that no initial progress notes, no risk management record, and no 72-hour monitoring notes following the physical aggression incident on 09/05/2026 were completed by the nursing staff. Record review of Resident #17's electronic medical record reflected that no alleged violation of resident abuse was reported to the State Survey Agency following the physical aggression incident on 09/05/2026. During an observation and interview on 09/08/2026 at 12:45 p.m., with Resident #17 revealed small wounds in healing stage to the front of his left hand. Resident stated that a female resident had hit him on his left hand with a water bottle and caused the open wounds. He stated that the staff did tell the other female resident to stop and he was given a bandage by the nurse. Resident #17's cognition was severely impaired, and he was unable to provide date of incident and stated that he was okay and that the wounds did not bother him. During an observation and interview on 09/09/2026 at 10:51 a.m., Resident #58 revealed her sitting in a wheelchair outside of her room. Resident #58 was oriented to person and place, but not to time or situation. Resident #58 was unable to recall the incident and asked if she had hurt another resident and if she needed to apologize to him. During an interview on 09/12/2026 at 11:13 a.m., the ADON revealed that she was notified of the physical aggression incident on 09/05/2026 involving Resident #17, but she could not recall specific details. She stated that residents were separated for their safety. She stated that the aggressor was placed on 1:1 supervision and Resident #17 was placed on 15-minute monitoring for 72 hours. ADON stated the Administrator is the Abuse Coordinator and she would be responsible for reporting ANE to the State and investigating all self-reports. She stated she was not sure if these steps had been taken. During an interview on 09/12/2026 at 1:20 p.m., the Administrator revealed that she provides the nursing staff with ANE training. She stated that staff are to report ANE to her immediately. She stated that incidents involving injuries are reported to the State within 2 hours. She stated that failure to report to the state could leave residents to continue to experience ANE. The Administrator stated that she was notified of the physical aggression incident towards Resident #17 on 09/05/2026. She stated that the incident occurred on 09/05/2026 and the State arrived shortly thereafter leaving her unable to report to the State. She added that she conducted her own investigation of the incident, but that it was not documented. Record review of policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating date revised September 2022, revealed All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all Investigations are documented and reported. 17. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator. Follow-Up Report 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2.The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report.Record review of policy titled, Resident Rights date revised February 2021, revealed Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence; b.be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility; 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.

Based on interview and record review the facility failed to ensure a nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review for 1 of 8 (Resident #8) residents reviewed for PASARR services in that:Resident #8 was positive for PASARR services, but the PASARR staff were not notified of the significant change of a feeding tube. This failure could place residents at risk of not receiving necessary care and services. The findings included: Record review of Resident #8's admission Record dated 9/12/2026, reflected he was admitted on [DATE] with diagnoses of intellectual disabilities of Schizophrenia and seizures. Record review of Resident #8's Comprehensive MDS dated [DATE] reflected he had short-long-term memory problems, he had a feeding tube, and he had diagnoses of schizophrenia and intellectual disabilities. Record review of Resident #8's Care plan dated 7/14/2026 reflected he was positive for PASARR services related diagnoses of intellectual disability, and tube feeding for nutrition. Record review of Resident #8's consolidated orders for September 2026 revealed he was ordered an enteral feeding every shift of Jevity 1.5 cc at 65 cc via g-tube (8/14/2026). Interview on 9/12/2026 at 5:10 PM, the Corporate MDS, stated Resident #8 was Positive of MI and ID on 11/10/2022. The Corporate MDS stated Resident #8's most recent meeting was on 7/22/2026 ongoing habilitation coordination. The Corporate MDS stated the PASARR staff were not notified of his significant change, feeding tube order on 8/14/2026. Interview on 9/11/2026 at 7:45 PM, the Corporate nurse stated the PASARR staff were not notified of a significant change for Resident #8. Interview on 9/12/2026 at 12:53 PM, the ADM stated to not Notify PASSAR of change of condition for Resident #8s feeding tube, could affect him not being able to receive the necessary care. Record review of facility policy, PASRR dated 07/29/2025, revealed The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1) reviewed for care plans in that: The facility failed to develop and/or implement a comprehensive person-centered care plan to address Resident #1's repeated entering of other residents' personal spaces.The care plan did not include individualized corrective interventions to prevent or reduce these incidents.Record review of Resident #1's face sheet, dated 7/8/26, revealed an admission date of 3/23/2026 with diagnoses that included: Dementia (disorder characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), hypertension (condition where the force of blood against the artery walls is consistently too high) and (major depressive disorder (is a mental health condition marked by a persistent low mood and loss of interest or pleasure in activities that were once enjoyable). Record review of Resident 1's Quarterly MDS assessment dated [DATE] revealed the resident's BIMS score was 2, which indicated severe cognitive impairment. Record review of Resident #1's care plan, last review/revision date 11/19/2025, did not reveal a care plan regarding Resident #1's history of repeatedly entering of other residents' personal spaces Record review of Resident #1's progress note dated 6/26/2026 1:10 PM revealed 8-hour checks due to altercations with another resident. Observation of Resident #1 on 7/8/2026 at 9:00 a.m revealed him in the dining room working on a puzzle. Interview with the ADON on 7.7.2026 at 10:45 a.m revealed [Resident # 1] likes to go into other residents' personal space On 6/25/2026, Resident # 1 went into another resident's room and sat on his unoccupied wheelchair, causing an altercation. The ADON stated she did not know why this behavior was not care-planned or who updated care plans. Interview on 07/08/2026 at 10:09 a.m., The Administrator stated the DON was responsible for updating the care plans. She stated the comprehensive person-centered care plan was essential because it identified the types of care and services residents were supposed to receive. The administrator confirmed that the care plan for Resident #1 had not been updated to address entering other residents' personal spaces and that staff would not know what corrective actions to take to minimize the behavior. The administrator stated the DON would audit / correct care plans to ensure accuracy, and she would monitor compliance at random. An Interview with the DON was attempted on 7/8/2026 at 10:30 a.m. via telephone but was unsuccessful. Record review of the facility policy and procedure titled Care Plans Comprehensive, dated 2001, and updated March 2022, revealed, in part, The interdisciplinary team reviews and updates the care plan .

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 8 Residents (Residents #1, #2, #5, #6, #7, and #8) reviewed for infection control. 1. The facility failed to place signage on the door indicating Resident #7's need for droplet isolation precautions due to positive COVID-19 status. 2. The facility failed to ensure CNA A and NA B wore a gown, gloves, and goggles or a face shield upon entering Resident #1, #2, #5 and #6's room who was on contact and droplet isolation for COVID-19. 3. The facility failed to ensure NA B used appropriate hand hygiene when exiting a room under contact and droplet precautions and before entering a resident room who had not tested positive for COVID-19 and when touching her own N95 facemask, face and hair. 4. The facility had an outbreak beginning on 10/14/23, which encompassed 27 staff and 57 residents. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 11/4/23 at 4:19 p.m. The IJ template was provided to the facility on [DATE] at 4:19 p.m. While the IJ was removed on 11/6/23, the facility remained out of compliance at a level of actual harm with a scope identified as pattern until interventions were put in place to ensure staff members were in compliance with infection control standards. These failures placed all residents at risk for the spread of infection through cross-contamination of pathogens and illness. Findings included: 1. Record review of a untitled facility document revealed 57 residents had tested positive for COVID-19 from 10/14/2023-to current (10/27/2023). Record review of Resident #7's face sheet dated 10/27/2023 revealed an admitted [DATE] with a readmitted [DATE] with diagnoses which included: COVID-19 (10/26/2023), type 2 diabetes mellitus, and morbid obesity due to excess calories. Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMs score of 15 which indicated the resident was cognitively intact. Record review of a facility document titled Root Cause Analysis, dated 10/26/23, revealed the following: RCA Events: One staff members [sic] tested positive for COVID Via [through] antigen testing (10/14/2023). Two staff members tested positive for Covid on 10/16/2023 during the 48 hour follow-up testing. two staff member [sic] tested positive for Covid on 10/17/23023. Three staff member [sic] tested positive for Covid on 10/18/1023. 1 staff member tested positive for Covid on 10/19/2023. (12 employees.) 3 employee [sic] tested positive for Covid 10/20/2023. 2 employee [sic] tested positive for Covid 10/22/23. Total 22 employees 77 retruned =15 employees with Covid. 10/24/2023. 10/25/2023-11 employees 10/26/2023-13 employees, 1 Prn Nurse, 1 can [sic] & 1 dietary cook. One resident tested positive on 10/14/2023. Two residents tested positive on 10/17/2023. 12 residents tested positive on 10/18/2023. 4 resident [sic] tested positive on 10/19/2023. 11 residents tested positive on 10/20/2023. Total of 49 residents with Covid on 10/24/2023. 10/25/2023 46 residents. During an observation/interview on 10/27/2023 at 12:07 p.m. Resident #7 was observed from the doorway to be in bed. His room did not have any signs indicating he was under any isolation precautions and there was no PPE outside of his door. Resident #7 stated he was feeling bad because he had COVID-19. He stated he just found out yesterday (10/26/2023). He stated he had a sore throat, headache, and body aches. During an observation on 10/27/2023 at 12:29 p.m. CNA A and NA B entered Resident #7's room briefly and interacted with the resident. They did not put on gown, gloves, or eye protection before entering the room. During an observation/interview on 10/27/2023 at 12:31 p.m., NA B stated she did not think Resident #7 had COVID-19 but she was not sure. She stated she was not really sure which residents had COVID-19 and which did not. NA B stated she thought the residents who had COVID-19 had signs on their doors for what to wear in the room. During the interview, NA B walked to Resident #7's room and looked at the door. She stated she did not think Resident #7 had COVID-19 because he did not have a sign on the door. NA B stated she was new to the facility. She stated it was her 3rd day working and was still on orientation. She stated CNA A was providing her training. During an interview on 10/27/2023 at 12:39 p.m., CNA A stated she was training NA B. She stated she was showing her how to take care of the residents. When asked if she had trained NA B on PPE use and COVID-19 isolation precautions, CNA A stated, she knows to put it on. CNA A stated residents were identified as positive for COVID-19 by the sign on their door. She stated Resident #7 did not have a sign on his door indicating he was under isolation precautions. CNA A stated Resident #7 was positive for COVID-19, and she thinks Resident #7 tested positive yesterday morning (10/26/23). CNA A stated she did not wear gloves, gown, or face protection in Resident #7's room because she forgot. During an interview on 10/27/2023 at 2:05 p.m., LVN C stated Resident #7 tested positive for COVID-19 on 10/26/2023. She stated she immediately notified housekeeping staff and the CNAs on the hallway he was positive. LVN C stated she did not put any signage on Resident #7's door for isolation precautions. She stated she was working with another staff member, testing residents for COVID. She stated she should have put signage on the door indicating isolation precautions, but it just slipped through the cracks. LVN C stated appropriate isolation precautions for someone who tested positive for COVID-19 would be gloves, gown, N95 mask and a face shield. 2. Record review of Resident #1's face sheet dated 10/27/2023 revealed an admitted [DATE] with a readmitted [DATE] with diagnoses which included: unspecified dementia with agitation, type 2 diabetes mellitus and COVID-19 (10/22/2023). Record review of a physician order for Resident #1 dated 10/23/2023 revealed: Isolation precautions: contact/droplet for COVID-19. Record review of Resident #1's Care Plan dated 10/23/2023 revealed: Alteration in Health Status, Active COVID-19 Infection with interventions which included Ensure resident/family aware of isolation precautions related to current infection. Record review of Resident #2's face sheet dated 10/27/2023 revealed an admitted [DATE] with diagnoses which included: sequelae of cerebral infarction (care following a stroke), generalized anxiety disorder and COVID-19 (10/22/2023). Record review of a physician order for Resident #2 dated 10/23/2023 revealed: Isolation precautions: contact/droplet for COVID-19. Record review of Resident #2's Care Plan dated 10/23/2023 revealed: Alteration in Health Status, Active COVID-19 Infection with interventions which included: Ensure resident/family aware of isolation precautions related to current infection. Record review of Resident #5's face sheet dated 10/27/2023 revealed an admitted [DATE] with readmitted [DATE] with diagnoses which included: schizophrenia (a mental health disorder), vitamin D deficiency, and COVID-19 (10/22/2023). Record review of Resident #5's Care Plan dated 10/23/2023 revealed: Alteration in Health Status, Active COVID-19 Infection with interventions which included Ensure resident/family aware of isolation precautions related to current infection. Record review of Resident #6's face sheet dated 10/27/2023 revealed an admitted [DATE] with diagnoses which included: generalized anxiety disorder, Down Syndrome (intellectual disability), and constipation. Record review of Resident #8's face sheet dated 10/27/2023 revealed an admitted [DATE] with diagnoses which included: Alzheimer's disease, major depressive disorder and constipation. During an observation on 10/27/2023 at 12:15 p.m., revealed CNA A and NA B entered Resident #1 and Resident #2's room with signs on the door indicating they were under contact and droplet isolation precautions without donning gloves, gown, or eye protection to deliver meal trays and provide meal set up assistance. PPE was observed in a portable plastic cart immediately outside this room. During an observation on 10/27/2023 at 12:18 p.m., revealed CNA A and NA B entered Resident #5 and Resident #6's room with signs on the door indicating the residents were under contact and droplet isolation precautions without donning gloves, gown, or eye protection to deliver meal trays and provide meal set up assistance. CNA A was observed assisting Resident #5 with positioning and touched both the resident, wheelchair, and bedside table. Resident #5 was observed handing CNA a used napkin. During the interaction, CNA A bent down to Resident #5 and with their faces only inches apart she exchanged a conversation with the resident. CNA A was wearing a N95 mask but Resident #5 was not wearing any mask. PPE was observed in a portable plastic cart immediately outside this room. During an observation on 10/27/2023 at 12:26 p.m. revealed CNA A entered Resident 8's room who was COVID-19 negative to provide feeding assistance. During an interview on 10/27/2023 at 12:31 p.m., NA B stated she was trained to wear a gown, gloves and a face shield when entering resident rooms with COVID. She stated she had not worn a gown, gloves or a face shield when entering resident rooms who were positive for COVID because she did not know where the protection was located. She stated she did not ask for assistance or ask anyone where they were kept the PPE. NA B stated she had been working with CNA A as an orientee and CNA A had not told her to wear PPE in COVID-19 positive rooms. During an interview on 10/27/2023 at 12:39 p.m. CNA A stated she had not worn the appropriate PPE for droplet precautions in rooms where resident had tested positive for COVID-19 because she forgot. She stated she had been trained to wear a gown, gloves, and eye protection in rooms with droplet precautions for COVID, but she forgot. CNA A stated it was important to follow contact and droplet precautions, so she did not spread the germs. 3. During an observation on 10/27/2023 at 12:21 p.m. revealed NA B exited Resident #5 and Resident #6's room with signs on the door indicating the residents were under contact and droplet isolation precautions. As NA B exited the room she did not complete any hand hygiene and she reached up and grabbed the front of her facemask and adjusted the mask and then walked into Resident #3 and Resident #4's room who did not have isolation precaution signs without washing or sanitizing her hands. During an interview on 10/27/2023 at 12:22 p.m. CNA A and NA B stated the Residents #5 and #6 had tested negative for COVID-19 and were not under any isolation precautions. During an observation on 10/27/2023 at 12:24 p.m. revealed NA B was observed accepted a used meal tray from an unknown resident with unknown COVID-19 status who had been walking down the hallway. NA B placed the used meal tray in the tray cart and then touched her face and hair and then adjusted her facemask all without using hand hygiene. During an observation on 10/27/2023 at 12:27 p.m. revealed NA B entered a resident room (unknown name) who was not on isolation precautions and again touched and adjusted the front of her N95 facemask while talking to the resident. During an interview on 10/27/2023 at 12:31 p.m. NA B stated she was touching her N95 facemask for she could pull the mask away from her face so she could breathe. NA B stated she had been trained to wear PPE and use hand hygiene when exiting a resident room and when touching her face. She stated she did not have access to hand sanitizer except for a container she kept in her pocket. NA B stated she knew it was important to wear appropriate PPE and to not touch her face or facemask or pull the mask away from her face to breathe because it would spread germs and cause infection. During an interview on 10/27/2023 at 12:58 p.m. the Infection Preventionist stated she has been out of the facility because she had tested positive for COVID-19, and this was her first day back. She stated without reviewing records it was not clear to her which residents was positive and who was negative for COVID-19. During an interview on 10/27/2023 at 2:28 p.m., the Infection Preventionist/ADON/MDS Coordinator stated the facility did not currently have a DON. She also stated the other ADON and Administrator were out because they were sick. She stated the facility was having a large outbreak and were unable to cohort residents by COVID-19 status. She stated there were COVID-19 positive and COVID-19 negative residents on some hallways. She stated a sign should include precautions for contact and droplet precautions. She stated donning and doffing instructions should also be posted on every COVID-19 positive resident door as a visual cue to ensure staff know how to do it right. The Infection Preventionist/ADON/MDS Coordinator stated staff should wear a gown, gloves, N95 mask and either a face shield or goggles, even if they only went into the room for a short time. She stated hand hygiene should include washing of the hands with soap/water when coming out of a COVID-19 positive room. She stated the CDC alcohol-based hand sanitizer was sufficient for COVID-19. The Infection Preventionist/ADON/MDS Coordinator stated the facility was not able to put hand sanitizer out in the hallway or resident rooms due to the type of resident population the facility house which included behaviors. She stated hand sanitizer was in the bins (plastic containers) outside the resident rooms. She stated if staff were not caring for resident who were COVID-19 positive, then they could use the hand sanitizer they kept in their pockets. She stated staff should not touch or adjust their N95 facemasks. She stated she had provided an in-service training recently about isolation precautions. She stated it was important to prevent contamination and they follow CDC guidelines. Record review of an in-service training dated 10/14/2023 titled Infection Control/COVID Precautions revealed: airborne precautions, contact precautions, standard precautions, Infection Control Policy, COVID symptoms, COVID-19 guidelines and PPE guidelines had been reviewed with staff. A review of the sign in sheet for the training revealed CNA A and NA B had not signed the sheet as having attended. During an interview on 10/27/2023 at 3:05 p.m., the Infection Preventionist/ADON/MDS Coordinator stated she was unable to find CNA A's signature on the in-service training on 10/14/23. She stated NA B was not an employee of the facility when the in-service was given. Record review of a facility policy titled Responding to Coronavirus (COVID-19) in Nursing Homes (undated) revealed: Resident with new-onset suspected or confirmed COVID-19: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. HCP (Health Care Providers) should use all recommended COVID-19 PPE for care of all residents on affected units (or facility-wide if cases are widespread). Record review of a facility policy titled Hand Hygiene dated 2012 revealed: Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. 1. Handwashing: When hands are visibly dirty or contaminated with proteinaceous material, are visibly soiled with blood or other body fluids .perform hand hygiene with either a non-antimicrobial soap and water or an antimicrobial soap and water 2. Waterless Handwashing products: If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed under handwashing above. Record review of a facility policy titled Infection Control Policy (undated) revealed: This facility will follow most current CDC guidelines. Record review of a facility policy titled Contact Precautions dated 2012 revealed: 2. Gloves and Hand Hygiene: A. Hand Hygiene should be completed prior to donning gloves B. Gloves should be worn when entering the room and while providing care for the resident. D. Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. 3. Gowns: A. A gown should be donned prior to entering the room . Record review of a facility policy titled Droplet Precautions: dated 2012 revealed: Droplet Precautions shall be used in addition to standard precautions .2. A mask should be worn when entering the resident's room . Record review of a facility policy titled Standard Isolation Precautions dated 2001 revealed: 3. Masks, Eye Protection, Face Shields A. Wear a mask and eye protection or a face shield to protect mucous membranes. 4. During a follow-up interview on 11/4/23 at 1:50 p.m., the ADON stated after the outbreak on 10/14/23, the facility educated their staff on infection control and transmission-based precautions. The ADON stated some staff members may not have been educated because the staff member may have been off schedule due to COVID-19. Record review of the facility's education dated from 10/14/23 - 10/26/23, revealed a total of 54 out of 63 total staff members were educated on COVID-19 and infection prevention standards. The Administrator, the ADON, and the co-owner were notified of an IJ on 11/4/23 at 4:19 p.m. and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 11/5/23 at 9:36 a.m. and included the following: 1. Staff inservice on the Infection Control Program with emphasis on prevention and precautions. This packet includes education on upper respiratory virus prevention of transmission with skills check off. See attached. This began on 11/1 [2023] and concludes on 11/5 [2023]. All working staff by 11/5 [2023] will be inserviced prior to starting their shift on 11/6 [2023]. Packet contains the following information: a. Donning [putting on] and Removal of PPE. Return Demonstration and observation of proper use and sequencing.Skills Check off. b. Handwashing/Glove Use: Return Demonstration and observation. Skills Ck off. c. Proper signage for door and facility for upper respiratory virus prevention and protection. d. Droplet precautions, airborne precautions, standard precautions, and contact precautions education. Transmission and Spread of infection education. The Administrator and Infection Control Preventionist will insure all staff are inserviced by 11/5 [2023]. Regional Nurse Consult will verify on 11/10/23. At am [a.m., referring to morning] report all new employees inservice on Infection Control Policy will be reviewed. This has begun 11/4 [2023]. Administrator will report compliance to qapi and any concerns immediately addressed.This begins 11/4/2023. 2. Observation and Auditing of Compliance a. 1/4ly at payroll all staff will be inserviced on Infection Control Program with return demonstration of proper use of PPE. b. Starting on 11/5 [2023] the facility will utilize the following audit tools for the infection prevention, Monitoring Compliance with Infection Prevention Policies by Observation, Environmental Checklist for Monitoring Environmental Cleaning, Compliance Rounds(Contact Precautions), and Compliance(Droplet Precautions). See attached. i. Monitoring Compliance with Infection Prevention Policy and Observation. This tool will be utilized 3x per week selecting 5 employees on various shifts by designated personnel from the Administrator and Infection Control Preventionist. Any deficient practice will be corrected with Return Demonstration and noted. This is to begin 11/5 [2023]. ii. Compliance Rounds(Contact Precautions) and (Droplet Precautions). This tool will be utilized 3x per week on various shifts monitoring the resident room who has precautions. This is to begin on 11/5 [2023]. Any deficient practice will be immediately corrected and findings brought to am report. iii. Environmental Checklist. This tool will be utilized 3x per week on various shifts by designated personnel from the administrator and Infection Control Preventionist. Administrator will report compliance to qapi and any concerns immediately addressed. This begins 11/4/2023. Regional Nurse consult will verify weekly beginning 11/10/23. The surveyor verification of the Plan of Removal on 11/5/23 to 11/6/23 was as follows: From 11/5/23 at 2:58 p.m. to 11/6/23 1:45 p.m., 45 of the 55 target staff members across all shifts (CNA, NA, LVN, Dietary Staff, Housekeeping Staff, Activities Director, Maintenance, Transporter, Medical Records, and Administrator) were interviewed. All 45 of the 55 staff members interviewed were able to verbalize they received education on the infection control policy, putting on of PPE, removing PPE, hand washing, proper signage, and transmission-based precautions. During a joint interview on 11/6/23 at 1:45 p.m., the Administrator and the Infection Preventionist stated the new employees will be required to do training on the infection control policy. The Administrator stated the Regional Nurse will arrive on 11/10/23 to verify the facility's audits and infection control compliance. The Administrator and Infection Preventionist were interviewed and stated all staff will be trained on the infection control policy and PPE use on a quarterly basis. The facility will target the date the staff must come in to pick up their checks. The Administrator and Infection Preventionist stated they are currently using audits to monitor compliance with Infection Control, transmission-based precautions, and environmental cleanliness. The Administrator stated she will report compliance to the facility's QAPI meeting. During an interview on 11/6/23 at 2:12 p.m., the Regional Nurse Consult stated she will be performing direct observations to ensure compliance with infection control, putting on PPE, removing PPE, posting of signage, and transmission-based precautions. Record review of facility educational in-services, dated 11/5/23, revealed the facility educated 55 employees across all shifts on infection control policy. Record review of a facility document titled, Monitoring Compliance with Infection Prevention Policies by Observation, dated 2012, revealed the facility was currently using an audit for monitoring compliance with hand hygiene, PPE usage, standard precautions, and transmission-based precautions. 5 employees have been observed for compliance. Record review of a facility document titled, compliance Rounds: Droplet Precautions, dated 2012, revealed the facility was currently using an audit for monitoring compliance with droplet precautions and ensuring appropriate PPE and signage was outside a resident's room. Record review of a facility document titled, compliance Rounds: Contact Precautions, dated 2012, revealed the facility was currently using an audit for monitoring compliance with droplet precautions and ensuring appropriate PPE and signage was outside a resident's room. Record review of a facility document titled, Environmental Checklist for Monitoring Terminal Cleaning, dated 2012, revealed the facility was currently using an audit to monitor compliance of resident room cleaning. Record review of the facility's agenda revealed the Administrator will report compliance to the QAPI and any concerns immediately addressed. This would begin 11/4/23. Record review of an adhoc QAPI meeting agenda revealed an adhoc meeting occurred on 11/4/23 to discuss the IJ and implementation of audits. Sign-in sheet of this meeting revealed 8 attendees, including the medical director, administrator, ADON, and other QAPI members. On 11/6/23 at 4:56 p.m., the Administrator, the ADON, and the co-owner were notified the IJ was removed. However, the facility remained out of compliance at a level of actual harm with a scope identified as pattern due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to be free from abuse and neglect for 3 of 24 residents (Residents #1, Resident #5, and Resident #6) whose care was reviewed in that: * Facility failed to prevent Resident #1 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 digitally penetrated Resident #5's rectum. Resident #5 was not capable of giving consent. * Facility failed to put protections in place for Resident #6 after he was moved to Resident #1's room on the memory care unit (Hall 300). * Facility failed to put protections in place for residents within the 300 hall from sexual misconduct of Resident #1 after being moved from Hall 100 to Hall 300 after sexually abusing Resident #5 who was not able to consent. ~ Freedom from neglect for Resident #1 * Resident #1's care plan dated 05/03/2022, revealed behavior for paraphilia (diagnosed [DATE]) interventions were not initiated until 03/22/2022. This failure could affect memory care residents by placing them at risk of further abuse and undesired physical trauma and psychosocial trauma. These failures resulted in an identification of an immediate Jeopardy {IJ} on 5/03/2022 at 6:41PM. While the IJ was removed 05/05/2022 at 5;17PM. The facility remained out of compliance at a potential for more than minimal harm that was not an immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. The findings were: Record review of Resident #1's face sheet revealed [AGE] year-old male resident diagnosed with paraphilia (a condition characterized by abnormal sexual desires, typically involving extreme or dangerous activities) on 10/08/2021, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) 12/02/2020, [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally) 12/01/2020. Record review of Resident #1's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 7 out of 15 indicating severe cognitive impact. Record review of Resident #1's paper progress notes, dated 09/19/2021, at 20:30 (10:30 PM), by unknown (unreadable) RN, which read resident [#1] sexually inappropriate with [Resident #4] reported to be dry humping [Resident #4] on day shift. Asked resident [#1] if it was true that he as being sexually inappropriate. Resident [#1] stated 'well he is always sticking his butt out so I can do it. and he is always grabbing my private part.' . Record review of Resident #1's paper progress notes, dated 10/06/2021, at 19:40 (7:40 AM), by unknown (unreadable) RN, which read reported by CNA A that she was walking down the hall and saw [Resident #1] with his head between [Resident #3's] legs. [Resident #3] had his shorts unbutton . Record review of Resident #1's progress notes dated 01/09/2022 at 15:17 (3:17 AM) by RN B, which read CNA (CNA A) reported resident (#1) inappropriate with resident across hall (Resident #2). Redirected but comes aggressive when attempts to redirect. Record review of facility Provider Investigation Report, dated 03/11/2022, revealed CNA (unknown) reported she went into [Resident #2's] room and witnessed [Resident #1] inserting his middle finger into [Resident #2's] rectum. [Resident #1] was removed from the other resident's room immediately . relocated to a private room on another hall. one-to-one supervision was provided at least 24 hours. Further review revealed Resident #1 was immediately moved to another room away from resident (#5) and then into the secured unit for increased monitoring. Record review of Resident #2's face sheet revealed [AGE] year-old male admitted on [DATE] and diagnosed with: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) 05/20/2015, [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally) 03/31/2020, [CONDITION(S)] disorder extreme mood swings that include emotional highs ([CONDITION(S)] or hypomania) and lows (depression) 3/31/2020. Record review of Resident #2's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 4 out of 15 indicating severe cognitive impact. Record review of Resident #5's face sheet revealed 34-old male resident admitted [DATE] and diagnosed with dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) 09/25/2019, psychotic disorder with delusions (type of serious mental illness - called a [CONDITION(S)]- in which a person cannot tell what is real from what is imagined) 07/01/2021, [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally) 02/14/2021, and [CONDITION(S)] (harm to the brain due to a lack of oxygen) 09/25/2019. Record review of Resident #5's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 99 (unmeasurable) out of 15 indicating severe cognitive impact. Record review of Resident #6's face sheet revealed [AGE] year-old male resident admitted on [DATE] and diagnosed with dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) 03/22/2016 and paraphilia (a condition characterized by abnormal sexual desires, typically involving extreme or dangerous activities) 12/06/2018. Record review of Resident #6's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 9 out of 15 indicating moderate cognitive impact. Record review of Resident #6's Care plan dated 05/03/2022 revealed Resident #6 had a PASRR positive status related to DX: Mental Illness Interview on 04/21/2022 at 14:31 (2:31 PM), CNA A stated, regarding incident on 01/09/2022, Resident #1's doorway was opened and Resident #2's doorway was opened, and they were ejaculating themselves in front of each other. Interview on 04/21/2022 at 14:43 (2:43 PM), RN B stated, regarding incident on 01/09/2022 that Resident #1 was standing in the doorway of Resident #2's room while Resident #2 was in his room and both men were ejaculating in front of each other. Interview on 04/22/2022 at 15:13 (3:13 PM), the MDS Coordinator confirmed that Resident #2's care plan in the EHR was not updated and that his MDS was not due until this month. The MDS Coordinator further confirmed that the facility is behind on getting all the resident's EHR care plans updated and projected that all of them would be completed in roughly 90 days because resident's MDS' are typically done quarterly during the year. The MDS Coordinator further stated she updated care plans per the resident's MDS schedule, and she updated the care plans in their EHR the week after the MDS is due. The MDS Coordinator believed residents were not affected negatively by not having their care plans updated in a timelier manner. Interview on 04/22/2022 at 15:16 (3:16 PM), the MDS Coordinator confirmed that Resident #3's care plan in the EHR was not updated and that it was due in February. The MDS Coordinator further confirmed that the facility is behind on getting all the resident's EHR care plans updated and projected that all of them would be completed in roughly 90 days because resident's MDS' are typically done quarterly during the year. The MDS Coordinator further stated she updated care plans per the resident's MDS schedule, and she updated the care plans in their EHR the week after the MDS is due. The MDS Coordinator believed residents were not affected negatively by not having their care plans updated in a timelier manner. Interview on 04/22/2022 at 15:18 (3:18 PM), the MDS Coordinator stated Resident #1's EHR care plan was not updated with the one-to-one supervision, from incident dated 03/11/2022, because it would have had to come off after the 24-hour period was completed. The MDS Coordinator confirmed that his care plan was due the week before 03/22/2022. The MDS Coordinator further stated she updates care plans per the resident's MDS schedule, and she updated the care plan the week after the MDS is due. The MDS Coordinator confirmed that the facility was behind on getting all the resident's care plan updated and projected that all of them would be completed in roughly 90 days because resident's MDS' are typically done quarterly during the year. The MDS Coordinator believed residents were not affected negatively by not having their care plans updated in a timelier manner. Interview on 04/22/2022 at 15:19 (3:19 PM), the DON stated the MDS Coordinator updated the resident's care plans per their MDS schedule. The DON continued that resident's care plans are updated in the EHR the week following the resident's MDS due date. However, the DON, did confirm that the facility is behind on getting all the resident's care plans updated and projected that all of them would be completed in roughly 90 days because resident's MDS' are typically done quarterly during the year. The DON did not believe residents were affected negatively by not having their care plans updated in a timelier manner. The DON also that the facility transitioned from paper records to EHR around November and therefore the facility is behind in getting the care plans in the residents' EHR updated. Interview on 04/22/2022 at 15:45 (3:45 PM), the Administrator confirmed that the facility is behind on getting all the resident's EHR care plans updated and projected that all of them would be completed in roughly 90 days because resident's MDS' are typically done quarterly during the year. The Administrator did not believe residents were affected negatively by not having their care plans updated in a timelier manner. The Administrator also stated that the facility transitioned from paper records to EHR around November and therefore the facility is behind in getting the care plans in the residents' EHR updated. Interview on 05/03/2022 at 2:20 PM with CNA D she was informed of the incident regarding Resident #1 sexually abusing another resident on a different hall and resident was moved to her hall (300 / secured unit) to protect Resident #5 from further harm. CNA D stated management put Resident #1 on 1 to 1 observation the first day he was on the secured unit then lifted it after that. CNA D stated currently there is no instruction or requirement for monitoring Resident #1 or processes in place to protect the other residents on the secured unit. CNA D said the only thing they must do is intervene if they hear yelling coming from Resident #1 or his roommate (Resident #6). Interview on 05/03/2022 at 2:45 PM with DON stated after the incident on 3/11/2022 Resident #1 was placed on the secured unit in a room alone. DON said staff were advised to provide 1 on 1 observation of the resident for at 24 hours, but it turned out to be four days. DON stated there was no standing plan in place for monitoring or observations of Resident #1 as of 3/14/2022 to ensure the safety of the secured unit residents because they have not had any additional incidents with Resident #1 since 3/11/2022. DON said the 1 on 1 was lifted after the resident's doctor changed his medications and no written plan for monitoring residents was put in place. DON stated the social worker and herself completed 4 weeks of monitoring which included Quality of life Rounds (residents are asked if they have any concerns with their quality of living) and Resident to Resident Sexual Behavior interviews of staff (staff are asked if they have seen anything and what to do if they do). DON said they have not had any issues with Resident #1 since the doctor changed his medications, so they do not have a need for 1-on-1 observations or worries about the other resident's well-being or safety. DON stated Resident #1's current roommate can verbalize his needs and will say something if Resident #1 tried to do something to him. She said there was not a standing plan in place to protect Resident #1's roommate (Resident #6) either. Interview 05/03/2022 at 5:50 PM CNA C stated she was in-serviced about two weeks ago for abuse and neglect. CNA C stated she will check on her residents every hour but that is not a facility requirement, that is her own preference. CNA C said she has not been given any monitoring requirements for Resident #1 even after the incident on 3/11/2022. She said she will normally keep a close eye on him because there are women on that hall (300 / secured unit), and she does not want anything to happen to them. CNA C stated Resident #1 has been verbally aggressive when staff attempts to redirect him. Interview on 05/03/2022 at 6:15 PM with DON she stated Resident #1's paraphilia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the reason that incident was not called in was because they were two consenting adults. DON said both Resident #1 and Resident #2 said they were ok with what was witnessed. DON stated both residents were given assessments by staff and their doctor and placed on medications to reduce this behavior. DON said after this incident Resident #1 had no problems until Resident #5 enticed him to do what he had done by laying nude in his bed with his back and bottom facing the door/hallway. DON stated the incident with Resident #1 and Resident #5 was called in because Resident #5 could not give consent. Interview on 05/04/2022 at 5:54 PM CNA D stated when she worked the hall that Resident #1 is on (300/Secured Unit), she will check on him as often as possible because he can become verbally and physically aggressive. CNA D stated she is worried that Resident #1 will hurt his current roommate, Resident #6, and management has not put in safeguards to protect the roommate or the other residents. Interview on 05/04/2022 at 6:05 PM CNA I stated she works on the 300 hall with Resident #1 and was not given any current requirements for monitoring that resident or protecting the other residents. CNA I stated she was told about Resident #1 sexual misconduct in his old room and she keeps a close eye on him because of that. CNA I said Resident #1 can become physically violent but has not recently. Record review of Resident #1's care plan, reviewed 12/09/2021, which read Problem/Needs: Resident is hypersexual [excessive preoccupation with sexual fantasies, urges or behaviors that is difficult to control] and has inappropriate behaviors. [ .] Approach, start 04/01/2021, maintain consistent firm boundaries, redirect to a positive activity, let staff know of inappropriate sexual behaviors, identify triggers and try to prevent sexual the inappropriate behavior from starting. [MEDICATION(S)] as per MD's orders. Consult with psych as needed. Record review of Resident #1's care plan dated 05/03/2022, revealed behavior for paraphilia interventions was not initiated until 03/22/2022 and 1 on 1 observation for 3/11/2022 was not documented. Record review of Resident #1's progress notes revealed on 3/11/2022 at 16:54 (4:54 PM) Resident #1 digitally penetrated another resident rectum who was not his roommate and was not capable of providing consent. During this incident both Resident #1 and the victim were living in the facility's general population. Resident #1 was placed in the secured unit in a single occupancy room. Record Review of Resident #1's progress note dated 3/11/2022 at 17:12 Nurses Note revealed: Resident was found in another resident's room and reported that he was poking resident in the Butt. Resident removed from room immediately moved to a single room and placed on one on one. MD Notified. Abuse coordinator notified. Signed by MDS M. Review of Resident #1's progress note dated 3/14/2022 14:40 (2:40 PM) Nurse's Note revealed, Spoke with (MD) with psych, gave new orders to increase [MEDICATION(S)] 10mg po qhs (by mouth at bedtime) and start [MEDICATION(S)] Dr 500mg po bid (by mouth twice a day). (MD) states he will check VPA level next week. Review of written witness statement dated 3/11/2022 revealed CNA N wrote a voluntary statement that read: I walked into (Resident # 5) room and saw (Resident #1) bent over (Resident #5). I walked closer to look over (Resident #1) shoulder and saw him inserting his middle finger repeatedly into (Resident #5) rectum. I told (Resident #1) he needed to leave immediately. He got startled and walked out without saying a word. (Resident #5) did not move nor react to what (Resident #1) was doing to him. (Resident #5) had no facial expression at all. I witnessed this a (sic) 5:04 PM 3-11-22. Record review of Resident Observation record dated 3/11/2022 revealed one on one observation began at 5:00 PM and continued until 3/13/2022 at 7:45 AM. No monitoring was noted from 8:00 AM to 9:15 AM and 10:30 AM through 6:00 PM on 3/13/2022. Further review revealed one on one continued from 3/13/2022 at 6:00 PM and ended 3/14/2022 at 4:00 PM The facility's Plan of Removal submitted by the facility was accepted on 5/5/2022 at 12:50 PM. While the IJ was removed 05/05/2022 at 5:17PM. The facility remained out of compliance at a potential for more than minimal harm that was not an immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. Problem: Freedom from Abuse, Neglect, and Exploitation Interventions: 1. Resident in question was placed on one-to-one monitoring on 5/3/22 at 1800 (6:00 PM) for 24 hours a day x72 hours. This will provide the resident time to acclimate to his new surrounding outside the secured care unit. Residents current private room is located at the start of hall closest to the nurse's station for better monitoring. The initial one to one monitoring was put into place on 3/11/22 at 1700 (5:00 PM) that lasted for 24 hours and then discontinued as resident was moved to secured unit and no further incidents had occurred and then it was re-implemented on 5/4/22 as a result of the POR. We will continue to monitor resident's movements every hour for an additional 24 hours and then every 2 hours after that following routine round observation. 2. Staff will be made aware of one-on-one monitoring; staff member will be assigned every shift via the staff assignment shifts. One to one monitoring intervention will be reflected in the care plan. Staff will be presented with a tracking time sheet and trained to use. 3. Resident in question was moved off secured unit to a private room on 5/4/22 as of 0800 (8:00 AM). 4. The medical director (MD) was notified of the immediate jeopardy situation on 5/3/22. 5. The medical director made no changes to the treatment plan due to fact that medication regimen/changes have been effective as evidenced by no further sexual behaviors to date. 6. 30-day notice for eviction presented to resident in question, notified family of situation on 5/4/22 at 09:54 AM and facility will continue to solicit placement to other facilities. 7. Ombudsman was contacted to aide in placing resident in an appropriate facility on 5/4/22. 8. Resident will continue current medication regimen as resident is cooperative and compliant with medication administration at this time. 9. Supporting documentation and care plan remains up to date that validates interventions remain effective without further incident. Care plans were updated on 3/22/22 after interventions were implemented on 3/11/22. No additional inventions required as current interventions remain effective as evidence by no incidents as of 3/11/22. 10. Facility Administrator and DON have audited residents' records with current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility management confirmed all appropriate interventions and treatment plans in place per the existing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 11. The following in-services were initiated by the DON and Administrator on the following dates 2/10/22- 3/21/22- 4/11/22-5/3/22. With these in-services 100% of staff has been trained. Proof of dates that staff has been trained is attached. a. What is Abuse/ Neglect/ Exploitation. b. Signs and symptoms of suspected abuse/ neglect/ exploitation. c. Examples of abuse/neglect/exploitation. d. Residents that are most vulnerable or higher risk for abuse/ neglect/ exploitation. e. Facility and Resident risk factors for abuse/ neglect/ exploitation. f. Consequences of abuse/ neglect/ exploitation on the elderly. g. Preventing abuse/ neglect/ exploitation. h. What steps does the staff member take if he/she witnesses abuse or neglect. i. Types of abuse and neglect. j. 5/03/2022 Abuse and Neglect The facility has in place measures to protect residents from further abuse or neglect. The facility's Plan of Removal monitoring included the following: Interventions: 1. a) 1 Staff observed in room (202 on 200 Hall) with Resident #1 completing current 1 on 1 observation. Room is a single occupancy room with no roommate. b) Record review of staff 1 on 1 log revealed 15-minute status details for Resident #1 beginning 5/3/2022 at 18:00 (6:00 PM) and continuing without gaps. c) Interview on 05/04/2022 at 4:15 PM with NA I she stated when she is conducting 1 on 1 with Resident #1 and her shift is over, she is required to give the sheet to the next person who will be conducting the observations. NA I stated the log requires staff to note the resident's activity every 15 per the codes listed on the log. d) Interview on 05/04/2022 at 4:30 PM with NA L she stated she was informed of the 1 on 1 and is currently providing it for Resident #1. She said if she needs to take a break she is required to get someone to take her place prior to her leaving Resident #1's side. NA L stated the logs are transferred to the next shift when they arrive, and each are signed off on by her and management. 2. a) Interview on 05/04/2022 at 3:30 PM with LVN E she stated she was informed of the 1 on 1 for Resident #1 and the requirement is that someone must be always with him. LVN E said if staff leaves for a break, they will have to find someone to cover until they get back. LVN E stated the observation log will be given to the next shift when they come in to relieve her. LVN E said the log requires staff to log what the resident is doing every 15 minutes. b) Interview on 05/04/2022 at 3:40 PM with CNA F she stated she was instructed on the requirement for Resident #1's 1 on 1 observation. CNA F stated staff must fill out the observation log if they have been assigned to complete observations of Resident #1. CNA F stated the resident's activities are noted on the log in 15-minute intervals. CNA said at shift change the log will be given to the person coming on and they must continue filling out the form as required. c) Interview on 05/04/2022 at 3:45 PM with CNA G stated she was informed of the 1 on 1 requirement for Resident #1. CNA G said she is aware that it is a 24-hour observation over the next several days. CNA G said the 1 on 1 requires staff to note what the resident is doing every 15 minutes of their shift. CNA G stated at shift change they are required to give the logs to the relieving staff. CNA G said if breaks are needed mid shift, she is to find someone to stand in for her until she gets back. d) Interview on 05/04/2022 at 3:50 PM with LVN H she said she was told that Resident #1 is currently on 24 hour one on one. LVN H said she knows to fill out the observation log with the resident's activity every 15 minutes she is conducting observations for him. LVN H said when she is going to lunch or taking a break, she is to get another staff member to take over until she gets back. LVN H said when she leaves for the day, she will give the log to the next shift to continue. e) Record review of in-service Sign in sheet with details about the one on one is being signed as shifts begin. f) Record review of Resident Observation Record revealed logs started 5/3/22 at 1800 (6:00 PM) for 24 hours a day x72 hours and require staff to note the resident's activity for every 15 minutes. 3. Observation on 5/05/2022 revealed Resident #1 was living in room [ROOM NUMBER] (200 Hall) alone . 4. Record review of Resident #1's progress notes revealed Medical Director (MD) was notified of Immediate Jeopardy involving Resident #1 on 5/03/2022 at 7:08 PM 5. Record review of Resident #1's undated Order Summary revealed no new orders 6. a) Record review of 30-day discharge for Resident #1 revealed document signed by administrator reporting discharge date of [DATE] and certified mailing to Resident #1 responsible party (RP) on 05/04/2022. b) Record review of progress notes revealed Resident #1's RP was notified of 30-day discharge on 5/04/2022 at 5:53 PM. 7. Record review of Resident #1's progress notes revealed Ombudsman was notified on 5/04/2022 at 9:42 AM. 8. a) Observation on 5/05/2022 at 3:00 PM revealed facility staff was performing 1 on 1 observation for Resident #1 b) Interview on 5/05/2022 at 3:00 PM with NA L she stated she is assigned to complete 1 on 1 observation for Resident #1 as her regular duty on her shift. NA L verified in-service training for 1 on 1 requirements for Resident #1 and acknowledged she is required to always have eyes on Resident #1. c) Record review of Resident #1's care plan dated 05/05/2022 revealed 1 on 1 observation had been added. 9. a) Record review of in-service sign-in sheets dated 2/10/22, 3/21/22, 4/11/22, and 5/3/22 revealed all staff have been in-serviced b) In-services include: What is Abuse/ Neglect/ Exploitation, Signs and symptoms of suspected abuse/ neglect/ exploitation, Examples of abuse/neglect/exploitation, Residents that are most vulnerable or higher risk for abuse/ neglect/ exploitation, Facility and Resident risk factors for abuse/ neglect/ exploitation, Consequences of abuse/ neglect/ exploitation on the elderly, Preventing abuse/ neglect/ exploitation, What steps does the staff member take if he/she witnesses abuse or neglect, Types of abuse and neglect, and 05/03/2022 Abuse and Neglect c) Interview on 05/05/2022 at 3:30 PM with LVN E stated she was in-serviced this week on A/N/E as well as the definitions for each type. She stated she was educated on the process for handling residents who are acting out abusively towards other residents to include Resident #1. d) Interview on 05/05/2022 at 3:40 PM with CNA F she stated she has been in-serviced this week on abuse and neglect and was given the definitions of each type. She said she was trained on what to do if a resident is found being abusive towards another resident and steps on how to stop it before it happens especially for resident #1. e) Interview on 05/05/2022 at 3:50 PM with CNA G she stated she stated she has been in-serviced this week on abuse and neglect and it was around the beginning of the week. She said management has detailed processes for keeping residents safe from high-risk residents like Resident #1 as well as how to identify signs of potential threats from that resident towards others. f) Interview on 05/05/2022 at 4:00 PM with LVN H she said she stated she was in-serviced this week about abuse and neglect and has been informed of the definitions for all they type of abuse and neglect. These failures resulted in an identification of an immediate Jeopardy {IJ} on 5/03/2022 at 6:41PM. While the IJ was removed 05/05/2022 at 5:17PM. The facility remained out of compliance at a potential for more than minimal harm that was not an immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interviews, and record reviews, the facility failed to ensure that one resident received adequate supervision and assistance device use to prevent injury for one (Resident #1) of four residents reviewed for accidents, in that: CNA A transferred Resident #1 from a chair to the bed using a mechanical lift by self and the resident suffered a laceration of right lower leg. Resident #1 was sent to the hospital and received 23 staples to the leg. This failure could place residents at risk for severe injury and/or death. Findings include: Record review of Resident #1's undated admission record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's undated care plan revealed a nursing intervention, with a start date of 5/5/18, requires total assist x2 staff with transfer tasks. Use resident lift for all transfers, Hoyer lift for all transfers. In an interview on 10/5/20 at 11:20 a.m., LVN B confirmed on 9/27/20 at 9:20 a.m. that CNA A transferred Resident #1 via a mechanical lift alone, without the required assistance of 2 persons, per Resident #1's care plan. LVN B provided first aide care to Resident #1 for injuries suffered to his right lower leg while being transferred by a mechanical lift from his wheelchair to his bed. LVN B confirmed she reported the incident to the physician and facilitated orders for Resident #1 to be transfer to the local hospital. Resident #1 was discharged from the hospital and returned to the facility. Resident #1 had 23 staples to the right lower leg wound. In an interview on 10/6/20 at 10:25 a.m., CNA A confirmed he was alone while transferring Resident #1 from his wheelchair to his bed via a mechanical lift on 9/27/20 at approximately 9:00 a.m. CNA A said he realized he had injured Resident #1 by having his leg scrape against the bedframe while the lift was engaged. CNA A stated he immediately alerted LVN B for first aide care. CNA A stated he knew Resident #1's care plan specified for 2 people for transfers with a mechanical lift, however on the day of the transfer he did not ask for any help. CNA A further stated, I feel super terrible for hurting (Resident #1), and I will never do that again, I am sorry. Observation on 10/6/20 at 11:01 a.m., of Resident #1 revealed him in his bedroom, in bed, watching television. Further observation of Resident #1's right lower leg revealed a healing wound with 23 staples. In an interview on 10/6/20 at 11:02 a.m., Resident #1 confirmed around the end of September he had suffered an injury to his right lower leg while being transferred from his wheelchair to his bed, after breakfast. Resident #1 confirmed CNA A was the CNA who used the mechanical lift to transfer him. Resident #1 confirmed CNA A was alone when he provided the mechanical lift transfer. Resident #1 confirmed upon transfer his leg became stuck on the bed frame as the lift was engaged and thereby suffered a right lower leg laceration. Record review of hospital records revealed that Resident #1 had been seen in the emergency room and to reason for the visit report read, Laceration of right lower leg without foreign body. Patient instructions reviewed revealed, DI for laceration repair - staples. Received 9/27/20 10:48. Record review of the facility's undated policy for Hoyer lift transfers titled Transfer, Two Person Hoyer (mechanical) Lift, stating Purpose: To safely get resident from one surface to another when a resident is unable to bear weight on his lower extremities.

Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 13 residents (#1) reviewed for neurological checks after an unwitnessed fall in that: LVN A and LVN B were not able to check Resident #1's pupils for 6 ,[DATE] hours for neurological checks after an unwitnessed fall and did not contact the physician. This deficient practice could affect residents who had unwitnessed falls and could result in injury or death. The findings were: Review of Resident #1's Face Sheet (undated) revealed she was admitted to the facility on [DATE]. She was [AGE] years old, was severely cognitively impaired and was taking an anticoagulant for [MEDICAL CONDITION]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's MDS assessment with an ARD of [DATE] revealed she had a severe cognitive deficit, inattention and disorganized thinking. She needed extensive assistance with her ADL's and had a history of [REDACTED]. Review of Resident #1's Comprehensive Plan of Care dated [DATE] revealed Problem/Needs .Potential for falls/injuries R/T dementia, mental disorders, balance/coordination problems, gait disturbances and poor safety awareness .Potential for clot formation/increased bleeding tendencies related [MEDICAL CONDITION].and [MEDICATION NAME] (inhibits blood clotting) use. Review of facility investigation of the incident for Resident #1 dated (MONTH) 21, 2019 revealed she fell at 09:00 a.m. .was found in the dining room lying on the floor next to her wheelchair. The nurse was alerted .she was found to have bleeding from her nose .Protocol for unwitnessed falls includes the initiation of serial neurological assessments .Neurological assessment revealed her pupils to be round, reactive to light at 3 mm/+. Resident vital signs and behaviors were at baseline level. Her condition remained stable throughout the day until at approximately 5:15 p.m her pupils changed from PERRL to non-reactive .nurse in charge at hospital in San[NAME]tated that .had an intra-cerebral hemorrhage (bleeding in the brain). Review of Resident #1's progress notes dated [DATE] at 09:00 a.m. when she fell and written by LVN B revealed resident found in floor in dining room, blood on right nostril. No noted wounds. Dr. called. Review of Resident #1's progress notes dated [DATE] at 3:,[DATE]:15 p.m. written by LVN A revealed Pt fell this a.m. refused to open eyes, squeezing shut, responding to commands .left eye was relaxed enough to check pupillary response, pupil was constricted and non-reactive, EMS called. Review of Resident #1's Neurological Record dated [DATE] and started at 09:00 a.m. revealed that from 09:45 a.m. until 4:15 p.m. her pupils were not checked for size and reactivity. Review of Resident #1's progress notes dated [DATE] at 08:30 a.m. revealed Spoke with manager in the ICU, he stated that resident has cerebral hemorrhage and is in critical condition, not doing well and is intubated. Interview on [DATE] at 07:30 a.m. with LVN B revealed, when she examined Resident #1 on the floor in the dining room, she had blood coming out of one side of her nose. She stated that Resident #1 was assisted to bed after breakfast, staff laid her down and she did not appear to have other injuries. She stated that she did not consider neurological checks to be complete without checking PERRLA, but that the resident did not open her eyes, so she just put R with a circle for refused each time. She stated that she did not notify the doctor that she was not able to check Resident #1's pupils. Interview on [DATE] at 10:40 a.m. with LVN A revealed she continued to do Resident #1's neurological checks, but could not get her to open her eyes to check PERRL[NAME] She stated that the resident would not open her eyes and kept them tightly shut. She stated she did not consider neurological checks to be complete without checking PERRLA, and that she did not notify the doctor that the resident would not open her eyes. She stated that at 5:15 p.m. she was able to check the left eye and her pupil was not reactive and she called EMS. Interview on [DATE] at 11:00 a.m. with the Administrator revealed Resident #1 passed away at the hospital where she was in the ICU for a brain hemorrhage. Interview on [DATE] at 12:00 p.m. with Dr. C revealed that he did not recall being told that Resident #1 fell and hit her head. The doctor stated that with her age and condition he would have sent her out to the Emergency Department right away. The doctor stated that it was his job to interpret data and the nurses job to report any changes to him. The doctor stated that he felt like not wanting to open her eyes could have been a change. The doctor stated that he should have been notified that she was not opening her eyes for PERRL[NAME] Review of Resident #1's MAR indicated [REDACTED]. Review of facility policy and procedure (undated) titled Emergency Treatment-Head Injuries revealed Procedure: 3. Determine the baseline for the patient .c. Evaluate pupil size and reaction to light. Review of facility policy and procedure titled Neurological Assessment (undated) revealed 1. Immediately following the injury/incident obtain vital signs, check the level of consciousness, mental status, speech, pupillary responses, motor and sensory functions to establish a baseline for future assessments. Review of Neurological checks for head injuries LTC Clinical Pearls: Powered by HCPro's Long-Term Care Nursing Library, (MONTH) 8, 2013 revealed Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology. Assess the resident immediately after the fall, then frequently throughout the shift. Assessment should continue for a minimum of 72 hours. Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength.