Every finding on record at Avir at Center

Based on observation, interview, and record review, the facility failed to ensure residents maintained the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 1 facility. The facility failed to ensure all residents had the right to receive visitors between 10:00 PM and 6:00 AM.The deficient practice could place residents at risk of isolation, decreased emotional well-being, and diminished quality of life. Findings include:Observation on 07/22/2025 at 6:15 AM revealed a sign posted on the main entrance Visitation hours: 6:00 AM to 10:00 PM During a confidential resident council meeting on 07/22/2025 the residents in attendance were not aware of limitation of visiting hours.Record review of a letter dated 06/24/2025 presented on 7/22/2025 by the Administrator addressed to families and visitors indicated the designated visiting hours as daily 6:00 AM to 10:00 PM. The letter indicated any visits outside of regular visiting hours were to be arranged with the administrative staff. The letter was signed by the social service director. During an interview with the interim Administrator on 07/23/2025 at 8:20 AM, he stated visiting hours were enacted in the middle of June 2025 due to complaints by more than one resident, relating to family members coming to the facility late at night and disturbing residents in the facility. He stated a family member had visited the facility after midnight while under the influence of intoxicants. He stated late night visits occurred on more than one occasion and involved more than one resident. The decision was made to limit visiting hours from 6:00 AM to 10:00 PM. He stated phone calls were made to all resident representatives regarding visiting hours and there were no complaints or concerns with limiting the visiting hours. The administrator stated a letter was sent to all resident representatives notifying them of the facility's visiting hours. He stated the decision was made to limit visiting hours to all visitors so that one family or resident would not be singled out, and equal treatment was being provided to all residents. He stated he has not received any resident complaint related to establishing visiting hours. The administrator stated the hours were to deter late night visitations that would disturb other residents. He stated limiting visitation hours could have a negative impact on the residents by causing emotional distress and fear related to the inability to see their family members.In an interview with the social worker on 07/23/2025, she stated the decision was made to limit visitation hours in the facility after complaints by residents related to family members visiting the facility late at night and waking them. She said one resident had a family member who had come into the facility on several occasions after midnight under the influence of intoxicants and disturbed the roommate and other residents. She stated a meeting was conducted with the family member related to the complaint and discussed how the late visits were disturbing other residents during hours of rest and the family member verbalized understanding of the concern but continued to make late night visits. After complaints continued by the residents, the administrative staff made the decision to limit visitation hours. The social worker stated phone calls were made to all family representatives to inform them of the visitation hours and there were no concerns or complaints during the telephone communications. The social worker stated no residents had voiced concern or complained about the visiting hours. She stated a letter was mailed to all resident representatives that indicated visiting hours were daily from 6:00 AM to 10:00 PM. She stated there has been no complaints or signs of negative effects to the residents related to limiting visitation hours. Record review of facility admission packet, a document titled Resident Rights revised 12/1/2018 indicated residents have the right to receive visitors.

Based on observations, interviews, and record reviews the facility failed to establish and 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 2 of 6 residents (Resident #10 and Resident #17) and 2 of 5 staff (LVN A and CNA B) reviewed for infection control. The facility failed to ensure LVN A and CNA B followed enhanced barrier precautions for Residents #10 and #17 on 07/21/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Resident #10Record review of Resident #10's facility face sheet dated 07/21/2025 revealed that Resident #10 was a [AGE] year old female that admitted on [DATE]. Record review of Resident #10's order summary report dated 07/21/2024 revealed Resident #10 had a diagnosis of dementia and required EBP every shift related to pressure wound. Record review of Resident #10's Quarterly MDS assessment dated [DATE] revealed Resident #10 had a BIMS of 9 indicating moderately impaired cognition, required maximal assistance with toileting and was incontinent of bowel and bladder. Record review of Resident #10's comprehensive care plan dated 07/03/2025 revealed Resident #10 required EBP during contact care and staff to provide and utilize appropriate PPE along with standard precautions while providing resident care. During an observation and interview on 07/21/2025 at 9:45 am Resident #10 had a yellow dot by her name outside her room. She said the staff wore gloves but not a gown when providing care to her. During an observation on 07/21/2025 at 2:45 pm CNA B provided incontinent care to Resident #10 with the ADON present for assistance. CNA B removed Resident #10's linens, provided incontinent care and turned and positioned Resident #10 with only gloves in place. Resident #17Record review of Resident #17's facility face sheet dated 07/22/2025 revealed that Resident #17 was a [AGE] year-old male that admitted on [DATE]. Record review of Resident #17's order summary report dated 07/22/2024 revealed Resident #17 had a diagnosis of cerebral infarction (stroke) and required EBP every shift related to urinary tract infection. Record review of Resident #17's Annual MDS assessment dated [DATE] revealed Resident #17 had a BIMS of 9 indicating moderately impaired cognition, required maximal assistance with toileting and was incontinent of bowel and bladder. Record review of Resident #17's comprehensive care plan dated 07/21/2025 revealed Resident #17 required EBP during contact care and staff to provide and utilize appropriate PPE along with standard precautions while providing resident care. During an observation and interview on 07/21/2025 at 10:00 am Resident #17's name at his door had a yellow dot and he said the staff did not wear a gown when providing care. During an observation on 07/21/2025 at 4:05 pm CNA B was observed providing incontinent care to Resident #17. CNA B performed incontinent care, changed the resident's linens and gown and assisted with positioning the resident with only gloves in place. During an observation and interview on 07/21/2025 at 4:30 PM LVN A did not wear a gown while administering intravenous medication to Resident #17. LVN A stated the resident had a yellow dot indicator on his name plate outside his door. She stated the yellow dot indicated the resident was on enhanced barrier precautions. She stated staff were to wear gowns, gloves and mask when providing care to residents on enhanced barrier precautions. LVN A stated staff should wear proper PPE when providing care to residents on enhanced barrier precautions to prevent the possible exposure and spread of germs to other residents and staff. During an interview on 07/21/2025 at 4:34 pm CNA B said the yellow dot on the name at the door meant the resident required a gown and gloves for EBP. She said she overlooked that Residents #10 and #17 had a yellow dot and should have applied a gown along with gloves. She said she knew what EBP was but could not recall the specific training she received. She said by not following EBP infections could spread. During an interview on 07/21/2025 at 4:37 pm the DON said she oversaw the infection control program, and all staff were educated on EBP along with other infection control measures on hire, annually and as needed. She said LVN A and CNA B had been trained and expected that the staff to follow the infection control program to prevent the spread of infections. During an interview on 07/23/2025 at 8:44 am the Administrator said that the DON was responsible for the infection control program. He said all staff were trained on hire and throughout the year on infection control including EBP. He said when a resident required EBP the resident name outside the door would have a yellow dot and the staff should wear a gown and gloves to provide care. He said he expected all staff followed the facilities infection control program to prevent the spread of infections. Record review of LVN A's nurse proficiency dated 08/30/2024 revealed LVN A had satisfactory completed training on infection control. Record review of CNA B's CNA proficiency dated 06/05/2025 revealed CNA B had satisfactory completed training on infection control. Record review of a facility policy titled Infection Control dated 03/2024 indicated, or residents for whom EBP are indicated, EBP is employed [NAME] performing the following high-contact resident care activities dressing, bathing, transferring, providing hygiene, changing linens, toileting, device care or use central line .

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or a centralized staff work area from toilet and bathing facilities for 1 of 4 residents reviewed for call lights. (Resident #11).The facility failed to ensure Resident #11's emergency call light in the bathroom would reach the floor. The call light cord for Resident #11 was three feet above the floor level.This failure could place residents at risk of not receiving timely assistance. Findings include: Record review of a face sheet dated 07/21/2025 indicated that Resident #11 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia (confusion due to aging with inability to remember), difficulty ambulating, and muscle wasting.Record review of a Quarterly MDS assessment dated [DATE] for Resident #11 indicated she had a BIMS score of 9, indicating that she had moderate cognitive impairment. The MDS indicated that the resident required supervision or touch assist of one person for toilet use and ambulated with a walker.Record review of a comprehensive care plan with a revision date 6/06/2025, revealed Resident #11 was at risk for injuries related to falls. During an interview and observation on 07/22/2025 09:15 AM Housekeeper A said the call light in Resident #11's bathroom was too short to be reached at floor level, the string was 3 feet from the floor. Housekeeper A said if Resident #11 had a fall she would not be able to reach the call light. She said if the resident fell, she could lay on the floor until someone heard her or when the next rounds were made by staff.During an interview on 07/22/25 at 10:00 AM, the Maintenance Director said the call lights in bathrooms needed to be accessible because if a resident were to fall, they needed to be able to reach the string to call for help. He said he would make a facility sweep to correct all strings to the required length. During an interview with the ADON on 07/22/2025 10:20 AM, the ADON said she would in-service staff to notify maintenance if the bathroom call strings did not reach floor level. The ADON said all staff members were responsible for ensuring call lights were in place. Residents could be at risk of not being able to call for help in an emergency, such as falls. Going forward, she would expect call lights to be checked every shift to make sure they are available. During an interview on 7/22/25 at 10:50 AM the Administrator said that the CNAs were responsible for ensuring that all call lights were in place and in working order and report to maintenance if there are no problems. He said that residents may not be able to call for help when needed if they can't reach their call light. Going forward, he would expect that all call lights be in place and functioning. Record review of a facility policy titled Call light - use of dated 12/2017 read .it is the policy of this home to ensure residents have a call light within reach and that they are physically able to access and that they have been instructed on its use .

Based on observations, interviews, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition with the pilot light burner staying lit for 1 of 6 burners and allowing gas to leak on 07/21/25 and 07/22/25. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.Findings included: During an observation on 07/21/25 at 9:00 a.m. the back right burner on the stovetop was observed to not light. Dietary Manager retrieved a striker and proceeded to light the pilot light with the striker. Pilot light behind the back right burner was observed behind the back right burner and was observed to be out. Dietary manager was unable to relight pilot light with striker and proceeded to light the burner. The burner lit with the striker. During an observation and interview on 07/22/25 at 9:15 a.m. the right back burner pilot light was observed to be out again. Dietary Manager was observed to light burner with striker. She said the vent in the ceiling would blow toward the pilot light on the back burner and cause it to blow out. During an observation and interview on 07/22/25 at 10:30 a.m. a vent was observed in the ceiling directly in front of the stove. Air was felt blowing straight down. There was a large pot observed on the back burner of the stove. [NAME] moved the pot and pilot light was observed to be lit. Burner lit with no issues. Dietary manager was in kitchen and said she knew it could be dangerous for the pilot light to keep going out and having to light the burner with a striker. She said she had been at this facility on and off for about 14 years and it had been a constant issue. She said she did not know what the facility had tried in the past to avoid the air from the vent blowing the pilot light out. She said maintenance had been made aware, but she could not remember the last time she had reported it to him. She said she would report it again and get it taken care of. She said she knew it could be a fire hazard having to relight the burner with a striker. During an interview on 07/22/25 at 1:14 p.m. the Maintenance Director said he was aware the pilot light did go out at times. He said the gas would still be running if the pilot light was out and it could potentially be a fire hazard. He said he would look at the issue and see if he could possibly divert the air flow to prevent the pilot light from being blown out. During an interview on 07/22/25 at 8:30 a.m. the Administrator said they did not have a facility policy for maintaining equipment. During an interview on 07/23/25 at 8:20 a.m. the Administrator said he was an interim and had only been here for a couple of months. He said the risks of fire should be low on the stove because they have the exhaust fan running all the time, but it still would be fixed. He said he was going to look into ways to try and divert the airflow from the vent to try and prevent the pilot light from being blown out. He said going forward, he would expect the stove to work properly.

Based on observation, interview, and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident, in 3 of 11 resident rooms reviewed for required square footage. (Resident room #s 300, 309 and 310). The facility did not have at least 80 square feet per resident in resident room #s 300, 309, and 310. This failure could place residents at risk of having inadequate space for personal belongings, guests, and limit the resident's ability to move about in the room. Based on observation, interview, and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident, in 3 of 11 resident rooms reviewed for required square footage. (Resident room #s 300, 309 and 310). The facility did not have at least 80 square feet per resident in resident room #s 300, 309, and 310. This failure could place residents at risk of having inadequate space for personal belongings, guests, and limit the resident's ability to move about in the room. Findings included: During an observation on 07/21/25 from 10:00 am until 10:30 am, room [ROOM NUMBER] was used for maintenance, room [ROOM NUMBER] was used for an office and room [ROOM NUMBER] was used as a sitting area in the locked unit. The rooms measured approximately as follows: * room [ROOM NUMBER]- 6 x 4 feet at entry and the main area was 13.4 x 10.4 feet.* room [ROOM NUMBER]- 12 x 12.4 feet; and * room [ROOM NUMBER]- 12.8 x 12.3 feet.Record review of a bed classification worksheet, completed by the facility administrator, dated 07/22/2025 indicated there were 11 resident rooms on the secured unit, including Resident room #s 300, 309, and 310. (Hall 300) During an interview on 07/21/25 at 10:30 am, the Administrator said there had been no structural changes to the building and he knew there had been a waiver granted in the past for three rooms on the secured unit. The Administrator said he would complete HHSC form 3762 (room size waiver for facilities).

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents. The facility failed to prevent Resident #1 from eloping on 7/23/2024 when he was able to exit the secured unit and exited the facility through the main entrance. The noncompliance was determined to be PNC (past non-compliance) . The IJ (Immediate Jeopardy) began on 7/23/24 and ended on 7/23/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for serious injury and accidents. Findings include: Record review of an Admission Record dated 3/25/2025 for Resident #1 reflected he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of dementia with behavioral disturbances (A group of symptoms that affects memory, thinking and interferes with daily life), Post Traumatic Stress Disorder (a mental health condition that's caused by an extremely stressful or terrifying event), psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), and Alzheimer's Disease (a neurodegenerative disease that usually starts slowly and progressively worsens). Record review of a Brief Interview for Mental Status (BIMS) assessment dated [DATE] reflected the Resident #1 had severe cognitive impairment with a score of 5. Record review of the baseline care plan dated 7/22/2024 reflected that Resident #1 was cognitively impaired and was at risk for elopement. Record review of a hospital Physician's Progress Note dated 7/17/24 reflected Resident #1 required a secure nursing facility placement related to his wandering behaviors and elopement risk. During an interview on 03/25/2025 at 1:30 PM, LVN A, who was the nurse on duty at the time of Resident #1's elopement, said she could not recall an elopement occurring in the last 12 months. During an interview with the Social Worker on 3/25/25 at 2:00 PM, she indicated there was an incident of a missing resident occurring in 2024. She was not able to recall the exact date. She said a resident from the secured unit was reported missing and she was able to recall assisting in looking for the resident in the facility. She stated the resident was located across the highway and was not injured. She said the resident was transferred to a behavioral health hospital shortly after the incident. During an interview with LVN B on 3/25/25 at 3:30 PM, she stated she recalled an elopement incident occurring with a resident last year. She stated that the resident no longer resided in the facility. She stated she was not working at the time of the incident therefore she did not know the details. During an interview with CNA C on 3/25/25 at 3:45 PM she stated that she recalled an elopement incident that occurred within the last 12 months. She could not remember any details. She stated she was not working at the time of the incident, but recalled the incident being discussed. During an interview with the Maintenance Supervisor on 3/25/25 at 4:00 PM, he was able to recall an elopement incident that involved Resident #1 during his stay. He stated he was unsure how the resident was able to exit the building. He stated the resident was located across the highway at the shopping center's parking lot. He stated at the time of the incident, all doors were secured and locking mechanisms were functioning properly. He denied any failures to the keypad systems required to open doors at the main entrance and the secured unit . During a telephone interview with Resident #1's responsible party on 3/26/25 at 8:45 AM she stated Resident #1 was admitted to the facility for a short period of time July 2024. She stated she received a telephone call from the facility second day the resident was at the facility in reference to Resident #1 leaving the facility unattended. She stated the facility reported that Resident #1 had exited the facility and was found across the highway at the shopping center's parking lot. She said the resident did not suffer any injuries as a result of the incident. She stated the facility reported that visitors opened the doors that allowed the resident to exit the facility. She stated Resident #1 was transferred to a behavioral health hospital shortly after the incident related to his aggressive behaviors. During an interview on 3/25/25 at 3:15 PM, the ADON said that she initiated the one-on-one monitoring for Resident #1 on 7/23/24 related to his aggressive behaviors and exit seeking. She said the resident had torn down curtains and was exhibiting aggressive behaviors on 7/23/24. She stated the resident was placed on continuous monitoring to ensure the safety of the resident as well as the other residents located in the secured unit . During an interview with the Administrator ADM on 3/25/25 at 1:00 PM he stated he was not able to recall any elopement incident occurring in the last 12 months. During a follow up interview, with ADON on 3/26/25 at 11:15 AM, she stated one on one observations were initiated related to Resident #1's elopement from the facility. She said on 7/23/24, LVN A asked her if she had seen Resident #1 and that she could not locate him in the secured unit. She said all staff were alerted and began looking for Resident #1. She said shortly after starting the search, Resident #1 was found by another staff member across the highway in the shopping center parking lot. She said Resident #1 was assessed, with no injuries noted. She said one on one monitoring was initiated. She stated she notified the physician of the incident. She stated the Administrator notified the responsible party. The ADON was not able to provide an explanation as to why an incident report was not completed During a follow up interview on 3/26/25 at 11:26 AM, the Administrator stated he was able to recall an elopement incident that occurred 7/23/24 with Resident #1. He said it was reported that Resident #1 was missing from the secured unit and the facility's missing resident protocol was initiated. He said Resident #1 was located within 10 minutes. He said the resident was found by staff across the highway and was escorted back to the facility without incident. During the interview, the Administrator presented a file containing in-services, written statements, and the resident elopement assessments completed on the date of the incident. During a follow up interview with LVN A on 3/26/25 at 1:00 PM she confirmed she was the nurse on duty on 7/23/24. She stated she could not recall an elopement incident with Resident #1. A written statement by LVN A written on 7/23/24 provided to her for review and she was unable to provide any details of the incident. During an observation performed 3/25/25 between 9:30 AM and 10:00 AM and 3/26/25 between 2:00 PM and 2:20 PM of the secured unit access door revealed visitors were unable to access the area from the main building unless a large red button located on the adjoining wall was pushed. A sign above the door reflected for anyone entering to not allow anyone out of the area and to ensure the door had shut after entering. Observation of the door from the secured unit to outdoor patio area revealed it required a 4 digit code to access the outside area and to enter from the outside back into the secured unit. Observation of the gate located in outdoor secured area revealed it required a 4 digit code to open to the parking area. A code was also required to enter the patio area from the parking lot. A 4 digit code was required to exit the secured unit to the main hallway. The doors or gate could not be opened without a code. Observation of the outdoor patio area revealed no loose or broken fencing noted. Observation of the main lobby area revealed the door was secured and unable to enter or exit building without a 4 digit code. Outside of the building was a doorbell used by visitors and staff entered a code to the door to allow entrance. A sign was observed at the entrance that reflected visitors not allow residents outside without notifying staff. During an observation performed on 3/25/25 10:00 AM of the windows located in secured unit revealed no cracked or broken glass to any windows. Windows were secured and closed. to the [NAME] were unable to be raised to a height that would allow a person to exit the room. During an observation performed on 3/25/25 at 12:00 PM of the facility entrance to the location that Resident #1 was found indicated that the resident had to walk across a 2 lane highway and approximately 100 yards to the parking lot of the shopping center. Review of the local weather conditions according to the National Weather Service on 7/23/24 reflected that the recorded high temperature was 94 degrees Fahrenheit and the recorded low temperature was 76 degrees Fahrenheit. Record review of the facility incident reports for July 2024 revealed there were no completed incident reports for Resident #1. Record review of Resident #1's progress notes dated 7/22/24 to 7/25/24 revealed the resident's length of stay, and did not reflect any elopement incident. Record review of one-on-one observation sheets for Resident #1 revealed the one-on-one started on 7/23/24 at 10:30 AM and were initiated by the ADON. One on one observations continued until 7/25/24 at 4:45 PM, when the resident was transferred to a behavioral health hospital. Record review of the Administrator's investigation file dated 7/23/2024 indicated an in service titled Resident Safety/ Elopement was performed for all staff on 7/23/24. The resident elopement/wandering risk assessments were performed on all residents. Written statements by the ADON, LVN A, CNA D and ADM dated 7/23/24 were contained in the file. Record review of written statement dated 7/23/24 at 10:00 AM written by the Administrator revealed Resident #1 was not in the building and a search was initiated. Resident#1 was found and returned to the building with no injury assessed. Staff education was initiated, and the resident was placed on one-on-one supervision. The statement indicated resident was out of the building for approximately 10 minutes. Record review of written statement dated 7/23/24 at 10:00 AM written by the ADON indicated LVN A approached the ADON and stated she could not find Resident #1. The ADON stated all staff were notified and a search for the resident was started. The ADON's statement reflected all doors and windows were checked for signs of exit. The statement reflected the resident was confused and agitated when he returned to the building. A head-to-toe assessment was performed by LVN A with no injuries noted. Record review of a statement by LVN A dated 7/23/24 indicated LVN A observed the resident walking up the hallway toward the front. The statement reflected no other details were provided. Record review of a statement by CNA D dated 7/23/24 indicated CNA D observed Resident #1 ambulating up hallway towards front. The statement reflected no other details were provided. The facility took the following actions to correct the noncompliance on 7/23/24: Record review of the documentation provided by the Administrator indicated in-services were conducted on 7/23/24 with all staff on resident safety and elopement. During an interview on 3/26/25 at 8:45 AM with Resident #1's responsible party, she indicated she was notified of the incident on 7/23/24. Record review of a progress note dated 7/23/24 indicated Resident #1's physician was notified and an order for behavioral health evaluation was obtained. Record review of the elopement/wandering assessments revealed assessments were performed on all residents in the facility on 7/23/2024. Record review of one-on-one observation for Resident #1 revealed the observations were started 7/23/24 at 10:30 AM and ended on 7/25/2024 at 4:45 PM. During interviews on 3/25/25 and 3/26/25 with 3 CNAs, 4 LVNs, 2 housekeeping staff and 1 dietary staff on day and evening shifts revealed the employees indicated they would report a missing resident to administrative staff. All staff indicated a search of the facility and grounds was to be performed and that law enforcement was to be contacted if a resident not located within 30 minutes. All staff indicated Code Orange was communicated to alert all facility personnel of a missing resident. All staff reported doors were to remain closed and secure. Staff reported door codes were not shared with residents or visitors. Record review of facility policy titled Abuse/ Reportable Events reflected It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect .and situations that may constitute abuse or neglect to any resident in the facility. The noncompliance was determined to be PNC (past non-compliance) . The IJ (Immediate Jeopardy) began on 7/23/24 and ended on 7/23/24. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment that did not result in bodily injury were reported to the state agency within 24 hours for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The Administrator failed to report to the state agency withing 24 hours concerning an allegation of neglect on 07/23/2024 when Resident #1 eloped from the secured unit out of the entrance doors to the unit and out of the front entrance of the facility. This failure could place residents at risk for harm and injury. Findings include: Record review of an Admission Record dated 3/25/2025 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia with behavioral disturbances (A group of symptoms that affects memory, thinking and interferes with daily life), Post Traumatic Stress Disorder (a mental health condition that's caused by an extremely stressful or terrifying event), psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), and Alzheimer's Disease(a neurodegenerative disease that usually starts slowly and progressively worsens). Record review of a Brief Interview for Mental Status (BIMS) assessment for Resident #1, dated 7/25/24, indicated severe cognitive impairment with a score of 5. Record review of baseline care plan dated 7/22/2024 indicated that Resident #1 was cognitively impaired and was at risk for elopement. Record review of hospital's physician progress note dated 7/17/24 indicated that the resident required a secure nursing facility placement related to his wandering behaviors and elopement risk. Record review of one-on-one observation sheets for Resident #1 revealed the one-on-one started on 7/23/24 at 10:30 AM and were initiated by the ADON. One on one observations continued until 7/25/24 at 4:45 PM when the resident was transferred to a behavioral health hospital. During an interview with the Social Worker on 3/25/25 at 2:00 PM, she indicated there was an incident of a missing resident occurring in 2024. She was not able to recall the exact date. She said a resident from the secured unit was reported missing and she was able to recall assisting staff in looking for the resident in the facility. She stated the resident was located across the highway and was not injured. She said the resident was transferred to a behavioral health hospital shortly after the incident. She was not certain if the incident was reported. She stated the administrator was responsible for reporting incidents. During an interview with the ADON on 3/26/25 at 11:15 AM, she stated one on one observations were initiated related to Resident #1's elopement from the facility. She said on 7/23/24, LVN A asked her if she had seen Resident #1 and she could not locate him in the secured unit. She said all staff were alerted and began looking for Resident #1. She said shortly after starting the search, Resident #1 was found by another staff member across the highway in the shopping center parking lot. She said Resident #1 was assessed with no injuries noted. She said one on one monitoring was initiated. She stated she notified the physician of the incident. She stated the Administrator notified the responsible party. The ADON did not complete an incident report. She stated the administrator was responsible for reporting incidents to the state agency. During an interview with the Administrator on 3/26/25 at 11:26 AM, he was able to recall an elopement incident that involved Resident #1 that occurred 07/23/24. He said it was reported that Resident #1 was missing from the secured unit and that the facility's missing resident protocol was initiated. He said Resident #1 was located within 10 minutes. He said the resident was found by staff across the highway and was escorted back to the facility without incident. He stated he did not report the incident due to the resident being found quickly and without injury. Record review of a nurse progress notes for Resident #1 dated 7/23/24 to 7/25/24 showed no documentation of the elopement that occurred on 07/23/2024. Record review of facility incident reports for July 2024. There were no completed incident reports for Resident #1. During an interview with the DON on 3/25/25 at 2:15 PM, she stated she had no knowledge of the incident because she was on approved leave during that time. Record review of a facility policy titled Elopement effective 12/2018 indicated, The following steps are to be followed when a resident is noted absent and is not found on initial search of home. This also includes when a resident leaves the home grounds without staff notification. Administrative staff will: Determine if elopement is reportable to state regulatory agency. Record review of a facility policy titled Abuse/Reportable Event no dated printed on policy, indicated, The facility administrator or designee will report the allegation to HHSC . If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. The policy defined an adverse event as untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation 1.The dietary aide failed to effectively wear a hair net to cover all her hair on [DATE] and [DATE]. 2. The facility failed to ensure foods stored in the refrigerator and freezer were labeled, dated, and not kept past their expiration dates. 3. The cook and dietary manager failed to properly perform hand washing when performing duties in the kitchen. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation on [DATE] at 9:06 am the dietary aide had hair from under her hairnet on her forehead. During an observation and interview on [DATE] at 9:16 AM one bag of green, purple, and orange shreds was in a bag located in the refrigerator with no date or label. The dietary manager said the bag contained cold slaw. The dietary manager said the cold slaw was delivered on [DATE] and someone had taken it out of its original box. During an observation on [DATE] at 9:20 AM one bag of round small brown balls was in the freezer and expired and two pies with no label or date were in the freezer. During an observation and interview on [DATE] at 9:25 AM one gallon zip lock bag with flat, round, white, hard disc like objects were in the freezer with no date or label. One bag of frozen hash browns was in the freezer and had an expiration date of ,d+[DATE]. During an observation on [DATE] between 9:25 AM to 10:34 AM the cook did not wash her hands between putting food on the steam table and preparing puree food and did not wash her hands when leaving the preparation area and using the dish machine to wash the food processor. The dietary aide did not have her hair fully covered by the hairnet and hair was out on her forehead. During an observation on [DATE] at 10:40 AM the dietary manager entered the kitchen without washing her hands, put gloves on, and helped with prepping the steam table. During an interview on [DATE] at 11:30 AM the dietary aide said all hair should be under the hairnet and if hair was not completely covered hair could fall in the food. The dietary aide said she had received training on hair coverage/nets but was not sure when or how often. She said she did not think about having her bangs in the front sticking out of her hair net. She said all food should be dated, labeled, and stored correctly. She said if food was not stored right the food could spoil, be old and get resident's sick. She said hands must be washed going in and out of the kitchen or when changing chores. She said proper glove use and hand washing was important to control spreading bad germs and bacteria that may cause residents to become ill. During an interview on [DATE] at 11:35 AM the cook said all hair should be covered or it may fall in the food causing contamination. She said she had been trained on proper hair covering regularly. She said if proper hand sanitation was not done correctly the residents may get germs or bacteria causing the residents to get sick. She said proper use of gloves was mandatory and if not used properly food can be contaminated and residents may become ill. She said all food should be dated and labeled as well as expiration dates visible. She said all outdated foods should be discarded immediately and it was the responsibility of all staff to check the refrigerator and freezer for properly labeled and expired foods. During an interview on [DATE] at 11:45 AM the dietary manager said she oversaw all kitchen staff were trained once per month on different policies. She said she provided training on hand washing, glove use, cleaning, dating/labeling, and temperatures. She said she did notice her aide having hair out in the front of her face. She said uncovered hair could get into the food and cross contaminate it. She said improper use of gloves and not washing hands correctly puts residents at risk of food borne illness and make them ill. She said all staff should wash hands when entering the kitchen. She said all food should be dated/labeled and all outdated items should be discarded if not residents may consume the wrong food or spoiled food. During an interview on [DATE] at 9:47 AM the Administrator said the dietary manager was responsible for the oversight of the kitchen. He said all food items should be dated, labeled, and stored properly upon receipt. He said all kitchen staff was responsible for dating, storing and labeling food upon delivery and monitoring for outdated and expired items. He said the dietary manager was responsible for training the kitchen staff. He said hands were to be washed when entering the kitchen, between each change of duty and after handling dirty supplies. He said gloves were to be worn and removed between tasks with proper hand hygiene. He said the risk of poor hand hygiene, not wearing hairnets appropriately and improperly stored food could cause infections, food that was served could be spoiled and residents to become ill. He said he expected the policy was followed, everyone was trained, and the kitchen was maintained daily. Record review of a facility policy dated [DATE] titled Employee Sanitation indicated, .The Nutrition and Food service employees of the facility will practice good sanitation practices in accordance with the stat and US Food Codes in order to minimize the risk of infection and food borne illness;3a. hairnets must be worn to keep hair from food and food contact surfaces, 5a. employees must wash their hands immediately before engaging in food preparation, during food preparation, 6a. gloves are not a substitute for thorough and frequent handwashing. When using gloves, always wash hands before touching or putting on new gloves .

Based on observations, interviews, and record reviews the facility failed to establish and 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 2 of 6 residents (Resident #34 and #25) and 2 of 4 staff (CNA E and CNA G) reviewed for infection control. The Hospice Aide did not follow enhanced barrier precautions when she provided care to Resident #34 on 6/3/2024. CNA C did not sanitize or wash her hands between glove changes and wiped a female resident from back to front when providing incontinent care to Resident #25 on 6/4/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: 1. Record review of a face sheet dated 6/4/2024 for Resident #34 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of heart failure (heart not able to pump effectively), dementia (may cause the inability to remember, think, or make decisions) and atrial fibrillation (an irregular heartbeat). Record review of active physician orders for Resident #34 indicated an order for enhanced barrier precautions due to chronic wounds that started on 4/26/2024. Record review of a Significant Change MDS assessment dated [DATE] for Resident #34 indicated he had severe impairment in thinking with a BIMS score of 7. He had a pressure ulcer/injury with three stage 2 wounds that were partial thickness/loss of dermis (skin) that was present on admission. Record review of a care plan for Resident #34 dated 4/30/2024 indicated he required EBP (Enhanced Barrier Precautions- an approach of targeted gown and glove use to prevent the spread of germs ) during contact care related to chronic wounds with interventions for staff to provide/utilize appropriate PPE along with standard precautions while providing resident care for ADL's (dressing, grooming, personal hygiene, transfers, linen changes), incontinent care/toileting, wound care, care to enteral tubes (use of a feeding tube to supply nutrients and fluids to the body if they are unable to safely chew or swallow), IV sites, catheters, tracheostomy (a surgical opening in the windpipe to breathe). Record review of a Quarterly MDS assessment dated [DATE] for Resident #34 was in process. During an observation on 6/3/2024 at 2:13 PM, the Hospice Aide was in the room of Resident #34 providing care that included shaving the resident. She was not wearing a gown and only had gloves on. During an interview on 6/3/2024 at 2:24 PM, the Hospice Aide said she saw Resident #34 five days a week and on Mondays, Wednesdays and Fridays were his shower days. She said he had just received a bed bath, skin, foot care and she shaved him. She said she was aware that when care was provided to Resident #34 that she had to wear a gown and gloves. She said she only wore gloves during care provided. She said she did not know why she did not put on a gown today. She said residents could be at risk for making things worse. 2. Record review of a face sheet dated 6/4/2024 for Resident #25 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, atherosclerotic heart disease (narrowed arteries that causes limited blood flow to the heart) and osteoporosis (brittle bones). Record review of a care plan revised 6/3/2024 for Resident #25 indicated an ADL self-care performance deficit related to weakness, osteoporosis (a condition that causes bones to become weak and brittle), and cognitive impairment. She required the assist of one direct care staff member for ADL completion for toilet use. Record review of a Quarterly MDS assessment dated [DATE] for Resident #25 indicated she had severe impairment in thinking with a BIMS score of 4. She was occasionally incontinent of bladder and frequently incontinent of bowel. During an observation on 6/4/2024 at 8:55 AM, CNA B and CNA C were in the room of Resident #25 to provide incontinent care. Both washed their hands and put on gloves. Supplies were in a plastic bag on the over bed table. CNA B assisted with positioning and holding the resident. CNA C opened the brief and pulled it down between Resident #25's thighs. CNA C removed a wipe from the plastic bag and wiped the resident's right inner thigh and folded it over and wiped the left inner thigh and placed the wipe in the trash. CNA C removed her gloves and placed gloves on both hands without washing or sanitizing them. CNA C removed a wipe from the plastic bag and wiped down the middle of the vagina from front to back. CNA C removed her gloves and placed them in the trash and sanitized her hands. CNA B rolled Resident #25 onto her left side. CNA C removed wipes from the plastic bag and wiped Resident #25's rectal area from back (buttocks) to front (vagina) and them removed her gloves and placed them in the trash. CNA C placed gloves on her hands without washing or sanitizing them and removed another wipe from the plastic bag and wiped both buttocks in a circular motion and removed the brief, gloves and placed them in the trash. CNA C placed gloves on her hands without washing or sanitizing them. CNA C removed a brief from the plastic bag and placed it underneath the resident's buttocks. Resident #25 was rolled onto her back and the brief was secured and the resident was repositioned in the bed. Both CNAs removed their gloves and washed their hands. During an interview on 6/4/2024 at 11:50 AM, CNA C said she had been employed at the facility for 1 1/2 years and worked on the 6 am-2 pm shift. She said the incontinent care provided to Resident #25 earlier, she should have washed her hands between glove changes and should have wiped her rectal area from front to back instead of back to front. She said she had a check off on skills not long ago by the ADON. She said residents could be at risk of infections if staff did not wash or sanitize their hands between gloves changes and wiping from back to front. Record review of a CNA Proficiency Skills Check dated 1/10/2024 conducted by the ADON for CNA C indicated she was satisfactory in perineal care for a female along with infection control on hand washing. During an interview on 6/4/2024 at 4:05 PM, the ADON said that Resident #34 was on enhanced barrier precautions because he had a history of ESBL (a bacteria that is resistant to some antibiotics that is usually found in the bowel). She said staff were required to wear a gown, gloves, and a mask according to their policy when providing care to him. She said staff were aware of the residents in the facility that were on enhanced barrier precautions as they had a yellow dot sticker on their name place as a reminder. She said she was not aware the Hospice Aide did not wear the appropriate PPE when she provided care to him on 6/3/2024. She said she had conducted an in-service with the staff on enhanced barrier precautions but did not in-service any of the hospice staff. She said hand hygiene should be performed before care was started, between glove changes and when care was finished. She said when incontinent care was provided to a female resident, staff should wipe them from front to back. She said residents could be at risk for UTI's and vaginal infections if staff did not wipe appropriately and were at risk for spreading germs if they did not wash or sanitize their hands between glove changes. She said they would plan to in-service staff and would conduct visual spot checks with staff. She said there was a risk of spreading infections to other residents if staff did not follow the enhanced barrier precautions. Record review of a list of residents in the facility listed for EBP undated indicated Resident #34 was on the list and had chronic wounds. During an interview on 6/4/2024 at 9:35 AM, the DON said she had been employed at the facility for 2 years and was the IP and was responsible for all things related to infection control. She said EBP was for any resident that had a history of MDRO's (multi drug resistant organisms), current chronic wounds, feeding tubes, and foley catheters. She said EBP would stay in place for residents that had MDRO's indefinitely. She said Resident # 34 was on EBP. She said staff were supposed to wear a gown and gloves when they are providing care up close and personal, when linens were changes, bathing, incontinent care, and wound care. She said she in-serviced staff in April on EBP. She said staff were aware of the residents that had EBP in place because they had yellow dot stickers by the resident's name plate outside their room door to let them know who was on EBP. She said there was a risk of spreading MDRO's to other residents if staff did not follow EBP. She said hand hygiene should be performed before care, between care, before and after glove changes and after care was provided. She said when incontinent care was provided to a female resident, staff should wipe them from front to back. She said she started an in-service with staff on yesterday 6/4/2024 on incontinent care. She said residents could be a risk of infections if staff did not wash or sanitize their hands and if they did not wipe appropriately when providing care to a female resident. Record review of an in-service training report dated 4/25/2024 on enhanced barrier precautions by the DON to staff. Record review of an in-service training report dated 6/4/2024 on incontinent care by the DON and ADON to staff. Record review of an in-service training report dated 6/4/2024 on enhanced barrier precautions by the DON to staff . During an interview on 6/4/2024 at 9:45 AM, the Administrator said EBP was for residents that had MDRO's, chronic wounds, and implanted devices to prevent spreading of bacteria. He said the facility started the EBP in April 2024 and the IP/DON and ADON started training the staff on the new requirements. He said staff should don (put on) and doff (take off) gown and gloves to prevent cross contamination for residents who were on EBP. He said they started in-servicing staff on yesterday 6/4/2024 to ensure they were following the new requirements. He said staff should wash or sanitize their hands anytime gloves were changed, and female residents should be wiped from front to back. He said there was a risk of contamination and infections if staff did not wipe appropriately when care was provided to female residents and if staff did not wash their hands after glove changes. Record review of a memo dated 3/20/2024 from CMS titled Enhanced Barrier Precautions in Nursing Homes indicated, .EBP recommendations now include use of EBP for residents with chronic wounds. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and glove during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . Record review of a facility policy titled Infection Control-Precautions-Categories and Notices revised 3/2024 indicated, .It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Precaution notices will be posted when isolation precautions are implemented. Enhanced Barrier Precaution Guidance: 1. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities; dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, and wound care: any skin opening requiring a dressing. 2. Ensure PPE and alcohol-based hand rub are readily accessible to staff. Record review of a facility policy titled Hand Washing dated 12/2017 indicated, .It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection. Employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions. After removing gloves .

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 4 residents (Residents #19) reviewed for respiratory care. The facility failed to ensure Resident #19's oxygen tubing was changed per the physician orders. These deficient practices could place residents at risk of developing respiratory infections and complications. Findings include: Record review of a facility face sheet dated 6/03/2024 indicated Resident # 19 was an [AGE] year-old female and readmitted to the facility on [DATE] with -diagnoses of dementia and urinary tract infection (infection of the urine). Record review of a physician ordered dated 5/01/2023 indicated change oxygen tubing every 7 days on Thursday. Record review of a comprehensive care plan dated 3/12/2024 indicated Resident # 19 had oxygen therapy and give as ordered by the physician. Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 19 had a BIMS of 01 indicating severely impaired cognition and required oxygen therapy. During an observation on 06/03/24 at 9:45 am Resident # 19 had oxygen in place at 3 liters per nasal cannula and the oxygen tubing was dated 5/17. During an observation on 06/04/24 at 7:45 am Resident #19 had oxygen in place at 3 liters per nasal cannula and the oxygen tubing was dated 5/17. During an interview on 06/04/24 at 9:29 AM LVN A said she had worked at the facility for 6 years. She said the nurses were responsible for changing the oxygen tubing weekly and was normally completed on the night shift. She said that the nurses should be checking oxygen flow rate and tubing on each shift and rounds to ensure the tubing is in date. She said that outdated oxygen tubing could cause an infection or ineffective oxygen delivery . During an interview on 06/05/24 at 7:46 AM the DON said she had been the DON for almost 2 years. She said the nurses on night shift were responsible for changing the oxygen tubing weekly. She said there had not been a specific training for the oxygen tubing and the nurse should be following the physician order. She said there was no monitoring system in place to ensure the tubing was changed. She said if oxygen tubing was not changed it could cause infections or affect the oxygen flow. She said she expected the nurses to follow the oxygen orders and change the tubing per the orders. During an interview on 06/05/24 at 9:33 AM the Administrator said he had been at the facility for 1 year and that the DON was responsible for oversight of the nursing department, but the nurses were responsible and had been trained on oxygen therapy and following orders. He said the oxygen tubing should be changed per the orders and policy to prevent infections and expected the nurses to follow the orders. Record review of a facility policy dated 12/2017 titled Respiratory indicated, .Oxygen therapy is administered as ordered by a physician. 15. replace entire setup every seven days

Based on observation, interview, and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident, in 5 of 18 resident rooms reviewed for required square footage. (Resident room #s 300, 306, 308, 309 and 310). The facility did not have at least 80 square feet per resident in resident room #s 300, 306, 308, 309, and 310. This failure could place residents at risk of having inadequate space for personal belongings, guests, and limit the resident's ability to move about in the room. Findings included: During an interview on 06/03/24 at 10:30 p.m., the Administrator said there had been no structural changes to the building and he knew there had been a waiver granted in the past for five rooms on the secured unit. The Administrator said he would complete HHSC form 3762 (room size waiver for facilities). During an observation on 06/03/24 from 10:00 a.m. until 10:24 a.m., room [ROOM NUMBER] was used for maintenance, rooms [ROOM NUMBERS] were used for the dining area, room [ROOM NUMBER] was used for an office and room [ROOM NUMBER] was used as a sitting area. The rooms measured approximately as follows: * room [ROOM NUMBER]- 6 x 4 feet at entry and the main area was 13.4 x 10.4 feet; * room [ROOM NUMBER]/308- 25.8 x 12.3 feet; * room [ROOM NUMBER]- 12 x 12.4 feet; and* room [ROOM NUMBER]- 12.8 x 12.3 feet. Record review of a bed classification worksheet, completed by the facility administrator, dated 06/03/2024 indicated there were 18 resident rooms on the secured unit. (Hall 300) Record review of the facility census report dated 06/03/2024 indicated 8 residents resided on the secured unit. Resident room #s 300, 306, 308, 309 and 310 were not occupied by residents.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication carts (nurse cart unit 1 and unit 2) and 1 of 2 medication storage rooms (unit 2) reviewed for labeling and storage. The facility failed to remove expired insulin from the nurse medication cart on unit 1 and unit 2 for Resident # 11 and Resident # 21. The facility failed to remove expired tuberculin PPD (purified protein derivative) Mantoux testing solution from the medication storage room on unit 2. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of facility face sheet dated 05/01/2023 indicated Resident # 11 admitted to the facility on [DATE] with diagnoses of sepsis (infection in blood), urinary tract infection, diabetes (blood sugar disorder). Record review of comprehensive care plan dated 1/30/23 indicated Resident # 11 had a diagnosis of diabetes and to administer insulin as ordered. Record review of Quarterly MDS dated [DATE] indicated Resident # 11 had a BIMS of 09 indicating moderately impaired cognition and required insulin injections. Record review of physician order dated 1/30/2023 indicated Resident # 11 required Humulin R insulin per sliding scale three times a day as needed for elevated blood sugar. Record review of face sheet dated 05/01/2023 indicated Resident # 21 admitted to the facility on [DATE] with diagnoses dementia, diabetes, and anxiety. Record review of Annual MDS dated [DATE] indicated Resident # 21 had a BIMS of 03 indicating severely impaired cognition and required insulin injections. Record review of comprehensive car plan dated 04/30/2023 indicated Resident # 21 had diabetes mellitus and to provide diabetes medication as ordered by doctor. Record review of physician order dated 09/22/2022 indicated Resident #21 required insulin lispro (Humalog) per sliding scale two times a day as needed for elevated blood sugar. Order dated 04/10/2023 indicated Resident # 21 required insulin glargine 100 units/ml inject 30 ml subcutaneous once a day. During an observation on 05/01/23 at 11:06 AM the nurse medication cart located on unit 1 stored Humulin R belonging to Resident # 11 with an open date of 3/23/2023. Medication storage directions indicated Humulin R was good for 31 days after opening and should have been discarded on 4/23/23. During an interview on 05/01/2023 at 11:16 am LVN A stated the nurses were responsible for checking all medications before administering including the open dates to ensure the medication can be given. She stated she had been trained on how long insulin was good for once opened or stored at room temperature and they had a table to follow as well. She stated she did not realize Resident # 11's Humulin R had passed the use by date. She stated the risk could be inaccurate blood sugars and adverse reactions. During an observation on 05/01/23 at 11:20 am the nurse medication cart located on unit 2 stored Humalog with an open date of 3/31/23 and insulin glargine with an open date of 4/01/23 belonging to Resident # 21. Medication storage directions stated Humalog was good for 28 days after opening and should have been discarded on 4/28/23 and insulin glargine was good for 28 days after opening and should have been discarded on 4/29/23. During an observation on 05/01/23 at 11:28 AM the medication storage room on unit 2 had 1 vial of tuberculin (Tubersol) PPD Mantoux solution in the refrigerator with an open date of 6/27/2022. The medication storage directions indicated Tubersol solution was to be discarded after 30 days of opening. During an interview on 05/01/23 at 11:33 AM LVN B stated that the nurses were responsible for checking all medication dates before administering. She stated the tuberculin solution was given by the nurses and tuberculin solution was good for 30 days once opening. She stated the admitting nurses administer tuberculin to the residents most of the time. She stated insulin expires at different times and she thought they had all been checked and updated. She stated they had been trained on medication expiration dates and was provided a table to follow as well. She stated the risk of residents receiving expired medication could be any complication. During an interview on 05/01/23 at 11:50 AM the DON stated the night shift nurses and the weekend RN supervisor were responsible for checking medication carts and the medication refrigerator for expired medications, but it was all nurse's responsibility before administering medications that they are in date. She stated the nurses had a table at each station to reference for expiration dates for multiuse vials. She stated the risk could be blood sugar abnormalities and incorrect tuberculin readings. She stated she would retrain all nursing staff on following expiration dates and expects that each nurse follows the policy and regulation. During an interview on 05/03/23 at 09:52 AM the Admin stated the DON, ADON and nurses were responsible for ensuring medications were labeled and stored correctly and that the use by date was followed. He stated the risk could be medication effectiveness. He stated the expectation going forward was that all nurses are retrained and understand the use by date and remove those medications when they have expired. Record Review of policy and procedure titled Medication Vials and ampoules of injectable dated 12/2017 indicated, .#4. Medication may be used until manufacturer's expiration date or for the length of time allowed by state law if inspection reveals problems. Record review of facility document titled Medication Open Vial Expiration Dates dated December 2017 indicated, Humalog and Lantus duration 28 days for opened vial at room temperature or in fridge, Humulin R duration 31 days after opening, and TB test solution duration 30 days after opening. Record review of the FDA reference 22. [NAME] S, et al. Effect of oxidation on the stability of tuberculin purified protein derivative (PPD) In: International Symposium on Tuberculins and BCG Vaccine. Basel: International Association of Biological Standardization, 1983. Dev Biol Stand 1986;58:545-552. Accessed at https://www.fda.gov dated 11/9/2020 indicated .A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Do not use after expiration date .

Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for one (Resident #19) of three residents reviewed for dignity in that: The facility failed to ensure Resident #19's feeding pump had a dignity/privacy cover while out of her room. This deficient practice could place residents in the facility at risk for a diminished quality of life, loss of dignity and self-worth. The findings included: Record review of a face sheet for Resident #19 dated 5/2/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of gastrostomy (feeding tube placed in the stomach), functional quadriplegia (complete inability to move due to severe disability), bipolar disorder (mental illness that causes shifts in a person's mood), and dementia with behavioral disturbance (mental disorder that causes a person to lose the ability to think, remember, learn, make decisions, and solve problems). Record review of an admission MDS dated [DATE] for Resident #19 indicated she had severe impairment in cognition with a BIMS score of 4. She was totally dependent in bed mobility, dressing, eating and personal hygiene with one-person physical assist. She had a nutritional approach that was performed during the last 7 days of the look back period for a feeding while not a resident and while a resident. Record review of a care plan for Resident #19 dated 2/21/2023 indicated a problem for nutritional status with an approach to continue primary nutrition per feeding tube in accordance with physician order. Record review of a physician order for Resident #19 dated 2/15/2023 indicated an order for enteral feeding with Isosource 1.5 at 55 ml/hr with a two-hour break on night shift from 8 pm to 10 pm. During an observation on 5/01/2023 at 11:14 AM, CNA D was pushing Resident #19 in a reclining chair to the dining room with her feeding pump uncovered. During an observation on 5/1/2023 at 11:18 AM, Resident #19 was sitting in a reclining chair in the dining room with her feeding pump uncovered. During an observation on 5/01/2023 at 11:45 AM, CNA D was pushing Resident #19. back to her room from the dining room without a privacy cover on the feeding pump. During an interview on 5/02/2023 at 11:05 AM, CNA D said she had been employed at the facility for 2 years. She said when a resident had a feeding tube, she would cover the resident's body with a sheet, so the g-tube was not exposed, but had never been told anything about covering the feeding pump when the resident was out of their rooms. During an interview on 5/2/2023 at 2:45 PM, the DON said she had been employed at the facility since August 2022. She said she was made aware of Resident #19 being out of her room without her feeding pump being covered. She said she was not aware nor was any of her staff that anything attached to a pole had to be covered when leaving the room. She said she was informed by the Regional Nurse about the feeding pump needed to be covered when leaving the room. She said she would in-service staff about privacy and dignity. She said dignity could be an issue for a resident if taken out of their rooms without the feeding pump being covered. She said she never thought about a feeding pump needed to be covered when a resident was out of their room. During an interview on 5/2/2023 at 2:50 PM, the Regional Nurse said she was notified by the DON earlier that day about Resident #19 being out of her room without her feeding pump being covered. She said any resident who has anything attached to a pole should be covered when they leave their rooms. She said going forward she would provide education to staff and all feeding pumps would be covered with a pillowcase or something to cover it. She said the facility did not have a policy on dignity. She said a resident could have negative feelings about not having their feeding pump covered. During an interview on 5/3/2023 at 9:25 AM, the Administrator said he was made aware of Resident #19 being taken out of her room without a dignity cover on her feeding pump. He said going forward residents with a pole would have dignity covers if out of their rooms. He said the facility started an in-service on yesterday 5/2/2023 with all staff about dignity and privacy covers. He said a resident could feel embarrassed or feel like the odd one out compared to anyone else because this was their home. Record review of the facility's statement of resident rights with a revised date of 12/1/2018 indicated, .You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. 5. Be treated with courtesy, consideration, and respect and in recognition of the individual's dignity and individuality .

Based on observations, interviews, and record reviews the facility failed to establish and 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 1 of 1 resident's reviewed for infection control. The facility failed to ensure that the urinary catheter bag for Resident #2 did not touch the floor. This failure could place residents at risk for infection. Findings Included: Record review of Resident #2's face sheet dated 5/2/23 revealed a [AGE] year-old male originally admitted to the facility on [DATE] and most recent admission on 4/19/23 with diagnoses including: sepsis (a serious condition in which the body responds improperly to an infection), hypotension (low blood pressure), pressure ulcer of sacral region (bedsore - injury to skin and underlying tissue), and functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord). Record review of care plan with start date of 2/27/23 for Resident #2 revealed that he had indwelling catheter related to pressure area to coccyx. Interventions included .check tubing for kinks and maintain the drainage bag off the floor . Record review of the Resident #2's Admission MDS dated [DATE] revealed the resident had a BIMS of 6 out of 15 indicating the resident had severe cognitive impairment. Question H0100 indicated that resident had an indwelling catheter. Record review of physicians' orders dated 5/2/23 for Resident #2 revealed that he had an order for Foley catheter care every shift and prn with start date of 4/11/23. During an observation on 5/2/23 at 9:45 a.m. Resident #2's urinary drainage bag was observed on floor next to bed. Bed was observed in lowest position with drainage bag hanging on side of bed frame covered by a privacy bag which was open at the bottom allowing the bottom of drainage bag to touch the floor. During an interview with LVN C on 5/2/23 at 9:45 a.m. she said that she knew the bag was not supposed to be on the floor due to risk for infection. She said she had received training on infection control, and it was just an oversight. She said that she would ensure it was hung elsewhere to ensure it was not touching the floor. During an interview with DON on 5/2/23 at 11:15 a.m. she said that she had never seen his drainage bag on the floor. The charge nurse was to ensure that bag was properly positioned and not touching the floor. She said that she would ensure all staff were keeping it off the floor. She said that the drainage bag being on the floor placed the resident at risk for infection. She said that she would begin in-servicing staff on infection control and catheter care. She said that going forward she would expect her staff to keep drainage bags off the floor and follow proper infection control procedures. During an interview with Admin on 5/3/23 at 9:20 a.m. he said that the charge nurse was to ensure that urinary drainage bags are cared for properly and he would expect his staff going forward to keep all urinary drainage bags off the floor. He also said that if the bag was on the floor, it could put the resident at risk for infection. Record review of facility policy titled Catheters - Insertion and Care - Indwelling, Straight, Suprapubic and External dated 12/2017 stated .Properly position bag below level of bladder (must not touch floor) . Record review of facility policy titled Infection Control - Prevention and Control Program dated 12/2017 stated .Implementing measures to prevent to transmission of infectious agents and to reduce risks for device and procedure-related infections .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 5 residents (Resident # 2) reviewed for medication administration. LVN C failed to administer Resident # 2's water flush through his feeding tube as ordered by the physician with medication administration. This failure could place residents who receive medications through a feeding tube at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of facility face sheet dated 05/02/2023 indicated Resident #2 admitted to the facility on [DATE] with a diagnosis of sepsis (blood infection), hypotension (low blood pressure), and encounter for gastrotomy (feeding tube). Record review of physician order dated 4/10/2023 indicated enteral feeding flush with 30-60 ml of water before and after medication administration and 5-15 ml of water between each medication. Record review of Admission MDS dated [DATE] indicated Resident # 2 had a BIMS of 06 indicating severely impaired cognition and required nutritional and hydration support of a feeding tube. Record review of comprehensive care plan indicated Resident # 2 required a feeding tube and to provide flushes as ordered by physician. During a medication pass observation on 05/02/23 at 07:25 AM LVN C administered Resident #2's medications per his feeding tube without flushing the feeding tube with water before and after medication administration and between each medication as ordered by the physician. During an interview on 05/02/2023 at 0755 LVN C stated she should have flushed Resident #2's feeding tube before and after medication administration and between each medicine. She reviewed Resident #2's orders and stated the order was for 30-60ml water flush before and after medication administration and 5-15 ml water flush between each medication. She stated she had been trained on proper flush technique during medication administration through a feeding tube and knew the orders but was nervous. She stated she had been a nurse for [AGE] years and employed at the facility 5 years. She stated the risk of not flushing medications through a feeding tube as ordered could be improper medication delivery or feeding tube occlusion. During an interview on 05/03/23 at 09:28 AM the DON stated the nurses have had yearly proficiencies and LVN C had been properly trained on feeding tube medication pass and water flushes. She stated she and the ADON were responsible for overseeing the nurses and the risk to the resident could be dehydration or a clogged feeding tube. She stated her plan was to retrain all nurses and expects that each nurse understands the risk to the resident. During an interview on 05/03/23 at 09:48 AM the Admin stated the DON and ADON were responsible for nurse training and oversight of residents with feeding tubes. He stated the risk could be a clogged tube and prevent proper delivery of medication. He stated his expectation is that all nurses appropriately administer medications through a feeding tube. Record review of policy and procedure titled Medication Administration dated 12/2017 section nasogastric/gastric medication administration indicated, .procedure 12. attach the barrel of the syringe to the tube and pour water into the syringe per physician order 13. flush the tube between medications as ordered, 14. pour additional water as ordered by the physician into the tube and instill to clear the tube of medication.

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 4 Residents (Resident #19) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The SW failed to refer Resident #19 for a resident review after being diagnosed with bipolar disorder current episode manic severe with psychotic features. The onset of the diagnosis was 3/11/2022. This deficient practice could place residents at risk of not receiving the needed PASSAR services. The findings were: Record review of a PL1 (PASSR Level 1 Screening) for Resident #19 was completed on 1/24/2023 following a hospital stay and indicated the resident was negative for mental illness (MI). Record review Record review of a face sheet for Resident #19 dated 5/2/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of gastrostomy (feeding tube placed in the stomach), functional quadriplegia (complete inability to move due to severe disability), bipolar disorder (mental illness that causes shifts in a person's mood), and dementia with behavioral disturbance (mental disorder that causes a person to lose the ability to think, remember, learn, make decisions, and solve problems) Record review of an admission MDS dated [DATE] for Resident #19 indicated she was not considered by the state level 2 PASSR process to have serious mental illness and/or intellectual disability or a related condition. She had severe impairment in cognition with a BIMS score of 4. She had a psychiatric mood disorder with diagnoses of anxiety disorder and bipolar disorder. Record review of a care plan dated 2/14/2023 for Resident #19 indicated she has increased potential for psychosocial well-being/mood problem related to diagnoses of mood affective disorder and bipolar disorder with anxiety. Approaches included to consult with the physician and daughter about medicinal intervention as indicated. Record review of Form 1012 titled Mental Illness/Dementia Resident Review for Resident #19 was submitted to the physician signed on 5/2/2023 and indicated the resident does not have a dementia diagnosis or has a dementia diagnosis but it is not primary. The nursing facility action was a new positive PASSR Level 1 Screening that was submitted on 5/2/2023 according to the instructiond on the form since it was indicated that Resident #19 had a mood disorder under mental illness. If any of the responses were yes, the nursing facility must complete a new PASSR Level 1 Screening and a full PASSR evaluation would be conducted after the nursing facility submits the new positive PASSR Level 1 Screening. Record review of a new PASSR Level 1 Screening was completed on 5/2/2023 and indicated the resident was positive for mental illness. Record review of a certificate of achievement dated 5/2/2023 certified that the SW and MDS nurse completed the course An Overview of the PASSR Process FY 2023 which was an online computer-based training offered by the Texas Health and Human Services Commission. During an interview on 5/2/2023 at 2:30 PM, the SW said Resident #19 had a negative PL1 and was not referred based on the screening that was completed by hospital staff prior to admission to the facility on [DATE]. She said the only time she referred residents for a PASSR evaluation was if the PL1 indicated the resident was positive for mental illness, intellectual disability, or developmental delay and Resident #19 did not have a mental illness. During an interview on 5/3/2023 at 9:00 AM, the SW said she had been employed at the facility for many years. She said if a resident identified as having a newly evident or possible MI, ID, or related condition after admission, the MDS nurse entered the diagnoses in the charting system as an active diagnosis and they would discuss in the care plan meetings with new diagnoses, new medications, or changes. She said the facility did have a psychiatrist and counseling services that came to the facility and Resident #19 was not receiving any counseling services and was not taking any antipsychotic medications. She said she was responsible for making the referrals to the local authority and entering the PASSR information into the portal. She said she resubmitted a new PL1 for Resident #19 on yesterday 5/2/2023 after this surveyor questioned if Resident #19 had a mental illness diagnoses without a PASSR evaluation to indicate Resident #19 was positive for MI and sent the form 1012 (Mental Illness/Dementia Resident Review) to the physician for review. During an interview on 5/3/2023 at 9:15 AM, the MDS nurse said she had been employed at the facility for 3 1/2 years and was responsible for completing the MDS assessments for all the residents in the facility. She said she was aware that Resident #19 had a diagnosis of bipolar and schizophrenia but was not responsible for the PASSR information. She said she reviewed diagnoses from hospital records and physician orders and would enter them into the charting system as active diagnoses for the residents. She said the physician would review the diagnoses and sign the orders if applicable. She said if a resident had a new diagnosis, the SW was aware, and the information came from hospital records after a hospital stay or a change in condition. During an interview on 5/3/2023 at 9:25 AM, the Administrator said he had been employed at the facility for a few months and was not aware of the circumstances for Resident #19. He said the SW informed him on yesterday 5/2/2023 that she had submitted a new PL1 for Resident #19 related to her diagnoses. He said going forward the facility would ensure all residents would receive correct services and follow the regulations. He said the PASSR information and diagnoses would be reviewed from day one of admission. He said a resident was at risk of not being appropriately cared for and or receiving needed services. He said the facility did not have policy related to PASSR, but they did follow the rules and regulations by Texas Health and Human Services Commission.

Based on observation, interview, and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident, in 5 of 18 resident rooms reviewed for required square footage. (Resident room #s 300, 306, 308, 309 and 310). The facility did not have at least 80 square feet per resident in resident room #s 300, 306, 308, 309, and 310. This failure could place residents at risk of having inadequate space for personal belongings, guests, and limit the resident's ability to move about in the room. Findings included: During an interview on 05/02/23 at 2:30 p.m., the Administrator said there had been no structural changes to the building and he knew there had been a waiver granted in the past for five rooms on the secured unit. The Administrator said he would complete HHSC form 3762 (room size waiver for facilities). During an observation on 05/02/23 from 10:00 a.m. until 10:24 a.m., room [ROOM NUMBER] was used for maintenance, rooms [ROOM NUMBERS] were used for the dining area, room [ROOM NUMBER] was used for an office and room [ROOM NUMBER] was used as a sitting area. The rooms measured approximately as follows: * room [ROOM NUMBER]- 6 x 4 feet at entry and the main area was 13.4 x 10.4 feet; * room [ROOM NUMBER]/308- 25.8 x 12.3 feet; * room [ROOM NUMBER]- 12 x 12.4 feet; and * room [ROOM NUMBER]- 12.8 x 12.3 feet. A bed classification worksheet dated 05/02/23 indicated there were 18 resident rooms on the secured unit. (Hall 300) The facility census report dated 05/02/23 indicated 9 residents resided on the secured unit. Resident room #s 300, 306, 308, 309 and 310 were not occupied by residents.

Based on interview and record review, the facility failed to ensure that residents were free from accidents for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to adequately supervise Resident #1 while being transferred with a Hoyer lift device on 4/15/2022. Resident #1 sustained a laceration to her forehead and required 5 sutures. This failure could put residents requiring Hoyer lift transfers at risk for harm including falls, lacerations, and other accidents. This was determined to be past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. Findings include: Review of Resident #1s face sheet dated 8/29/22 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses: Alzheimer's disease, reduced mobility, muscle wasting, personality and behavior disorder, acute kidney failure, and [CONDITION(S)]. Review of Resident #1's MDS dated [DATE], revealed a Brief Interview for Mental Status should not be conducted because resident was rarely/never understood. The MDS further revealed the resident's functional status was a 4 for transfers indicating total dependence and a 3 for support in transfers indicating she was two or more person assist. Review of Resident #1's care plan dated 1/28/2022 revealed limited physical mobility with an intervention/approach .Hoyer with 2 person assist Review of Resident #1's emergency room records revealed that she visited the emergency roiagnom on [DATE] with a diagnosis of facial laceration. Review of Resident #'1's progress note dated 04/15/2022 at 7:32 a.m., and signed by [LVN L], this nurse was in hallway at medication cart when heard CNA saying nurses name and help. This nurse and therapy that was coming down hallway went into resident room; resident was in Hoyer lift above the geri chair with CNA holding the top bar of the Hoyer lift off of resident and the Hoyer lift is tilted to the right side. Therapy and CNA safely released the attached lift pad while this nurse held bar/Hoyer lift from resident head. With resident safely in chair and the Hoyer lift straightened back to upright position, assessed resident and noted 2cmX1cm laceration to left side of forehead. Area cleaned with normal saline and pressure gauze applied. Very minimal bleeding noted. First assessment of neuros taken and was within normal limits. EMS called to transport resident to emergency room . [Physician] notified of event, after 3 calls to [family member], received call back and [family member] notified, stated he will call back later in the day for an update. Resident left building with EMS at 7:05 [a.m.]. Report called to emergency room , called Regional Nurse/DON [name] and reported event. Record review of witness statement dated 4/15/2022 and signed by CNA K reflected, Resident crooked in gerichair, CNA was attempting to reposition patient in chair during repositioning a portion of the lift bumped resident forehead. Notified charge nurse immediately. Record review of a witness statement dated 4/15/2022 and signed by the PTA reflected, PTA was walking down the hall to get a resident for therapy when I heard CNA call for nurses name asking for help. The nurse and PTA entered resident room at same time. Resident was in geri chair with Hoyer lift tilted over. CNA was holding arm of lift off resident, asking for assistance safely un-attaching lift pad from lift. CNA stated that lift tilted over as she was getting resident to chair, and lift arm struck resident in forehead causing laceration. Lift was safely un-attached, and resident positioned in chair. Resident had no signs of altered mental status, nurse called EMS for further assessment. Record review of a witness statement dated 4/15/2022 at 10:00 a.m., signed by the ADON reflected, Phone interview with [CNA K]. [CNA K] says that [Resident #1] was already up in the gerichair and she was going to take her to the dining room for breakfast and it seemed like resident was sitting crooked in her chair so [CNA K] says that she decided to straighten resident up before taking her to the dining room. She reconnected her lift pad back to the Hoyer lift and made sure that the feet of the Hoyer lift were opened all the way and was going to raise her just enough to straighten her when the lift tilted to the right and the top bar corner bumped residents head. [CNA K] said that she knew that the nurse was just outside of the room in the hall with her med cart, so she yelled for the nurse to come help. Record review of a witness statement dated 4/15/2022, signed by Maintenance, reflected, On Friday, April 15, 2022, maintenance inspected the Hoyer lifts used at facility. Found both lifts to be in working order with no malfunction, no disrepair, and no missing parts. During an interview on 08/29/2022 at 11:59 a.m. with LVN C, she stated she had been working at the facility since February 2022. She stated it was policy to use 2 people for the Hoyer lift. During an interview on 08/29/2022 at 2:35pm, LVN D stated that she had been employed here for 1 week. She also stated that using a Hoyer was always a 2 person assist. During an interview on 08/29/2022 at 2:37pm LVN E, stated that she had been employed in this facility a little over 3 years. She said that using a Hoyer lift would always be at least a 2 person assist. During an interview on 08/29/2022 at 12:03 p.m. with CNA G, she stated that she had been working at the facility for 4 years. She stated she would always use 2 people when making transfers with a Hoyer lift as that was the facility policy, and safer. During an interview on 08/29/2022 at 12:05 p.m. CNA F stated it was the facility policy to always use 2 people for Hoyer lift transfers. CNA F stated she would not transfer anyone without help. During an interview on 08/29/2022 at 2:30pm CNA H stated that she had been here 4 years. She stated that a Hoyer transfer was always a 2 person assist. During an interview on 08/29/2022 at 11:00 a.m. with the ADON, she stated on the date of incident CNA K was transferring Resident #1 to the Geri-chair with the Hoyer lift, and as she had her over the chair the lift tilted, and the arm made contact with resident's forehead causing a laceration. She said the resident was transferred to the emergency room by ambulance, received sutures and was transferred back to the facility the same day. The aide had been employed at the facility since January 2022 and had been trained on the policy of using at least two (2) people when transferring using the Hoyer lift. She also said she was unsure why the CNA decided to use the lift alone that morning. The ADON stated there was one on one training with CNA K and Maintenance looked at the lift to make sure it was in proper working condition. The ADON said all aides were in-serviced that day on Hoyer lift transfers. The ADON stated the facility policy was to use 2 people when using the Hoyer lift to transfer residents. The ADON said CNA K was suspended pending the investigation and returned to work 2 to 3 days later. During an interview on 08/29/2022 at 1:00 p.m. the Administrator stated regarding the incident with Resident #1, she remembered it being reported, and the aide was suspended because she was using the Hoyer lift by herself. The Administrator stated proficiencies were done with all aides due to this incident. The Administrator stated CNA K was given a one-on-one in-service. She stated there were risks of harm to residents by using a lift alone, such as falls, and lacerations, and a second person was needed to assist with movements of resident. The Administrator stated the CNA had been trained on proper use of the Hoyer lift, so she was unsure why she decided to use the lift alone that morning. She stated CNA K was suspended pending the investigation, retrained immediately and came back to work in 2-3 days. The Administrator stated all staff was retrained on the proper policy and procedures regarding use of the Hoyer lift. It was determined these failures resulted in Resident #1 being harmed on 4/15/22. Facility took the following actions to correct the noncompliance : Record review of the facility's Provider Investigation Report indicated in-services were conducted on 4/15/22 with all staff regarding proper use of the Hoyer lift. Record review of Quality Assurance and Performance Improvement reveal that individual check-offs for CNA's were completed in April, May, and June of 2022 for using the Hoyer lift. During interviews with 3 CNAs and 3 LVNs on the morning and evening shift, all employees indicated they would always use at least 2 persons when transferring a resident using the Hoyer lift. A review of the facility's policy Mechanical Lift dated December 2017 reflected, .Lifting a resident with a mechanical lift is always a two-person procedure

Based on observation and interview the facility failed to maintain all mechanical and electrical equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating condition. The facility failed to ensure the kitchen oven door sealed properly and unsafe objects were not used to ensure seal. The facility failed to ensure the freezer door sealed properly after use. These failures pose a risk of essential kitchen equipment malfunctions causing delayed meal service to residents. Findings included: During an observation and interview in the kitchen on 4/11/22 at 9:40 a.m. revealed a towel on the side of the oven door. The Dishwasher said the towel was in the door to make sure it was sealed. She said the oven had been not latching for 1 year and the dietary manager and maintenance knew about it. During an observation and interview in the kitchen on 4/11/22 at 10:00 a.m. revealed this surveyor was unable to close the freezer door after exiting. The Cook said it occasionally built-up ice around the door frame causing it not to latch properly. The cook proceeded to obtain a tire jack from the storage room and knocked the ice buildup off the door. During an interview on 4/13/22 at 8:26 a.m., the maintenance man said there had been an issue with the stove not shutting. He said he had been thinking of a solution on how to seal it safely. The maintenance man said the door on the freezer was not getting closed completely and there is ice buildup as the result. He said staff needed to close the door hard enough for it to latch. He said staff notified him of issues verbally or in a logbook. During an interview on 4/13/22 at 9:22 a.m., the cook said the oven door had been broken for 1 year and upper management knew about it. She said due to the door not sealing correctly, the knobs got hot and burned you. The cook said we put a towel in the door to seal it, but it could possibly cause a fire. During an interview on 4/13/22 at 9:52 a.m., the dietary manager said the oven door has had been reported multiple times to the maintenance log and man. She said it had to be taken apart to fix it and the maintenance man is not qualified to do it. The dietary manager said the oven door had been broken for a couple of months. She said she brought a board to put up against it, but staff put rags in the door. The dietary manager said it could cause a fire. She said she told the staff multiple times not to put rags in the oven door. The dietary manager said if the freezer door is not closed hard it will not seal correctly. She said maintenance was aware of the freezer door not closing properly. She said the freezer not closing easily could cause the temperature to decrease and food items could be thawing and refreezing. She said she had seen the ice buildup on the door and shelf so knew it was probably happening. During an interview on 4/13/22 at 4:45 p.m., the admin said she expected the kitchen equipment to be in working order and safe. She said she did not know about the oven door and freezer but has only been at the facility for a few weeks. On 4/13/22 at 5:00 p.m. a facility policy related to equipment was unavailable.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility did not label and date all food items stored in the refrigerators and freezer. The facility failed to ensure storage lids were secured on containers. The facility failed to ensure a cleaning schedule was followed. The facility did not prevent flies from being in the kitchen. The facility did not keep the kitchen neat and orderly. The facility failed to ensure food items stored in the refrigerator was free of mold, freezer burn, and exposure. The facility failed to measure the temperature of three steam table items during lunch service. The facility failed to use proper liquid to prepare puree food items. The facility failed to ensure kitchen staff used infection control prevention in the kitchen. This failure placed residents at risk of food-borne illness. Findings included: During an observation on [DATE] at 9:35 a.m. revealed the dishwasher in the kitchen with no hair net. During an observation in the refrigerator and freezer on [DATE] starting at 9:36 a.m. revealed all-purpose seasoning with not date; clear container with beige liquid with no date or label; 1 unopened large bag of flour not dated; 1 unopened large can of grape jelly not dated; 2 metal containers with unidentifiable food with no date or label; 1 plastic bag of breaded meat with no date or label; 1 opened jug of apple juice no date; 1 plastic bag of lunch meat no date or label; 1 opened jug of b-que sauce no date; 1 opened jug of pickle relish no date and not tightly sealed; 1 bag of sliced, yellow food item no date or label; 1 bag of white, sliced food item no date or label; 1 bag of shredded, yellow food item no date or label; 1 opened box of single sour cream packet no date; 1 opened bag of hamburger buns no date; 4 bags of boiled eggs no label or date; 34 cups of white liquid no date or label; 36 cups of orange liquid no date or label; 39 bowls of dark brown pudding no label or date; 20 cups of red liquid no label or date; 1 box of opened smoked sausage no date; 1 bag of sliced, red meat no label; 1 frozen bag of fries no label; 1 frozen bag of chicken breast no label; 4 frozen bags of meat no label or date; 2 containers of b-que sauce no date; 1 box of cinnamon rolls no date; 1 frozen box with a log of meat, no label or date; and 1 bag of frozen meat no label or date. During an observation in the kitchen pantry on [DATE] starting at 9:36 a.m. revealed 1 container of corn meal with the lid not tightly secured; 3 large plastic containers of cereal with the lid not tightly secured; 5 large plastic containers of pasta with the lid not tightly secured. During an observation in the kitchen on [DATE] at 10:03 a.m., revealed mandatory dietary cleaning schedule dated [DATE] with several days of no initial on assigned cleaning tasks. The dishwasher did not have initials for assigned tasks of juice/coffee table, microwave, pantry storage, lid and condiment shelf, and proper storage from [DATE]st-[DATE]th. The cook did not have initials for assigned tasks of ovens, stove top, back of stove, drip pans, small prep table, under prep table, deep fryer, and freezer from [DATE]st-[DATE]th. During an observation in the kitchen on [DATE] at 10:05 a.m. revealed the juice dispenser collector with slimy yellow liquid with gnats noted; 3 metal bowls with yellow food particles; brown/yellow film on the steam table; 10 metal lids with oily film; 1 metal pan with carbon buildup; oily film to oven doors; left burner drip pan with food particles; oily film underneath the deep fryer and oily stain on the floor of the pantry. During an observation in the freezer on [DATE] at 10:15 a.m. revealed 1 bag of frozen chicken patties exposed to air; 1 box of filets opened and exposed to air; 1 bag of chicken exposed and stuck to the metal shelf, and 1 bag of veil tips freezer burned. During an observation on [DATE] at 10:25 a.m. the cook was temping food on the steam table with gloves. The cook dropped an alcohol package on the floor and picked the package off the floor. The cook then preceded to temp the food on the steam table. During an observation on [DATE] at 10:30 a.m. revealed the cook serving fried squash, cornbread muffins, mechanical soft pinto beans with sausage, pureed cornbread muffins, macaroni and cheese, and pureed okra without temping (check food to ensure safe temperature of food before serving). During an observation on [DATE] at 10:35 a.m. revealed cornbread muffins on the steam table with covering and two flies noted flying around the kitchen, none observed landing on uncovered muffins. During an observation on [DATE] at 10:45 a.m. revealed the cook adding water to the pureed rice. During an interview on [DATE] at 9:03 a.m., the dishwasher said she had been working at the facility for 6 years and worked 5 a.m.-12 p.m. She said she was responsible for washing dishes, prepping desserts, wrapping silverware, printing tray cards, and cleaning the dining room. The dishwasher said when you enter the kitchen you should place a hair net on and wash your hands. She said she did not have one a hair net on [DATE] when this surveyor entered the kitchen. The dishwasher said she knew it was important to wear a hair net and to have all hair in the net to prevent hair from getting into food. She said if she found a hair in her food, she would be mad and disgusted. The dishwasher said the cleaning schedule rotated monthly and staff were supposed to initial when the task was completed. She said the dietary manager looked at the schedule every day for completion of tasks. The dishwasher said all dietary staff do not complete cleaning tasks and the kitchen was not as clean as it should be. She said she would not want to eat out of a dirty kitchen, and it could cause residents to get sick. The dishwasher said sometimes it was hard for 2 staff to complete all the task required in the kitchen. She said there were a lot of flies in the kitchen but normally that only happened in the spring and summer. The dishwasher said it was gross to have flies around the food, but they can only swat them away. She said the drink dispenser trap had slimy, smelly juice in it. She said it was the pm shift cleaning task and she had not noticed the gnats in it. The dishwasher said it was gross to have gnats in the kitchen and it could cause cross contamination. During an interview on [DATE] at 9:22 a.m., the cook said she had worked at the facility for 6 years during the 5am-12:30 p.m. shift. She said she was responsible for prep, cooking and cleaning. The cook said the cleaning schedule had task to completed daily, once a week and twice a week. She said the cleaning schedule was developed by the dietary manager and rotated monthly. She said staff was required to initial by the assigned task to indicated it was completed. The cook said some staff complete the tasks but not others. She said if dietary staff was completing their assigned tasks, the kitchen would look better. She said the dietary manager was responsible for ensuring the assigned tasks were completed. The cook said she told the dietary manager and the old administrator, she felt like the pm shift was not completing the assigned cleaning tasks. She said if the kitchen was not clean it could cause foodborne illnesses. The cook said all staff should wear hair nets in the kitchen because it keeps hair out of the food. She said the dietary staff was responsible for putting dates on products when it is received. The cook said when food is placed in another container it should be labeled and dated. She said the dietary manager was responsible for ensuring all items were labeled and dated. The cook said dietary staff did not have to label and dated cups of liquid. She said all staff should ensure lids are secured on containers to prevent sickness. The cook said it was important to secure lids to ensure the freshness of food items and keep things out. She said food with freezer burn would indicate it was not good. The cook said all kitchen staff was responsible for making sure pans don't have carbon build up. She said normally they are thrown away, but there were still some of those in there on Monday. The cook said carbon build up was not good for the food. The steam table had a grease film, food particles, it should have been cleaned it was halfway cleaned. She said the drink dispenser should be cleaned by the kitchen aide to make sure it was clean. The cook said there were gnats in the nozzle and the drip pan should be soaked in hot water. She said the gnats and slime could make people sick. The cook said in spring and summer flies are bad here. She said we can make sure flies don't lie on the food. The cook said the flies that are in the kitchen now we will use a fly swatter to get them. She said a fly landing on your food isn't good, it can cause germs, she would not want flies in my house at home. The cook said residents would not want flies on food. She said staff in the kitchen cooking was responsible for letting maintenance know the oil was leaking from the fryer. The cook said you do not want oil on the kitchen floor because you could fall. She said you are supposed to use milk or broth with pureed foods. She said it was important to use milk because it had nutrients in it. The cook said the pureed rice was thinned with water yesterday and she should not have done that, it made it a little soupy and the nutritional value went down. She said we normally use a digital thermometer, but it was not in there. The cook said the correct process is to cook the food, take the temp to the chop puree, regular food. She said she cleaned the probe in between with an alcohol swab. She said the probe should not touch the bottom of the pan. The cook said if something falls on the floor when doing temperatures, do not pick it up, complete the task. She said she should not do that cause it can get germs on the food. She said she should temp all food that is served to the residents. She said she did not temp the bread, macaroni or mech soft. The cook said the okra was done on the stove not the steam table. She said the okra should be temped on the steam table. During an interview on [DATE] at 09:52 a.m. the dietary manager said she had been at the facility this time since 2018. She said she had previously worked here. The dietary manager said her duties included scheduling, ordering the groceries, making sure diets match nursing and dietary orders, watch over the weight loss and refer to dietician, oversee the staff, spend down documentation, care plans, MDS, progress notes. She said staffing consisted of 2 per shift, one cook and one aide. The Dietary manager said that is not enough to do all she need for the kitchen. She said she ended up in the kitchen a lot. The dietary manager said she had a cleaning schedule for each of them to do. She said she knew that assigned task had been performed and sometimes they did not initial the schedule. The dietary manager said she was short one staff right now. She said the oven had a greasy layer; different things were not done. The dietary manger said she worked Monday through Saturday. She said she the oven surfaces should be cleaned at least once a week if not twice a week. She said she would expect all other surfaces to be cleaned daily. She said the film on the steam table should be cleaned before use. The dietary manager said they are not signing off on their stuff that is done. She said she had strong staff and some not so much. She said cleanliness was important in the kitchen, so you are not spreading germs or contaminating anything. She said she was responsible for making sure the kitchen was cleaned appropriately. She said she was a week behind. She said she did daily sweeps during the day and may point out things that need to be done or she did those things. The dietary manager said hair nets should be on when they walk in the door, so no hair contaminates the food. She said she all food should be labeled and dated. The dietary manager said all food items should be labeled with date received and the date it was opened. She said when freight is put up, whoever touched the item needs to label and date the item as to when it was opened. She said if it is taken out of the original box then it should be labeled what it is, the date received, and when they opened it. She said it is dated so that we know the food is not old and know how long it had been opened. The dietary manager said it stops salmonella and other contaminates. She said items should be sealed, tightly to keep air and any kind of fly out of it. The dietary manager said when something is freezer burned it indicates the freezer door is not being closed. She said if there is mold on an item it means it has gotten moisture and is no good. She said she was responsible for ensuring the cooks disposed of expired or bad food items, and closed lids and bags appropriately. She said she usually made a sweep in the freezer but was off on the weekend. She said 3 to 4 times a week she would check it. The dietary manager said the pans should be clean, sterilized, and no food droppings or carbon build up. She said it was probably time to order new pans. She said pans with carbon build up needed to be thrown away. She said carbon build up on pans could be hazardous. She said the drink dispenser failed to be cleaned by the aides and she would make sure it was done. The dietary manager said the drink dispenser pan was normally ran through the dishwasher daily. She said the findings in the drink dispenser pan was nasty and contaminates and a good way to make someone sick. She said the kitchen had some flies and the facility had a thing on the back porch that mists. She said she encouraged staff to keep the doors closed. She said we cannot kill the flies while we serve food. She said she told maintenance the kitchen needed something to keep the flies out. She said it was important to keep flies out of the kitchen because they vomit and poop when they land. She said she did not want that on food because it could contaminate the food and spread germs. The dietary manager said pureed food should be thinned with broth from the meat, or milk not with water. She said it took away from nutritional value. She said all food should be temped before serving. She said if staff had something fall to floor and picked it up without changing gloves was unacceptable. During an interview on [DATE] at 4:45 p.m., the administrator said she expected all food to be labeled and dated. She said she expected the kitchen to be clean and staff preventing cross contamination. Record review of a facility mechanically altered textures policy dated 2016 revealed .add small amount of liquid (milk, broth, or other liquid as specified in recipe) to food . Record review of a facility food storage policy dated 2018 revealed .to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal .to ensure freshness, store opened and bulk items in tightly covered containers .all containers must be labeled and dated .date, label and tightly seal all refrigerated using clean .covered containers . Record review of a facility taking temperatures policy dated 2018 revealed .the facility realizes the critical nature of serving foods at the correct temperatures to ensure the health of its residents .the facility will take and record the temperatures of all foods prior to services . Record review of a facility employee sanitation policy dated 2018 revealed .the facility will practice good sanitation practices .in order to minimize the risk of infection and food borne illness .hairnet must be worn to keep hair from food and food-contact surfaces .change gloves: between each food preparation task .after touching items, utensils or equipment not related to task .after touching other sources of contamination . Record review of a facility general kitchen sanitation policy dated 2018 revealed .the facility recognized that food borne illness has the potential to harm elderly and frail residents .maintain clean, sanitary kitchen facilities .in order to minimize risk of infection and food borne illness .clean and sanitize all food preparation areas and equipment .clean food contact surfaces of grills, griddles and similar cooking devices and the cavities and door .keep food contact surfaces of all cooking equipment free of encrusted grease deposits .have a professional pest-control program in place . Record review of a facility cleaning schedule policy dated 2018 revealed .the facility will maintain a cleaning schedule .followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards .the cleaning list will be posted weekly and initialed off and sated by each employee upon completion of the task .the nutrition and food service manager or designee will verify that the tasks were completed . Record review of a facility coffee machine and juice machine dated 2018 revealed the facility will maintain .juice machines in a clean and sanitized condition to minimize the risk of food hazards .juice machines will be cleaned once per day .

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse for 2 of 7 residents reviewed for abuse. (Resident #'s 1 and 2) The facility did not implement interventions to prevent Resident #1 from verbally abusing Resident #2. Resident #2 responded to Resident #1's verbal abuse with physical abuse. This failure could place residents at risk for abuse. An Immediate Jeopardy situation was identified on 05/09/19. The Immediate Jeopardy was removed on 05/13/19. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective measures. Finding included: A policy of abuse, reportable events effective 01/10/17 indicated all residents have the right to be free from abuse, neglect, residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents. The facility will provide and ensure the promotion and protects of resident rights. it is everyone responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of [REDACTED]. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. The policy indicated willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict, injury or harm. An undated face sheet indicated Resident #1 was admitted on [DATE] from another nursing facility. He was 69-years-old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was cognitively intact and required extensive assistance with bed mobility, locomotion on and off unit, limited assistance with transfer. The MDS indicated Resident #1 had no behaviors. A weight variance report dated 04/01/19-05/09/19 indicated Resident #1 weighed 157 pounds on 04/15/19. A care plan dated 04/29/19 and updated 05/08/19 indicated Resident #1 had socially inappropriate/disruptive behavioral symptoms as evidence by cursing staff and residents. Interventions included move resident as appropriate for personal safety and safety of others and provide one on one when appropriate. An undated face sheet indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was cognitively intact and required supervision with ADLs. The MDS indicated Resident #2 displayed no behaviors and had a [DIAGNOSES REDACTED]. A care plan dated 09/27/18, revised on 04/03/19 indicated Resident #2 was at risk for mood problems related to [MEDICAL CONDITION], anxiety, and [MEDICAL CONDITION]. Interventions included to monitor, record, report to physician as needed mood patterns and signs /symptoms of depression, anxiety, and sad moods. The care plan did not address signs and symptoms of [MEDICAL CONDITION] or interventions related to [MEDICAL CONDITION]. A weight variance report dated 04/01/19-05/09/19 indicated Resident #2 weighed 438 pounds on 05/07/19. An electronic nursing note dated 04/23/19 at 5:50 p.m., indicated Resident #1 was verbally abusive, in the dining room hollering at Resident #2 get up off your fat ass. Resident #2 got out of his wheelchair and hollered at Resident #1, I'm up, now what do you want to do? Further documentation indicated LVN A intervened and asked Resident #2 to leave the dining room and Resident #1 was unsuccessfully redirected, he was taken to his room. An electronic note dated 04/23/19 at 7:07 p.m., indicated LVN A heard Resident #2 calling her name, upon arrival to Resident #2's room Resident #1 was seen sitting in the doorway of Resident #2 room. The note indicated Resident #1 was removed from in front of Resident #2 doorway, he was kicking the door and stated, I'm not moving, I'm waiting for this fat [***] to get up and do something. The note indicated Resident #2 got up of out of his bed and walked over and grabbed Resident #1 by the neck yelling, I'm fixing to show you what I'm going to do. The note indicated LVN A intervened removed both residents from one another and notified the RP, MD, DON, ADON and voicemail left for the administrator. An event report dated 04/23/19 at 7:08 p.m. by LVN A indicated Resident #1 was sitting outside of Resident #2's room, when asked to move Resident #1 stated No I'm waiting for this fat [***] to get up and do something. The event report indicated Resident #2 got up and walked over to Resident #1 grabbing him by his throat. Both residents were removed from the altercation with no bruising or redness to Resident #1's neck. A typed statement dated 04/23/19 at 8:50 p.m., signed by Resident #2 indicated after supper, Resident #1 told him to get off his fat ass and he walked over and got in Resident #1's face put his hands on the wheelchair and said, I'll beat your ass, you don't know who you are messing with. The statement indicated LVN A walked up to Resident #2 he pushed her back and told her No I'm about to knock this son of [***] out. The statement indicated LVN A was able to get Resident #2 to leave the area. The statement indicated concerning the incident Resident #2 said he was in his room when he looked up and saw Resident #1 sitting at his door, he said he called for LVN A to come get him and Resident #1 started cursing and yelling again. The statement indicated Resident #2 said he came out of his room pushed Resident #1 wheelchair against the wall, had his fist up with his hand around Resident #1 throat and told him I'm going to knock the[***]out of you. The statement indicated Resident #2 said LVN A stopped him from hitting Resident #1 and he went back to his room. A progress note dated 04/25/19 by the psychologist indicated Resident #1 was delusional and/or confabulation as he styled himself as an army officer who came across staff member whom falling on their jobs and he (Resident #1) called them out by telling him to get off his butt and do the job he was paid to do. During an interview on 5/8/19 at 10:30 a.m., Resident #1 appeared to be confused he stated, I am here to get this animal in shape like I was told to do, if that is not what you want then tell me and I will let them run loose. During an interview on 05/08/19 at 10:36 a.m. the SW said there was an incident when Resident #2 grabbed Resident #1 by the throat. She said Resident #1 was put on 1:1 supervision (4/23/19). The facility started looking for other placement for Resident #1 and a psych evaluation was done. She said there were no interventions put into place or special supervision for Resident #2 after the incident. She said Resident #2 had no behaviors and she had not been advised to get a psych evaluation of Resident #2 after the incident. She said Resident #1 was confused and felt he was in the army at times. She said Resident #1 would curse at staff and other residents at times. During an interview on 05/08/19 at 10:45 a.m., Resident #2 said regarding the incident with Resident #1 there had been an incident earlier in the dining room with Resident # 1. He said Resident #1 told him to get off his fat ass and do something. Resident #2 said he got up out of his chair (electric scooter) and got in Resident #1's face and said, I'm up now what do you want to do. He said LVN A told him to leave the dining room. He said later that night Resident #1 was sitting outside his door. Resident #2 said he called for LVN A to come get Resident #1. He said Resident #1 started cursing at LVN A. Resident #2 stated I guess I snapped and got Resident #1 by the neck and pulled him up out of the wheelchair by the neck. Resident #2 said, [MEDICAL CONDITION] is real, and I snapped, I could feel his throat, and I would do it again if I got the chance. He said (Resident #1) does not need to be here. During an interview on 05/08/19 at 12:26 p.m., LVN A said she was working on the day of the incident on 04/23/19. She said there had been an incident earlier with Resident #1 and Resident #2 in the dining room. She said Resident #1 told Resident #2 to get up off his fat ass. She said Resident #2 walked over to Resident #1 and got in his face and said, I'm up what are you going to do. LVN A said she got in between the residents and asked Resident #2 to leave the dining area. She said Resident #2 made the statement I'm going to kick his ass. LVN A said she later heard Resident #2 calling her name and she went to his room, she said Resident #1 was sitting in his wheelchair outside of Resident #2's door. She said Resident #1 was not saying anything at the time only sitting and looking in the room. She said as she went to move Resident #1 away from the door, Resident #1 kicked the door and said, I'm not going anywhere until he (Resident #2) gets off his fat ass and do something. She said Resident #2 got up and came out in the hall and grabbed Resident #1 by the throat, she said Resident #2 had Resident #1 by the throat with his head pushed back. She said Resident #2 was angry and when she told him to let Resident #1 go, he said no he was going to hurt Resident #1. LVN A said Resident #2 finally let go and went back into his room. She said she never witnessed Resident #1 be physically aggressive only verbally aggressive, she said he was confused and did not know what he was doing. She said Resident #2 was oriented and felt he knew what he was doing. She said she felt Resident #1 was in danger at the time. She said called the ADON who came to facility and Resident #1 was put on 1:1 supervision. During an interview on 05/13/19 at 11:50 a.m., LVN A said Resident #1 was sitting in front of Resident #2's door with his legs crossed not saying anything. LVN A said Resident #1 only said something when she went to remove him from in front of Resident #2's door. LVN A said Resident #2 had Resident #1 by the throat with one hand on Resident #1's wheelchair. She said Resident #1 was in his wheelchair which was across the hallway (approximately 20 feet and 4 inches) against the wall when Resident #2 came over and grabbed him by the throat. She said Resident #2 said, I'm up, my fat ass is up, what are you going to do about it?, as he was holding Resident #1 by the throat. LVN A said she finally persuaded Resident #2 to release Resident #1's throat. She said Resident #1's face had turned red and he could not take a breath in. LVN A said Resident #1 gasped for air when Resident #2 released him. LVN A said Resident #2 was angry and wanted to hurt Resident #1. LVN A said she was afraid Resident #2 was going to hurt Resident #1. LVN A said when she was trying to get Resident #2 to release Resident #1, it was as if he was hearing her, but he didn't care. During an interview on 05/08/19 at 12:42 p.m., CNA B said she was working on 04/23/19 the day of the incident with Resident #1 and Resident #2. She said prior to the incident Resident #1 was talking ugly to the staff and Resident #2. She said another resident told Resident #1 he could not talk to staff like that. She said regarding the incident when Resident #2 grabbed Resident #1 by the throat, Resident #1 was sitting in the hallway in front of Resident #2's door. She said Resident #1 said he was waiting on Resident #2 to get off his fat ass. She said Resident #2 got up out of his bed and grabbed Resident #1 around his neck, CNA B said they told Resident #2 to stop and he said no. CNA B said she never saw Resident #1 go into Resident #2's room at any time during the incident. CNA B said at the time of the incident she felt Resident #1 was in danger. CNA B said she had never witnessed Resident #1 be physically aggressive only verbally aggressive. She said to her knowledge Resident #2 was not put on any kind of special supervision only Resident #1 was put on one on one supervision. During an interview with the administrator on 05/08/19 at 1:20 p.m., she said the incident between Resident #1 and Resident #2 was not called into the state agency. She said it was felt that the incident was not a willful act on the part of Resident #2. She said there were no apparent injuries noted and no evidence that Resident #2 had squeezed or choked Resident #1, only that Resident #2 had put his hands around Resident #1's neck. She said no interventions had been put in place for Resident #2 because Resident #1 was felt to be the aggressor, she said she felt Resident #2 was angry at Resident #1 because another resident had been discharged from the facility due to an incident involving Resident #1. The administrator said Resident #2 was not a threat to Resident #1 because he knew he could possibly be discharged if there was another incident. She said Resident #1 had been seen by the psychologist and he felt that Resident #1 thought he was at the army base and he could not tell the difference between staff and other residents. She said Resident #1 felt everyone should be up doing something. During an interview on 05/09/19 at 3:05 p.m. the ADON said when she got to the facility on [DATE] she put Resident #1 on 1:1 supervision. She said there was already a CNA sitting with Resident #1 when she arrived at the facility. She said she assessed Resident #1, he was guarded initially. She said she asked the regional nurse about monitoring for Resident #2 and they did not think he needed additional monitoring. The ADON said the monitoring was to protect other residents from Resident #1 starting something. She said there was no special supervision for Resident #2, she indicated he was the aggressor. The ADON said she got a statement from Resident #2, she typed it and he read over the statement and signed it. During an interview on 05/09/19 at 3:30 p.m., the administrator said staff told her Resident #2 was angry at the time of the incident, but he calmed down. She said the incident was discussed with administrative staff and the conclusion was made it was not a reportable incident and no interventions needed to be put in place for Resident #2. She said it was felt Resident #1 did not have the capacity to know what he was doing and Resident #2 did not seem to still be upset about it and had left the situation in the dining room and gone to his room. She said it was felt Resident #2 was pushed to a limit. She said Resident #2 was easily redirected, and Resident #1 was the aggressor. She said she felt at the time Resident #2 did not need any special supervision because he was not the aggressor. She said Resident #2 has a grudge against Resident #1 because another resident that was his friend had to leave due to an incident with Resident #1. She said she did not feel there was a possibility that Resident #2 would hurt Resident #1 again. She said she felt Resident #2 understood the consequences and did not want to be kicked out himself. She said she had not asked Resident #2 if he wanted to hurt Resident #1. She said they were aware that Resident #2 had [DIAGNOSES REDACTED]. She said she did not think Resident #2 would seek Resident #1 out. During an interview on 05/09/19 at 3:45 p.m., Resident #2 said the incident happened 2 nights prior to his friend having an altercation with Resident #1. He said on 04/23/19 he was in the dining room and passed by Resident #1 on his scooter when Resident #1 said why don't you get off your fat ass and do something . Resident #2 said he got off his scooter and was eye to eye with Resident #1 and told him to leave him alone. Resident #2 said that same night Resident #1 was cursing at the staff and another resident told him to shut up and Resident #1 grabbed the resident by the shirt. Resident #2 said he got off his scooter and grabbed Resident #1's arms. Resident #2 said staff came and got Resident #1 and took him to his room which was right next door to his at the time. Resident #2 said he went to his room and Resident #1 came to his door and he called for LVN A. Resident #2 said Resident #1 started cursing at staff. Resident #2 said I snapped and had him by the throat up out of the chair and against the wall. He said the ADON arrived to take statements. Resident #2 said he knew he was not supposed to put his hands-on another resident. Resident #2 said he did not like Resident #1 one bit. Resident #2 stated my [MEDICAL CONDITION] kicked in and I did what I had been trained to do. Resident #2 said he would do the same thing if the incident were to happen again today. Resident #2 said they had moved Resident #1 to the other end of the facility because they were afraid he would hurt Resident #1. Resident #2 said I go all over the building and I would do the same thing again. During an interview on 5/9/19 at 4:21 p.m., the administrator was notified an Immediate Jeopardy was identified. During an interview on 5/9/19 at 5:40 p.m., the administrator said Resident #2 had been put on 1:1 supervision. She said Resident #2 refused to be seen by the psychiatrist and would be immediately discharged . She said his son had been notified of plans to immediately discharge Resident #2. On 05/09/19 at 6:15 p.m. the Plan of Removal was accepted and included: Problem: Resident Safety Interventions: *Resident #1 and Resident #2 currently reside on separate sides of the building. *Resident #1 and Resident #2 currently eat their meals in their rooms. *Resident #2 was placed on one-on-one supervision to ensure the safety of the other residents. *Resident #2 issued an immediate discharge notice. Both resident and his son/RP were notified in writing and verbally of the intent to discharge. *VA representatives were notified of the event. *All other residents were audited for the presence of a [DIAGNOSES REDACTED]. *Resident #4, Resident #5, Resident #6, and Resident #7 were identified as having this diagnosis. *Resident #4, Resident #5, Resident #6 and Resident #7 were assessed for any aggressive behaviors because of [MEDICAL CONDITION]. *All staff in-service to be completed by DON/ADON on abuse, neglect, exploitation, recognizing [MEDICAL CONDITION], and avoiding triggers of [MEDICAL CONDITION]. Staff members will receive in-servicing prior to the start of their shift/or before returning to work. Monitoring: *Residents with current [DIAGNOSES REDACTED]. *Residents will be assessed prior to admission for high risk diagnoses/behaviors to determine appropriateness for nursing facility admission. *Residents will be assessed for dx [MEDICAL CONDITION], behaviors, outbursts, aggression on admission. *The QA committee will review findings monthly for a minimum of 6 months and make changes as needed. During an interview on 05/13/19 at 11:10 a.m., the administrator said Resident #2 had been discharged on [DATE] at 5:00 a.m., home with son and the facility was assisting the VA to find placement for Resident #2. An electronic nursing note dated 5/12/19 at 4:56 a.m., written by LVN C: Resident #2 came to station 3 and started speaking with nurse and CNA (unnamed). Resident #2 stated that Resident #1 should not be breathing. Nurse told resident not to speak like that. Resident #2 continued to state he has plans in his mind and nurse said to keep them in your mind do not speak them or act on them think positive. Resident #2 said that he should go knock on Resident #1's door. Nurse told him no. Resident #2 stated that you can't stop me. Nurse stated that she will do anything in her power to stop resident. Resident #2 then proceeded to state that on his last day at facility that Resident #1 will not be a problem any longer. That we should have 3 people at his room (Resident #1) on the day he (Resident #2) leaves. Nurse told Resident #2 that he should go back on station 1. Resident #2 turned scooter toward the direction of Resident #1 room. Then backed up and went back to station 1. Nurse called ADM immediately. Nurse then reported incident to station 1 nurse. A progress note dated 5/13/19 at 1:11 a.m., (flagged as a late entry on 5/13/19 at 1:30 a.m.) by LVN D indicated: Resident #2 came to nurses' station at approx. 0345 and asked if he could have a pain pill, pain medication given at that time. Resident #2 then went to his room. This nurse received a call from administrator and she stated the station 3 nurse (LVN C) had called her and reported Resident #2 had been there and made threatening remarks about another resident (Resident #1). I spoke with LVN C regarding residents remarks and she then told me what Resident #2 had said. She also told me ADM was on her way to the facility along with the police and ADON to do an immediate discharge on Resident # 2. Also, Resident #2's son, had been notified to come to the facility to get his dad. Residents #2's son arrived at approximately 04:30 a.m., he was angry with staff for kicking his dad out of facility. Resident #2 told his son he was just joking with the station 3 nurse and he wasn't serious. Resident #2 left facility at approximately 0500. A written statement dated 5/12/19 by CNA E: Resident #2 stated we better have 3 people watching certain resident cause when he leaves he was taking him out. Stated he could do it with his hands or it can go in one way and come out another. Charge nurse kept redirecting resident than asked him to go back to his hall. A typed statement dated 05/12/19 at 4:00 a.m. signed by LVN C indicated: Resident #2 came to station 3 and started speaking with nurse and CNA, indicating Resident #1 should not be breathing. Nurse told resident that he cannot be saying remarks like that. Resident #2 stated that it doesn't matter. Resident #2 said that he should go knock on Resident #1 door right now. Nurse told him no. He said you can't stop me. Resident then proceeded to state that on his last day at the facility the Resident #1 will not be a problem any longer. That we should have 3 people at his room on the day he leaves. Nurse told resident that he should go back to station 1. Resident turned scooter toward the direction of Resident #1 room. Then backed up and went back to station 1. Nurse called administrator immediately. Nurse then reported incident to station 1 nurse. During an interview on 05/13/19 at 2:00 p.m., the administrator said Resident # 1 was on 1:1 monitoring from the 10th forward. She said regarding Resident #2 he went to the nurse's station on 3 and started talking to the nurse. Talking about his frustration. The nurse was able to redirect him back to his room. She called me immediately, we called the police, we called the son and told him he had to come get Resident # 2 immediately. Resident # 1 was in his room in bed. She said Resident #2 was at station 3 and made it to the corner around the nurse's station, but the nurse got up and kept him from going down the hall. She said Resident #2 said the day he got out of here they better have 3 people with him because he was going to take him out. She said Resident #2 was on 1:1 at that time. The person that was monitoring him was standing at Station 1 while he was at station 3. He appeared to be doing his morning routine, changing the date. She said 1:1 was explained to the staff as maintaining line of sight. The administrator said on 05/09/19 Resident #2 son didn't think it was a good idea for him to go to the hotel. He wanted us to help find placement for him. We contacted the VA. The son talked to another person at the VA because the contact person was out until Monday. We had to wait until we could get a safe discharge for him. When he left here he went home with his son. On 05/13/19 it was confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: The facility provided documentation of residents with the [DIAGNOSES REDACTED]. 2 LVNs and 4 CNAs could identify what constituted abuse/neglect and whom to report abuse and neglect to. They said they had been in serviced on [MEDICAL CONDITION] and could identify some possible triggers and of residents with [DIAGNOSES REDACTED]. During an interview on 05/13/19 at 3:24 p.m., the COO and DON were notified the Immediate Jeopardy was removed, but the facility remained out of compliance at an isolated pattern to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for 2 of 7 residents reviewed for abuse. (Resident #'s 1 and 2) The facility did not implement interventions to prevent Resident #1 from verbally abusing Resident #2. Resident #2 responded to Resident #1's verbal abuse with physical abuse. This failure could place residents at risk for injury and death. An Immediate Jeopardy situation was identified on 05/09/19. The Immediate Jeopardy was removed on 05/13/19. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective measures. Finding included: An undated face sheet indicated Resident #1 was admitted on [DATE] from another nursing facility. He was 69-years-old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was cognitively intact and required extensive assistance with bed mobility, locomotion on and off unit, limited and with transfers. The MDS indicated Resident #1 had no behaviors. A weight variance report dated 04/01/19-05/09/19 indicated Resident #1 weighed 157 pounds on 04/15/19. A care plan dated 04/29/19 and updated 05/08/19 indicated Resident #1 had socially inappropriate/disruptive behavioral symptoms as evidence by cursing staff and residents. Interventions included move resident as appropriate for personal safety and safety of others and provide one on one when appropriate. An undated face sheet indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was cognitively intact and required supervision with ADLs. The MDS indicated Resident #2 displayed no behaviors and had a [DIAGNOSES REDACTED]. A care plan dated 09/27/18, revised on 04/03/19 indicated Resident #2 was at risk for mood problems related to [MEDICAL CONDITION], anxiety, and [MEDICAL CONDITION]. Interventions included to monitor, record, report to physician as needed mood patterns and signs /symptoms of depression, anxiety, and sad moods. The care plan did not address signs and symptoms of [MEDICAL CONDITION] or interventions related to [MEDICAL CONDITION]. A weight variance report dated 04/01/19-05/09/19 indicated Resident #2 weighed 438 pounds on 05/07/19. An electronic nursing note dated 04/23/19 at 5:50 p.m., indicated Resident #1 was verbally abusive, in the dining room hollering at Resident #2 get up off your fat ass. Resident #2 got out of his wheelchair and hollered at Resident #1, I'm up, now what do you want to do? Further documentation indicated LVN A intervened and asked Resident #2 to leave the dining room and Resident #1 was unsuccessfully redirected, he was taken to his room. An electronic note dated 04/23/19 at 7:07 p.m., indicated LVN A heard Resident #2 calling her name. Upon arrival to Resident #2's room, Resident #1 was sitting in the doorway of Resident #2's room. The note indicated Resident #1 was removed from in front of Resident #2's doorway. He was kicking the door and stated, I'm not moving, I'm waiting for this fat [***] to get up and do something. The note indicated Resident #2 got out of his bed and walked over and grabbed Resident #1 by the neck yelling, I'm fixing to show you what I'm going to do. The note indicated LVN A intervened removed both residents from one another and notified the RP, MD, DON, and ADON and left a voicemail for the administrator. An event report dated 04/23/19 at 7:08 p.m. by LVN A indicated Resident #1 was sitting outside of Resident #2's room. When asked to move, Resident #1 stated No I'm waiting for this fat [***] to get up and do something. The event report indicated Resident #2 got up and walked over to Resident #1, grabbing him by his throat. Both residents were removed from the altercation with no bruising or redness to Resident #1's neck. A typed statement dated 04/23/19 at 8:50 p.m., signed by Resident #2 indicated after supper, Resident #1 told him to get off his fat ass. He walked over and got in Resident #1's face, put his hands on the wheelchair, and said, I'll beat your ass, you don't know who you are messing with. The statement indicated when LVN A walked up to Resident #2, he pushed her back and told her No, I'm about to knock this son of a [***] out. The statement indicated LVN A was able to get Resident #2 to leave the area. Concerning the incident with Resident #2, the statement indicated he was in his room when he looked up and saw Resident #1 sitting at his door. He said he called for LVN A to come get him and Resident #1 started cursing and yelling again. The statement indicated Resident #2 said he came out of his room, pushed Resident #1's wheelchair against the wall, had his fist up and had his other hand around Resident #1's throat and told him, I'm going to knock the[***]out of you. The statement indicated Resident #2 said LVN A stopped him from hitting Resident #1 and he went back to his room. A progress note dated 04/25/19 by the psychologist indicated Resident #1 was delusional and/or confabulation as he styled himself as an army officer who came across staff member whom falling on their jobs and he (Resident #1) called them out by telling him to get off his butt and do the job he was paid to do. During an interview on 05/08/19 at 10:30 a.m., Resident #1 appeared to be confused and he stated, I am here to get this animal in shape like I was told to do, if that is not what you want then tell me and I will let them run loose. During an interview on 05/08/19 at 10:36 a.m. the SW said there was an incident when Resident #2 grabbed Resident #1 by the throat. She said Resident #1 was put on 1:1 supervision (4/23/19). The facility started looking for other placement for Resident #1 and a psych evaluation was done. She said there were no interventions put into place or special supervision for Resident #2 after the incident. She said Resident #2 had no behaviors and she had not been advised to get a psych evaluation of Resident #2 after the incident. She said Resident #1 was confused and felt he was in the army at times. She said Resident #1 would curse at staff and other residents at times. During an interview on 05/08/19 at 10:45 a.m., regarding the incident with Resident #1, Resident #2 said there had been an incident earlier in the dining room with Resident #1. He said Resident #1 told him to get off his fat ass and do something. Resident #2 said he got out of his chair (electric scooter) and got in Resident #1's face and said, I'm up now what do you want to do. He said LVN A told him to leave the dining room. He said later that night, Resident #1 was sitting outside his door. Resident #2 said he called for LVN A to come get Resident #1. He said Resident #1 started cursing at LVN A. Resident #2 stated, I guess I snapped and got Resident #1 by the neck and pulled him up out of the wheelchair by the neck. Resident #2 said, [MEDICAL CONDITION] is real and I snapped. I could feel his throat, and I would do it again if I got the chance. He said (Resident #1) does not need to be here. During an interview on 05/08/19 at 12:26 p.m., LVN A said she was working on the day of the incident, 04/23/19. She said there had been an incident earlier with Resident #1 and Resident #2 in the dining room. She said Resident #1 told Resident #2 to get up off his fat ass. She said Resident #2 walked over to Resident #1 and got in his face and said, I'm up what are you going to do. LVN A said she got in between the residents and asked Resident #2 to leave the dining area. She said Resident #2 made the statement, I'm going to kick his ass. LVN A said she later heard Resident #2 calling her name and she went to his room, she said Resident #1 was sitting in his wheelchair outside of Resident #2's door. She said Resident #1 was not saying anything at the time, only sitting and looking in the room. She said as she went to move Resident #1 away from the door, Resident #1 kicked the door and said, I'm not going anywhere until he (Resident #2) gets off his fat ass and do something. She said Resident #2 got up and came out in the hall and grabbed Resident #1 by the throat. She said Resident #2 had Resident #1 by the throat with his head pushed back. She said Resident #2 was angry and when she told him to let Resident #1 go, he said no, he was going to hurt Resident #1. LVN A said Resident #2 finally let go and went back into his room. She said she never witnessed Resident #1 be physically aggressive only verbally aggressive. She said he was confused and did not know what he was doing. She said Resident #2 was oriented and felt he knew what he was doing. She said she felt Resident #1 was in danger at the time. She said called the ADON who came to facility and put Resident #1 on 1:1 supervision. During an interview on 05/13/19 at 11:50 a.m., LVN A said Resident #1 was sitting in front of Resident #2's door with his legs crossed not saying anything. LVN A said Resident #1 only said something when she went to remove him from in front of Resident #2's door. LVN A said Resident #2 had Resident #1 by the throat with one hand on Resident #1's wheelchair. She said Resident #1 was in his wheelchair which was across the hallway (approximately 20 feet and 4 inches) against the wall when Resident #2 came over and grabbed him by the throat. She said Resident #2 said, I'm up, my fat ass is up, what are you going to do about it?, as he was holding Resident #1 by the throat. LVN A said she finally persuaded Resident #2 to release Resident #1's throat. She said Resident #1's face had turned red and he could not take a breath in. LVN A said Resident #1 gasped for air when Resident #2 released him. LVN A said Resident #2 was angry and wanted to hurt Resident #1. LVN A said she was afraid Resident #2 was going to hurt Resident #1. LVN A said when she was trying to get Resident #2 to release Resident #1, it was as if he was hearing her, but he didn't care. During an interview on 05/08/19 at 12:42 p.m., CNA B said she was working on 04/23/19, the day of the incident with Resident #1 and Resident #2. She said prior to the incident, Resident #1 was talking ugly to the staff and Resident #2. She said another resident told Resident #1 he could not talk to staff like that. Regarding the incident when Resident #2 grabbed Resident #1 by the throat, she said Resident #1 was sitting in the hallway in front of Resident #2's door. She said Resident #1 said he was waiting on Resident #2 to get off his fat ass. She said Resident #2 got out of his bed and grabbed Resident #1 around his neck. CNA B said they told Resident #2 to stop and he said no. CNA B said she never saw Resident #1 go into Resident #2's room at any time during the incident. CNA B said at the time of the incident, she felt Resident #1 was in danger. CNA B said she had never witnessed Resident #1 be physically aggressive only verbally aggressive. She said to her knowledge, Resident #2 was not put on any kind of special supervision. Only Resident #1 was put on one on one supervision. During an interview on 05/08/19 at 1:20 p.m., the administrator said the incident between Resident #1 and Resident #2 was not called into the state agency. She said it was felt that the incident was not a willful act on the part of Resident #2. She said there were no apparent injuries noted and no evidence that Resident #2 had squeezed or choked Resident #1, only that Resident #2 had put his hands around Resident #1's neck. She said no interventions had been put in place for Resident #2 because Resident #1 was felt to be the aggressor. She said she felt Resident #2 was angry at Resident #1 because another resident had been discharged from the facility due to an incident involving Resident #1. The administrator said Resident #2 was not a threat to Resident #1 because he knew he could possibly be discharged if there was another incident. She said Resident #1 had been seen by the psychologist and he felt that Resident #1 thought he was at the army base and he could not tell the difference between staff and other residents. She said Resident #1 felt everyone should be up doing something. During an interview on 05/09/19 at 3:05 p.m., the ADON said when she got to the facility on [DATE] she put Resident #1 on 1:1 supervision. She said there was already a CNA sitting with Resident #1 when she arrived at the facility. She said she assessed Resident #1, he was guarded initially. She said she asked the regional nurse about monitoring for Resident #2 and they did not think he needed additional monitoring. The ADON said the monitoring was to protect other residents from Resident #1 starting something. She said there was no special supervision for Resident #2. She indicated he was the aggressor. The ADON said she got a statement from Resident #2, she typed it, and he read over the statement and signed it. During an interview on 05/09/19 at 3:30 p.m., the administrator said staff told her Resident #2 was angry at the time of the incident, but he calmed down. She said the incident was discussed with administrative staff and the conclusion was made it was not a reportable incident and no interventions needed to be put in place for Resident #2. She said it was felt Resident #1 did not have the capacity to know what he was doing and Resident #2 did not seem to still be upset about it and had left the situation in the dining room and gone to his room. She said it was felt Resident #2 was pushed to a limit. She said Resident #2 was easily redirected and Resident #1 was the aggressor. She said she felt at the time Resident #2 did not need any special supervision because he was not the aggressor. She said Resident #2 has a grudge against Resident #1 because another resident that was his friend had to leave due to an incident with Resident #1. She said she did not feel there was a possibility that Resident #2 would hurt Resident #1 again. She said she felt Resident #2 understood the consequences and did not want to be kicked out himself. She said she had not asked Resident #2 if he wanted to hurt Resident #1. She said they were aware that Resident #2 had [DIAGNOSES REDACTED]. She said she did not think Resident #2 would seek Resident #1 out. During an interview on 05/09/19 at 3:45 p.m., Resident #2 said the incident happened 2 nights prior to his friend having an altercation with Resident #1. He said on 04/23/19, he was in the dining room and passed by Resident #1 on his scooter when Resident #1 said, Why don't you get off your fat ass and do something? Resident #2 said he got off his scooter and was eye to eye with Resident #1 and told him to leave him alone. Resident #2 said that same night Resident #1 was cursing at the staff and another resident told him to shut up and Resident #1 grabbed the resident by the shirt. Resident #2 said he got off his scooter and grabbed Resident #1's arms. Resident #2 said staff came and got Resident #1 and took him to his room, which was right next door to his (Resident #2) at the time. Resident #2 said he went to his room and Resident #1 came to his door and he called for LVN A. Resident #2 said Resident #1 started cursing at staff. Resident #2 stated, I snapped and had him by the throat up out of the chair and against the wall. He said the ADON arrived to take statements. Resident #2 said he knew he was not supposed to put his hands on another resident. Resident #2 said he did not like Resident #1 one bit. Resident #2 stated, My [MEDICAL CONDITION] kicked in and I did what I had been trained to do. Resident #2 said he would do the same thing if the incident were to happen again today. Resident #2 said they had moved Resident #1 to the other end of the facility because they were afraid he would hurt Resident #1. Resident #2 stated, I go all over the building and I would do the same thing again. During an interview on 05/09/19 at 4:21 p.m., the administrator was notified an Immediate Jeopardy was identified. During an interview on 05/09/19 at 5:40 p.m., the administrator said Resident #2 had been put on 1:1 supervision. She said Resident #2 refused to be seen by the psychiatrist and would be immediately discharged . She said his son had been notified of plans to immediately discharge Resident #2. On 05/09/19 at 6:15 p.m. the Plan of Removal was accepted and included: Problem: Resident Safety Interventions: *Resident #1 and Resident #2 currently reside on separate sides of the building. *Resident #1 and Resident #2 currently eat their meals in their rooms. *Resident #2 was placed on one-on-one supervision to ensure the safety of the other residents. *Resident #2 issued an immediate discharge notice. Both resident and his son/RP were notified in writing and verbally of the intent to discharge. *VA representatives were notified of the event. *All other residents were audited for the presence of a [DIAGNOSES REDACTED]. *Resident #4, Resident #5, Resident #6, and Resident #7 were identified as having this diagnosis. *Resident #4, Resident #5, Resident #6 and Resident #7 were assessed for any aggressive behaviors because of [MEDICAL CONDITION]. *All staff in-service to be completed by DON/ADON on abuse, neglect, exploitation, recognizing [MEDICAL CONDITION], and avoiding triggers of [MEDICAL CONDITION]. Staff members will receive in-servicing prior to the start of their shift/or before returning to work. Monitoring *Residents with current [DIAGNOSES REDACTED]. *Residents will be assessed prior to admission for high risk diagnoses/behaviors to determine appropriateness for nursing facility admission. *Residents will be assessed for dx [MEDICAL CONDITION], behaviors, outbursts, aggression on admission. *The QA committee will review findings monthly for a minimum of 6 months and make changes as needed. During an interview on 05/13/19 at 11:10 a.m., the administrator said Resident #2 had been discharged on [DATE] at 5:00 a.m., home with son and the facility was assisting the VA to find placement for Resident #2. An electronic nursing note dated 5/12/19 at 4:56 a.m., written by LVN C indicated: (Resident #2) came to station 3 and started speaking with nurse and CNA (unnamed.) Resident #2 stated that Resident #1 should not be breathing. Nurse told resident not to speak like that. Resident #2 continued to state he has plans in his mind and nurse said to keep them in your mind do not speak them or act on them think positive. Resident #2 said that he should go knock on Resident #1's door. Nurse told him no. Resident #2 stated that 'you can't stop me.' Nurse stated that she will do anything in her power to stop resident. Resident #2 then proceeded to state that on his last day at facility that Resident #1 will not be a problem any longer. That we should have 3 people at his room (Resident #1) on the day he (Resident #2) leaves. Nurse told Resident #2 that he should go back on station 1. Resident #2 turned scooter toward the direction of Resident #1 room. Then, he backed up and went back to station 1. Nurse called ADM immediately. Nurse then reported incident to station 1 nurse. A progress note dated 05/13/19 at 1:11 a.m., (flagged as a late entry on 05/13/19 at 1:30 a.m.) by LVN D indicated: (Resident #2) came to nurses' station at approx. 0345 and asked if he could have a pain pill, pain medication given at that time. (Resident #2) then went to his room. This nurse received a call from administrator and she stated the station 3 nurse (LVN C) had called her and reported (Resident #2) had been there and made threatening remarks about another resident (Resident #1). I spoke with LVN C regarding resident's remarks and she then told me what Resident #2 had said. She also told me ADM was on her way to the facility along with the police and ADON to do an immediate discharge on Resident # 2. Also, Resident #2's son, had been notified to come to the facility to get his dad. Residents #2's son arrived at approximately 04:30 a.m., he was angry with staff for 'kicking his dad out of facility.' Resident #2 told his son he was just joking with the station 3 nurse and he wasn't serious. Resident #2 left facility at approximately 0500. A written statement dated 05/12/19 by CNA E: (Resident #2) stated we better have 3 people watching certain resident (Resident #1) cause when he leaves he was taking him out. Stated he could do it with his hands or it can go in one way and come out another. Charge nurse kept redirecting resident than asked him to go back to his hall. A typed statement dated 05/12/19 at 4:00 a.m. signed by LVN C indicated: (Resident #2) came to station 3 and started speaking with nurse and CNA, indicating Resident #1 should not be breathing. Nurse told resident that he cannot be saying remarks like that. Resident #2 stated that it doesn't matter. Resident #2 said that he should go knock on Resident #1 door right now. Nurse told him no. He said you can't stop me. Resident then proceeded to state that on his last day at the facility the Resident #1 will not be a problem any longer. That we should have 3 people at his room on the day he leaves. Nurse told resident that he should go back to station 1. Resident turned scooter toward the direction of Resident #1 room. Then backed up and went back to station 1. Nurse called administrator immediately. Nurse then reported incident to station 1 nurse. During an interview on 05/13/19 at 2:00 p.m., the administrator said Resident #1 was on 1:1 monitoring from the 10th forward. She said regarding Resident #2 he went to the nurse's station on 3 and started talking to the nurse. Talking about his frustration. The nurse was able to redirect him back to his room. She called me immediately, we called the police, we called the son and told him he had to come get Resident #2 immediately. Resident # 1 was in his room in bed. She said Resident #2 was at station 3 and made it to the corner around the nurse's station, but the nurse got up and kept him from going down the hall. She said Resident #2 said the day he got out of here they better have 3 people with him because he was going to take him out. She said Resident #2 was on 1:1 at that time. The person that was monitoring him was standing at Station 1 while he was at station 3. He appeared to be doing his morning routine, changing the date. She said 1:1 was explained to the staff as maintaining line of sight. The administrator said on 05/09/19, Resident #2's son did not think it was a good idea for him to go to the hotel. He wanted us to help find placement for him. We contacted the VA. The son talked to another person at the VA because the contact person was out until Monday. We had to wait until we could get a safe discharge for him. When he left here, he went home with his son. A policy of abuse, reportable events effective 01/10/17 indicated All residents have the right to be free from abuse, neglect, residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents. The facility will provide and ensure the promotion and protects of resident rights. it is everyone responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of [REDACTED]. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. The policy indicated willful as used in this definition of abuse meant the individual must have acted deliberately, not that the individual must have intended to inflict, injury or harm. On 05/13/19 it was confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: The facility provided documentation of Residents with the [DIAGNOSES REDACTED]. 2 LVNs and 4 CNAs could identify what constituted abuse/neglect and whom to report abuse and neglect to. They said they had been in serviced on [MEDICAL CONDITION] and could identify some possible triggers and of residents with [DIAGNOSES REDACTED]. During an interview on 05/13/19 at 3:24 p.m., the COO and DON were notified the Immediate Jeopardy was removed, but the facility remained out of compliance at a isolated pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 6 residents reviewed for pharmacy services. (Resident #1) Although, the nurse and medication record indicated all anticonvulsants (medications that prevent [MEDICAL CONDITION]) were given, Resident #1 had [MEDICAL CONDITION] resulting in two hospitalization s and lab tests indicated no levels of the anticonvulsant medications. During both hospitalization s, Resident #1's labs tests for anticonvulsant medications returned to therapeutic levels. This failure could place 30 residents who received anticonvulsants at risk for [MEDICAL CONDITION] activity and hospitalization . Findings included: Physician orders [REDACTED].#1 admitted [DATE], was a [AGE] year-old female with [DIAGNOSES REDACTED]. Her medications included [MEDICATION NAME] suspension (an anticonvulsant used to treat [MEDICAL CONDITION]) 100 milligrams (mg)/5 milliliters (ml) give 11 ml at 9am and 9 pm, levetiracetam (an anticonvulsant used to treat [MEDICAL CONDITION]) 100 mg/ml give 10 ml at 9am and 9pm, and [MEDICATION NAME] (a barbiturate used to treat [MEDICAL CONDITION]) 20 mg/5 ml give 9 ml at 9 am and 9 pm. A care plan initiated 07/10/18 for Resident #1 said she had a [MEDICAL CONDITION] disorder with the following interventions .give [MEDICAL CONDITION] medications as ordered by doctor, monitor/document side effects and effectiveness, monitor labs and report any sub therapeutic or toxic results to MD . A census log dated 07/16/18 indicated Resident #1 admitted [DATE] for respite care, transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. A hospital laboratory flowsheet dated 07/13/18 indicated: *7/8/18 at 11:15 p.m., Resident #1's levetiracetam level was undetected in the blood (therapeutic range 10-40). Her [MEDICATION NAME] level was <2.0 mcg/ml. (therapeutic range 4-12) *7/9/18 at 3:25 p.m., [MEDICATION NAME] level was 3.6 microgram (mcg0/ml) *7/13/18 at 11 a.m., [MEDICATION NAME] level reached therapeutic range at 5.2 mcg/ml A census log dated 07/16/18 indicated Resident #1 was readmitted to the facility on [DATE]. A nursing note dated 07/15/18 at 11:38 p.m., documented by LVN B, indicated Resident #1's mother made accusations that Resident #1 did not get her bedtime medication and now was having [MEDICAL CONDITION]. The note indicated Resident #1's physician was notified and sent to the local emergency department at approximately 11:15 p.m. A physician emergency department note dated 7/15/18 at 11:41 p.m., indicated Resident #1 was presented with recurrent [MEDICAL CONDITION]. A hospital laboratory flow sheet dated 07/16/18 at 12:21 a.m., showed Resident #1's [MEDICATION NAME] level had decreased to <2.0 since 07/13/18 and her [MEDICATION NAME] had decreased to 15 micrograms (mcg)/ml from 17 mcg on 07/13/18. During an observation on 07/17/18 at 12:47 p.m., Resident #1 was sitting in a specialized wheelchair being fed a pureed diet by her RP. Resident #1 kept her mouth open at all times and food and drink had to be poured into her mouth. If Resident #1's head was tilted the wrong way, items placed in her mouth will run back out. Resident #1's eyes moved when spoken to but she did not attempt to speak. A Medication Administration Record [REDACTED]. During an interview on 07/16/18 at 4:35 p.m., LVN A said his schedule was from 6 am to10 pm on Saturdays and Sundays and he provided care for Resident #1. He said he provided care for Resident #1 on 7/7/18, 7/8/18, after Resident #1 returned from the hospital on [DATE], 7/14/18 and 7/15/18. LVN A denied ever witnessing a [MEDICAL CONDITION]. He said all of Resident #1's medications were in liquid form and administered at 9 a.m. and 9 p.m. During an interview on 7/17/18 at 9:01 a.m., the RP said she assisted LVN A in giving Resident #1 her evening medications on 7/15/18. She said she told LVN A that he did not bring all of Resident #1's medications and he denied the allegation. She said then Resident #1 had to be sent to the emergency room because she was having [MEDICAL CONDITION]. During an interview on 07/18/18 at 10:13 a.m., the DON said she expected medications to be administered as ordered. During an interview on 07/18/18 at 10:41 a.m., the VPCR said the laboratory had [MEDICAL CONDITION] in their computers. She did not know if Resident #1's laboratory results from the hospitalization were accurate or when the blood was actually drawn. During an interview on 07/18/18 at 10:58 a.m., a laboratory representative from the hospital confirmed that the laboratory computer system had [MEDICAL CONDITION] approximately a week ago, but their machines were not affected and their results were accurate. She said the only effect [MEDICAL CONDITION] had was a delay in sending results through the computer. The representative also confirmed Resident #1's laboratory results received by the hospital dated 07/13/18 were also drawn on 07/13/18. A medication administration policy and procedure dated 12/2017 indicated .It is the policy of this home that medications will be administered and documented by the physician and in accordance with state regulations . At https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/ 5s078s080, 5s021s024lbl.pdf Accessed 07/19/18 indicated the following: .Absorption of levetiracetam is rapid, with peak plasma concentrations occurring in about an hour following oral administration the tablets and oral solution are bioequivalent in rate and extent of absorption. Food does not affect the extent of absorption of levetiracetam Steady state is achieved after 2 days of multiple twice-daily dosing clinically significant interactions with other drugs through competition for protein binding sites are therefore unlikely Plasma half-life of levetiracetam across studies is approximately 6-8 hours . During an interview on 7/18/18 at 11:32 a.m., the MDS coordinator provided a list that indicated 30 residents were prescribed medications to prevent [MEDICAL CONDITION].

Based on 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 4 of 8 residents reviewed for quality of life. (Resident #s 2, 18, 19, and 20) The facility did not protect residents from potential abuse from Resident #18. * Resident #2 reported that Resident #18 was sexually harassing him, and nothing had been done to stop the harassment. Resident #2 suffered psychological harm due to mistreatment from Resident #18, and he stopped smoking when he wanted to smoke because of Resident #18. * Resident #19, a former roommate of Resident #18, experienced embarrassing and upsetting sexual advances from Resident #18. * Resident #20, a former roommate of Resident #18, experienced embarrassing and upsetting sexual noises by Resident #18. This failure could place the census of 70 residents at risk of decreased quality of life. Findings included: 1. Physicians orders printed 06/23/17 indicated Resident #2 was a [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was moderately cognitively impaired, had clear speech with the ability to make self understood and to understand others, and had no behavior problems. A care plan dated 02/23/17 indicated Resident #2 wished to smoke cigarettes and had been assessed to smoke with supervision. The care plan also addressed that Resident #2 needed out of room social, spiritual, and stimulus activities and mental stimulation. The nursing notes for Resident #2 indicated the following: * 02/26/17, .resident complained and stated, I turned (Resident #18) in this week for asking me to let him suck my dick, and nothing has been done, he still rolling around here rubbing on his private, informed resident it would be reported. * 06/10/17, heard yelling, another male resident was at this resident's door, separated residents, asked what was going on, this resident reported that male resident stopped at his door and was blowing kisses, educated this resident to report behaviors to nurse, resident stated he understood. During an interview on 06/12/17 at 5:31 p.m., Resident #2 said Resident #18 would roll into his room and describe sexual acts that he wanted to perform with Resident #2, such as oral sex. He said Resident #18 has exposed himself, and will begin fondling himself. Resident #2 said Resident #18 would stare at him and lick his lips in a very exaggerated manner. Resident #2 said he found these advances embarrassing, bothersome, and it made him angry. Resident #2 said he had reported these incidents to staff repeatedly, but nothing has been done. Resident #2 said both he and Resident #18 are smokers, but he did not smoke as he wanted to because of the way Resident #18 treated him. Resident #2 said he monitored Resident #18's presence in the smoking area and sometimes did not smoke when he wanted to because of Resident #18 being there. Resident #2 said he did not want to, but if this situation continued he would defend himself by hitting Resident #18 with his cane. Resident #2 said just a few mornings ago, Resident #18 came to his room and was blowing kisses at him, and this was very upsetting. During an interview on 06/13/17 at 5:12 p.m., Resident #2 said Resident #18 has asked him to come to his room for sexual activities, and has told him he wants to have sexual relations with anyone, whether it be man, woman, or child. Resident #18 has asked him how he could get a child into his room. He said Resident #18 fondles himself on a regular basis in public. Resident #2 said this morning he was in the smoking area, and he wasn't through smoking yet, but Resident #18 began staring at him and licking his lips in an exaggerated manner. Resident #2 said although he was not through smoking yet, he put his cigarette out and left. Resident #2 said this bothers him due to everything that has happened. 2. During an interview on 06/13/17 at 1:42 p.m., Resident #20 said in the recent past they moved him in with Resident #18 as his roommate. He said he was embarrassed to talk about it but he would tell me. He said during the very first night in the room, Resident #18 masturbated all night, and was very loud with his activities. He said Resident #18 was also verbally loud, and was speaking as if someone was present in the bed with him. Resident #20 said he did not sleep any that night, and it was a very bothersome situation. He said the following morning he told staff to push his bed out in the hallway, because he would rather live/sleep in the hall than spend another night in the same room with Resident #18. 3. Physician orders [REDACTED].#18 was a [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #18 had moderate cognitive impairment and exhibited behaviors. The resident had physical behavioral symptoms directed towards others 1 to 3 days per week, and had other behaviors not directed towards others 1 to 3 days per week. The resident exhibited wandering 1 to 3 days per week. A care plan for Resident #18 dated 01/11/17 with revised/continued dates of 02/23/17, 04/23/17 and 05/18/17 indicated the resident had behaviors of sexually inappropriate actions, by attempting to touch residents and staff. Interventions included .evaluating the resident's ability to understand behaviors, explain acceptable expressions of sexuality, and listen/talk to resident to see if they will tell why they do the behavior . The care plan also included that Resident #18 was a smoker and went to the smoking area for supervised smoking. During an interview and observation on 06/13/17 at 5:29 p.m., Resident #18 was in his room lying in bed. The resident voiced no complaints about the facility care and services. The nursing notes for Resident #18 indicated the following: * 01/12/17, CNA was showering the resident and he tried to touch her inappropriately, resident was told not to do this. * 01/12/17, resident was feeling on another male resident, he was removed from the room, and told not to touch other residents. * 01/20/17, resident was discharged to a behavior hospital. * 02/01/17, resident readmitted to facility. * 02/18/17, 6:15 a.m., Called to resident room by roommate (Resident #19). Roommate stated resident was yelling inappropriate racial/sexual statements, .yelling for black dicks and I want to suck a black dick right now. Resident was present during accusation, no denial was made, and resident asked for the time. Nurse educated resident on acceptable and appropriate behavior. Resident stated understanding and left the room. Roommate remained very upset and anxious about new roommate stating, he needs to get out of here .he shouldn't be saying things like that, I don't like that, this is not right. Attempts to reassure roommate of safety and calm roommate were unsuccessful. Will continue to monitor. * 02/19/17, resident came up hallway with no bottoms or underwear on, staff took to room to dress. Resident rubbing his genitals while outside in front of other residents. Resident able to make needs known, uses wheelchair. * 02/25/17, resident up in wheelchair, lunch in dining room, able to make needs known goes out on smoke breaks, transfers self from chair to bed. * 02/26/17, resident propelling self in wheelchair, rubbing genitals, educated resident to not do that in front of residents . * 03/18/17, a resident from Station 1 reported that resident (#18) rubbed up his leg and across his genital area, nurse spoke with resident. * 03/31/17, resident again made a sexually explicit comment and continues to touch himself inappropriately in public areas. This has been a problem for this resident in the past. Resident agreed to admission to behavior hospital, facility will transport today. * 04/19/17, resident readmitted to facility. * 06/10/17, 8:54 a.m., resident was propelling self past another male residents door and stopped and was blowing kisses to male resident, heard yelling, separated residents, took resident to his room and asked him to not do that, resident stated he understood. The behavior nursing note assessments for Resident #18 indicated the following: * 01/07/17, resident is rubbing on staff and other residents in a sexual manor, and states that he wants to have sex with them. Intervention implemented of every 15 minute checks. There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/08/17, .resident continuing to try and touch staff in a sexual manner, MA was trying to get resident's blood pressure, resident run his hand down MAs private part, and when a female resident wandered into resident's room, resident was laying in bed and told female resident to get in bed with him and give him H---, and a male resident walked into resident's room and he told male resident to bend over and he would give it to him. Intervention implemented of every 15 minute checks . There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/12/17, Resident continues inappropriate sexual behavior towards staff and residents ., continues on every 15 minute monitoring. There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/14/17, resident continues to try to touch staff and other residents, educated resident on the need to not do that, resident stated OK. Intervention implemented of every 15 minute checks. There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/15/17, resident was trying to rub on another male resident's private parts, staff redirected resident to his room, resident was then seen trying to go into another male resident room, resident was told he could not go into other residents room, he stated OK and went down the hall, turned around and went back into other residents room again, staff educated resident on not going into other resident room. Intervention implemented of every 15 minute checks. There was no documentation found of conducting every 15 minute monitoring for the resident. During an interview on 06/13/17 at 1:17 p.m., CNA A said she had worked in the facility for at least as long as Resident #18 has been residing at the facility. She said Resident #18 has inappropriate sexual behaviors and required redirection. She said the resident transferred himself from bed to wheelchair and self-propels about the facility independently. She said Resident #18 exposes and fondles himself in front of others. CNA A said she found Resident #18 attempting to touch other residents but had intervened before he got his hand near their private parts. She said approximately two weeks ago she was supervising the smoking and Resident #18 was present. The resident had on a pair of shorts, and while everyone was sitting there smoking, Resident #18 pulled up one of his short pant legs, pulled his penis outside of his garments, exposed himself, and began to masturbate in front of everyone. She said she re-directed the resident, he complied, and covered himself. She said as soon as the smoke break was over, and she got all the residents back inside, she immediately went and informed the charge nurse. CNA A said Resident #18 routinely exhibited this behavior and she reports it to the charge nurse. She said she had never known of Resident #18 to be on every 15 minute monitoring. During an interview on 06/13/17 at 2:10 p.m., LVN C said Resident #18 had frequent sexual behaviors. She said the resident was mobile, could transfer self to and from bed and into wheelchair, and he self-propelled about the facility at will. LVN C said the resident will expose himself, and fondle himself in front of others. She said every time Resident #18 exhibited these behaviors she reported it to the DON. LVN C said recently Resident #18 was coming in from smoking and he went up to another male resident in a wheelchair and put his hand on the other resident's leg above the knee and began to run his hand up the resident's leg toward the resident's genitals. She said she stopped the resident before he actually touched the other resident's genitals, and redirected him. LVN C could not remember who the other resident was. She said several mornings ago she was passing medications and she heard Resident #2 yell and say you better go on and get out of here. She said she immediately went down the hall and Resident #18 was in his wheelchair at Resident #2's door. LVN C said Resident #2 was very upset and said Resident #18 had come to his room and was blowing kisses at him. She said she re-directed Resident #18 back to his room. LVN C said Resident #2 said he is going to keep on until I have to knock the[***]out of him. LVN C said this was not normal for Resident #2, he was a very kind and sweet person, and did not like to complain. She said for months now Resident #18 had seemed to target Resident #2 and frequently did things to upset him. She said Resident #2 had told her that he had frequently reported Resident #18's behavior to the administration, but nothing had been done. She said several times she had heard Resident #2 say that if they don't do something soon that he doesn't know how much longer he can take it. She has also heard Resident #2 say that it has gotten to where it is not worth going out to smoke because Resident #18 is out there. She said she had worked with Resident #18 since he had lived at the facility, and she had never known of him to be on every 15 minute monitoring. During an interview on 06/13/17 at 1:36 p.m., LVN B said she had worked at the facility approximately a year, ever since Resident #18 had been in the facility. She said she had never known of Resident #18 to be on every 15 minute monitoring. During an interview on 06/13/17 at 6:28 p.m., the DON said an incident report should be completed when a resident has a behavior. Reviewed the documentation concerning Resident #18 and his behaviors with her. She said each instance of behaviors should have an incident report completed, and subsequent investigation of the situation. She said she thought Resident #18s behaviors had subsided and she was not aware of resident currently having these behaviors. Incident reports dated 01/01/17 to 06/13/17 indicated no reports for Resident #18 related to inappropriate sexual behaviors. Resident Rights Guidelines for All Nursing Procedures policy dated 10/2010, indicated staff are to receive training on resident rights, including: preventing, recognizing and reporting resident abuse; and, resident dignity and respect. The Abuse Prevention Program policy dated 12/2016, indicated .residents have the right to be free of abuse and neglect, including sexual abuse . The Abuse and Neglect Clinical Protocol policy dated 12/2016, indicated .other forms of abuse are mistreatment (inappropriate treatment of [REDACTED]. The information for on-site visit sheet, completed by facility on 06/06/17, indicated a census of 70 residents.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit abuse for 1 of 11 residents reviewed for abuse/neglect. (Resident #2) The facility did not investigate or report to State agency when Resident #2 reported that Resident #18 was sexually harassing him, exposing himself and masturbating in the presence of other residents. The facility did not protect residents from further potential abuse. This failure could place the facility census of 70 residents at risk of abuse or neglect. Findings included: The Abuse Prevention Program policy dated 12/2016, indicated .residents have the right to be free of abuse and neglect, including sexual abuse . The Abuse Investigation and Reporting policy dated 12/2016, indicated .all reports of abuse, neglect, exploitation, mistreatment .shall be promptly reported to local, state, and federal agencies, and thoroughly investigated by facility management . The Abuse and Neglect Clinical Protocol policy dated 12/2016, indicated .other forms of abuse are mistreatment (inappropriate treatment of [REDACTED]. The policy also indicated .the facility will investigate possible occurrences of abuse and neglect to clarify what happened and identify causes . The Accident and Incidents Investigating and Reporting policy dated 07/2016, indicated .all incidents involving residents occurring on facility premises shall be investigated and reported to the administrator . 2. Physicians orders printed 06/23/17 indicated Resident #2 was a [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was moderately cognitively impaired, had clear speech with the ability to make self understood and to understand others, and had no behavior problems. A care plan dated 02/23/17 indicated Resident #2 wished to smoke cigarettes and had been assessed to smoke with supervision. The care plan also addressed that Resident #2 needed out of room social, spiritual, and stimulus activities and mental stimulation. The nursing notes for Resident #2 indicated the following: * 02/26/17, .resident complained and stated, I turned (Resident #18) in this week for asking me to let him suck my dick, and nothing has been done, he still rolling around here rubbing on his private, informed resident it would be reported. * 06/10/17, heard yelling, another male resident was at this resident's door, separated residents, asked what was going on, this resident reported that male resident stopped at his door and was blowing kisses, educated this resident to report behaviors to nurse, resident stated he understood. During an interview on 06/12/17 at 5:31 p.m., Resident #2 said Resident #18 would roll into his room and describe sexual acts that he wanted to perform with Resident #2, such as oral sex. He said Resident #18 has exposed himself, and will begin fondling himself. Resident #2 said Resident #18 would stare at him and lick his lips in a very exaggerated manner. Resident #2 said he found these advances embarrassing, bothersome, and it made him angry. Resident #2 said he had reported these incidents to staff repeatedly, but nothing has been done. Resident #2 said both he and Resident #18 are smokers, but he did not smoke as he wanted to because of the way Resident #18 treated him. Resident #2 said he monitored Resident #18's presence in the smoking area and sometimes did not smoke when he wanted to because of Resident #18 being there. Resident #2 said he did not want to, but if this situation continued he would defend himself by hitting Resident #18 with his cane. Resident #2 said just a few mornings ago, Resident #18 came to his room and was blowing kisses at him, and this was very upsetting. During an interview on 06/13/17 at 5:12 p.m., Resident #2 said Resident #18 has asked him to come to his room for sexual activities, and has told him he wants to have sexual relations with anyone, whether it be man, woman, or child. Resident #18 has asked him how he could get a child into his room. He said Resident #18 fondles himself on a regular basis in public. Resident #2 said this morning he was in the smoking area, and he wasn't through smoking yet, but Resident #18 began staring at him and licking his lips in an exaggerated manner. Resident #2 said although he was not through smoking yet, he put his cigarette out and left. Resident #2 said this bothers him due to everything that has happened. 3. Physician orders [REDACTED].#18 was a [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #18 had moderate cognitive impairment and exhibited behaviors. The resident had physical behavioral symptoms directed towards others 1 to 3 days per week, and had other behaviors not directed towards others 1 to 3 days per week. The resident exhibited wandering 1 to 3 days per week. A care plan for Resident #18 dated 01/11/17 with revised/continued dates of 02/23/17, 04/23/17 and 05/18/17 indicated the resident had behaviors of sexually inappropriate actions, by attempting to touch residents and staff. Interventions included .evaluating the resident's ability to understand behaviors, explain acceptable expressions of sexuality, and listen/talk to resident to see if they will tell why they do the behavior . The care plan also included that Resident #18 was a smoker and went to the smoking area for supervised smoking. During an interview and observation on 06/13/17 at 5:29 p.m., Resident #18 was in his room lying in bed. The resident voiced no complaints about the facility care and services. The nursing notes for Resident #18 indicated the following: * 01/12/17, CNA was showering the resident and he tried to touch her inappropriately, resident was told not to do this. * 01/12/17, resident was feeling on another male resident, he was removed from the room, and told not to touch other residents. * 01/20/17, resident was discharged to a behavior hospital. * 02/01/17, resident readmitted to facility. * 02/18/17, 6:15 a.m., Called to resident room by roommate (Resident #19). Roommate stated resident was yelling inappropriate racial/sexual statements, .yelling for black dicks and I want to suck a black dick right now. Resident was present during accusation, no denial was made, and resident asked for the time. Nurse educated resident on acceptable and appropriate behavior. Resident stated understanding and left the room. Roommate remained very upset and anxious about new roommate stating, he needs to get out of here .he shouldn't be saying things like that, I don't like that, this is not right. Attempts to reassure roommate of safety and calm roommate were unsuccessful. Will continue to monitor. * 02/19/17, resident came up hallway with no bottoms or underwear on, staff took to room to dress. Resident rubbing his genitals while outside in front of other residents. Resident able to make needs known, uses wheelchair. * 02/25/17, resident up in wheelchair, lunch in dining room, able to make needs known goes out on smoke breaks, transfers self from chair to bed. * 02/26/17, resident propelling self in wheelchair, rubbing genitals, educated resident to not do that in front of residents . * 03/18/17, a resident from Station 1 reported that resident (#18) rubbed up his leg and across his genital area, nurse spoke with resident. * 03/31/17, resident again made a sexually explicit comment and continues to touch himself inappropriately in public areas. This has been a problem for this resident in the past. Resident agreed to admission to behavior hospital, facility will transport today. * 04/19/17, resident readmitted to facility. * 06/10/17, 8:54 a.m., resident was propelling self past another male residents door and stopped and was blowing kisses to male resident, heard yelling, separated residents, took resident to his room and asked him to not do that, resident stated he understood. The behavior nursing note assessments for Resident #18 indicated the following: * 01/07/17, resident is rubbing on staff and other residents in a sexual manor, and states that he wants to have sex with them. Intervention implemented of every 15 minute checks. There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/08/17, .resident continuing to try and touch staff in a sexual manner, MA was trying to get resident's blood pressure, resident run his hand down MAs private part, and when a female resident wandered into resident's room, resident was laying in bed and told female resident to get in bed with him and give him H---, and a male resident walked into resident's room and he told male resident to bend over and he would give it to him. Intervention implemented of every 15 minute checks . There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/12/17, Resident continues inappropriate sexual behavior towards staff and residents ., continues on every 15 minute monitoring. There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/14/17, resident continues to try to touch staff and other residents, educated resident on the need to not do that, resident stated OK. Intervention implemented of every 15 minute checks. There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/15/17, resident was trying to rub on another male resident's private parts, staff redirected resident to his room, resident was then seen trying to go into another male resident room, resident was told he could not go into other residents room, he stated OK and went down the hall, turned around and went back into other residents room again, staff educated resident on not going into other resident room. Intervention implemented of every 15 minute checks. There was no documentation found of conducting every 15 minute monitoring for the resident. During an interview on 06/13/17 at 1:17 p.m., CNA A said she had worked in the facility for at least as long as Resident #18 has been residing at the facility. She said Resident #18 has inappropriate sexual behaviors and required redirection. She said the resident transferred himself from bed to wheelchair and self-propels about the facility independently. She said Resident #18 exposes and fondles himself in front of others. CNA A said she found Resident #18 attempting to touch other residents but had intervened before he got his hand near their private parts. She said approximately two weeks ago she was supervising the smoking and Resident #18 was present. The resident had on a pair of shorts, and while everyone was sitting there smoking, Resident #18 pulled up one of his short pant legs, pulled his penis outside of his garments, exposed himself, and began to masturbate in front of everyone. She said she re-directed the resident, he complied, and covered himself. She said as soon as the smoke break was over, and she got all the residents back inside, she immediately went and informed the charge nurse. CNA A said Resident #18 routinely exhibited this behavior and she reports it to the charge nurse. She said she had never known of Resident #18 to be on every 15 minute monitoring. During an interview on 06/13/17 at 2:10 p.m., LVN C said Resident #18 had frequent sexual behaviors. She said the resident was mobile, could transfer self to and from bed and into wheelchair, and he self-propelled about the facility at will. LVN C said the resident will expose himself, and fondle himself in front of others. She said every time Resident #18 exhibited these behaviors she reported it to the DON. LVN C said recently Resident #18 was coming in from smoking and he went up to another male resident in a wheelchair and put his hand on the other resident's leg above the knee and began to run his hand up the resident's leg toward the resident's genitals. She said she stopped the resident before he actually touched the other resident's genitals, and redirected him. LVN C could not remember who the other resident was. She said several mornings ago she was passing medications and she heard Resident #2 yell and say you better go on and get out of here. She said she immediately went down the hall and Resident #18 was in his wheelchair at Resident #2's door. LVN C said Resident #2 was very upset and said Resident #18 had come to his room and was blowing kisses at him. She said she re-directed Resident #18 back to his room. LVN C said Resident #2 said he is going to keep on until I have to knock the[***]out of him. LVN C said this was not normal for Resident #2, he was a very kind and sweet person, and did not like to complain. She said for months now Resident #18 had seemed to target Resident #2 and frequently did things to upset him. She said Resident #2 had told her that he had frequently reported Resident #18's behavior to the administration, but nothing had been done. She said several times she had heard Resident #2 say that if they don't do something soon that he doesn't know how much longer he can take it. She has also heard Resident #2 say that it has gotten to where it is not worth going out to smoke because Resident #18 is out there. She said she had worked with Resident #18 since he had lived at the facility, and she had never known of him to be on every 15 minute monitoring. During an interview on 06/13/17 at 1:36 p.m., LVN B said she had worked at the facility approximately a year, ever since Resident #18 had been in the facility. She said she had never known of Resident #18 to be on every 15 minute monitoring. During an interview on 06/13/17 at 6:28 p.m., the DON said an incident report should be completed when a resident has a behavior. Reviewed the documentation concerning Resident #18 and his behaviors with her. She said each instance of behaviors should have an incident report completed, and subsequent investigation of the situation. She said she thought Resident #18s behaviors had subsided and she was not aware of resident currently having these behaviors. The ncident reports dated 01/01/17 to 06/13/17 indicated no reports for Resident #18 related to inappropriate sexual behaviors. The state agency facility history reports on 06/23/17 indicated no self-report incidents reported to the state agency concerning Resident #18. The information for on-site visit sheet, completed by facility on 06/06/17, indicated a census of 70 residents.

Based on interview and record review, the facility failed to prevent neglect and implement its written policies and procedures to prevent abuse for 2 of 11 residents reviewed for abuse/neglect. (Resident #s 2 and 18) Resident #2 reported that Resident #18 was sexually harassing him, exposing himself, and verbalizing desired sexual acts that he wished. Resident #18 also exposes himself and fondles himself in front of others. The facility did not protect Resident #2 from further potential abuse from Resident #18. Resident #18 quit his usual activities due to the sexual harassment by Resident #2. This failure could place the census of 70 residents at risk of mistreatment by other residents. Findings included: 1. Physicians orders printed 06/23/17 indicated Resident #2 was a [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was moderately cognitively impaired, had clear speech with the ability to make self understood and to understand others, and had no behavior problems. A care plan dated 02/23/17 indicated Resident #2 wished to smoke cigarettes and had been assessed to smoke with supervision. The care plan also addressed that Resident #2 needed out of room social, spiritual, and stimulus activities and mental stimulation. The nursing notes for Resident #2 indicated the following: * 02/26/17, .resident complained and stated, I turned (Resident #18) in this week for asking me to let him suck my dick, and nothing has been done, he still rolling around here rubbing on his private, informed resident it would be reported. * 06/10/17, heard yelling, another male resident was at this resident's door, separated residents, asked what was going on, this resident reported that male resident stopped at his door and was blowing kisses, educated this resident to report behaviors to nurse, resident stated he understood. During an interview on 06/12/17 at 5:31 p.m., Resident #2 said Resident #18 would roll into his room and describe sexual acts that he wanted to perform with Resident #2, such as oral sex. He said Resident #18 has exposed himself, and will begin fondling himself. Resident #2 said Resident #18 would stare at him and lick his lips in a very exaggerated manner. Resident #2 said he found these advances embarrassing, bothersome, and it made him angry. Resident #2 said he had reported these incidents to staff repeatedly, but nothing has been done. Resident #2 said both he and Resident #18 are smokers, but he did not smoke as he wanted to because of the way Resident #18 treated him. Resident #2 said he monitored Resident #18's presence in the smoking area and sometimes did not smoke when he wanted to because of Resident #18 being there. Resident #2 said he did not want to, but if this situation continued he would defend himself by hitting Resident #18 with his cane. Resident #2 said just a few mornings ago, Resident #18 came to his room and was blowing kisses at him, and this was very upsetting. During an interview on 06/13/17 at 5:12 p.m., Resident #2 said Resident #18 has asked him to come to his room for sexual activities, and has told him he wants to have sexual relations with anyone, whether it be man, woman, or child. Resident #18 has asked him how he could get a child into his room. He said Resident #18 fondles himself on a regular basis in public. Resident #2 said this morning he was in the smoking area, and he wasn't through smoking yet, but Resident #18 began staring at him and licking his lips in an exaggerated manner. Resident #2 said although he was not through smoking yet, he put his cigarette out and left. Resident #2 said this bothers him due to everything that has happened. 2. Physician orders [REDACTED].#18 was a [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #18 had moderate cognitive impairment and exhibited behaviors. The resident had physical behavioral symptoms directed towards others 1 to 3 days per week, and had other behaviors not directed towards others 1 to 3 days per week. The resident exhibited wandering 1 to 3 days per week. A care plan for Resident #18 dated 01/11/17 with revised/continued dates of 02/23/17, 04/23/17 and 05/18/17 indicated the resident had behaviors of sexually inappropriate actions, by attempting to touch residents and staff. Interventions included .evaluating the resident's ability to understand behaviors, explain acceptable expressions of sexuality, and listen/talk to resident to see if they will tell why they do the behavior . The care plan also included that Resident #18 was a smoker and went to the smoking area for supervised smoking. During an interview and observation on 06/13/17 at 5:29 p.m., Resident #18 was in his room lying in bed. The resident voiced no complaints about the facility care and services. The nursing notes for Resident #18 indicated the following: * 01/12/17, CNA was showering the resident and he tried to touch her inappropriately, resident was told not to do this. * 01/12/17, resident was feeling on another male resident, he was removed from the room, and told not to touch other residents. * 01/20/17, resident was discharged to a behavior hospital. * 02/01/17, resident readmitted to facility. * 02/18/17, 6:15 a.m., Called to resident room by roommate (Resident #19). Roommate stated resident was yelling inappropriate racial/sexual statements, yelling for black dicks and I want to suck a black dick right now. Resident was present during accusation, no denial was made, and resident asked for the time. Nurse educated resident on acceptable and appropriate behavior. Resident stated understanding and left the room. Roommate remained very upset and anxious about new roommate stating, he needs to get out of here .he shouldn't be saying things like that, I don't like that, this is not right. Attempts to reassure roommate of safety and calm roommate were unsuccessful. Will continue to monitor. * 02/19/17, resident came up hallway with no bottoms or underwear on, staff took to room to dress. Resident rubbing his genitals while outside in front of other residents. Resident able to make needs known, uses wheelchair. * 02/25/17, resident up in wheelchair, lunch in dining room, able to make needs known goes out on smoke breaks, transfers self from chair to bed. * 02/26/17, resident propelling self in wheelchair, rubbing genitals, educated resident to not do that in front of residents . * 03/18/17, a resident from Station 1 reported that resident (#18) rubbed up his leg and across his genital area, nurse spoke with resident. * 03/31/17, resident again made a sexually explicit comment and continues to touch himself inappropriately in public areas. This has been a problem for this resident in the past. Resident agreed to admission to behavior hospital, facility will transport today. * 04/19/17, resident readmitted to facility. * 06/10/17, 8:54 a.m., resident was propelling self past another male residents door and stopped and was blowing kisses to male resident, heard yelling, separated residents, took resident to his room and asked him to not do that, resident stated he understood. The behavior nursing note assessments for Resident #18 indicated the following: * 01/07/17, resident is rubbing on staff and other residents in a sexual manor, and states that he wants to have sex with them. Intervention implemented of every 15 minute checks. There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/08/17, .resident continuing to try and touch staff in a sexual manner, MA was trying to get resident's blood pressure, resident run his hand down MAs private part, and when a female resident wandered into resident's room, resident was laying in bed and told female resident to get in bed with him and give him H---, and a male resident walked into resident's room and he told male resident to bend over and he would give it to him. Intervention implemented of every 15 minute checks . There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/12/17, Resident continues inappropriate sexual behavior towards staff and residents ., continues on every 15 minute monitoring. There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/14/17, resident continues to try to touch staff and other residents, educated resident on the need to not do that, resident stated OK. Intervention implemented of every 15 minute checks. There was no documentation found of conducting every 15 minute monitoring for the resident. * 01/15/17, resident was trying to rub on another male resident's private parts, staff redirected resident to his room, resident was then seen trying to go into another male resident room, resident was told he could not go into other residents room, he stated OK and went down the hall, turned around and went back into other residents room again, staff educated resident on not going into other resident room. Intervention implemented of every 15 minute checks. There was no documentation found of conducting every 15 minute monitoring for the resident. During an interview on 06/13/17 at 1:17 p.m., CNA A said she had worked in the facility for at least as long as Resident #18 has been residing at the facility. She said Resident #18 has inappropriate sexual behaviors and required redirection. She said the resident transferred himself from bed to wheelchair and self-propels about the facility independently. She said Resident #18 exposes and fondles himself in front of others. CNA A said she found Resident #18 attempting to touch other residents but had intervened before he got his hand near their private parts. She said approximately two weeks ago she was supervising the smoking and Resident #18 was present. The resident had on a pair of shorts, and while everyone was sitting there smoking, Resident #18 pulled up one of his short pant legs, pulled his penis outside of his garments, exposed himself, and began to masturbate in front of everyone. She said she re-directed the resident, he complied, and covered himself. She said as soon as the smoke break was over, and she got all the residents back inside, she immediately went and informed the charge nurse. CNA A said Resident #18 routinely exhibited this behavior and she reports it to the charge nurse. She said she had never known of Resident #18 to be on every 15 minute monitoring. During an interview on 06/13/17 at 2:10 p.m., LVN C said Resident #18 had frequent sexual behaviors. She said the resident was mobile, could transfer self to and from bed and into wheelchair, and he self-propelled about the facility at will. LVN C said the resident will expose himself, and fondle himself in front of others. She said every time Resident #18 exhibited these behaviors she reported it to the DON. LVN C said recently Resident #18 was coming in from smoking and he went up to another male resident in a wheelchair and put his hand on the other resident's leg above the knee and began to run his hand up the resident's leg toward the resident's genitals. She said she stopped the resident before he actually touched the other resident's genitals, and redirected him. LVN C could not remember who the other resident was. She said several mornings ago she was passing medications and she heard Resident #2 yell and say you better go on and get out of here. She said she immediately went down the hall and Resident #18 was in his wheelchair at Resident #2's door. LVN C said Resident #2 was very upset and said Resident #18 had come to his room and was blowing kisses at him. She said she re-directed Resident #18 back to his room. LVN C said Resident #2 said he is going to keep on until I have to knock the[***]out of him. LVN C said this was not normal for Resident #2, he was a very kind and sweet person, and did not like to complain. She said for months now Resident #18 had seemed to target Resident #2 and frequently did things to upset him. She said Resident #2 had told her that he had frequently reported Resident #18's behavior to the administration, but nothing had been done. She said several times she had heard Resident #2 say that if they don't do something soon that he doesn't know how much longer he can take it. She has also heard Resident #2 say that it has gotten to where it is not worth going out to smoke because Resident #18 is out there. She said she had worked with Resident #18 since he had lived at the facility, and she had never known of him to be on every 15 minute monitoring. During an interview on 06/13/17 at 1:36 p.m., LVN B said she had worked at the facility approximately a year, ever since Resident #18 had been in the facility. She said she had never known of Resident #18 to be on every 15 minute monitoring. During an interview on 06/13/17 at 6:28 p.m., the DON said an incident report should be completed when a resident has a behavior. Reviewed the documentation concerning Resident #18 and his behaviors with her. She said each instance of behaviors should have an incident report completed, and subsequent investigation of the situation. She said she thought Resident #18s behaviors had subsided and she was not aware of resident currently having these behaviors. Incident reports dated 01/01/17 to 06/13/17 indicated no reports for Resident #18 related to inappropriate sexual behaviors. The information for on-site visit sheet, completed by facility on 06/06/17, indicated a census of 70 residents.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents, for 1 of 5 residents reviewed for accidents (Resident #1). Facility staff (CNA B and Staff A) did not secure Resident #1's wheelchair properly during a transport in the facility van. The resident fell forward in her wheelchair, sustaining a fractured ankle when the vehicle came to a sudden stop. This failure could place 17 residents in wheelchairs who were transported in the facility van at risk of injury. Findings included: A Face Sheet dated 06/21/16 indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was cognitively intact, she required extensive assistance with her ADLs, which included mobility, transfers, and locomotion on and off the unit. The MDS indicated Resident #1 walked in her room and in the corridor only once or twice, with the assistance of one staff member in the assessment period of 05/07/16-05/13/16. A nursing care plan revised on 12/06/15 indicated Resident #1 required extensive assistance with ADLs related to physical limitations. A fall with injury note dated 05/21/16 at 1:47 p.m., and revised on 06/28/16 at 1:37 p.m., indicated Resident #1 was a passenger in the facility van. When the van came to a sudden stop at a traffic light, Resident #1, fell forward out of her wheelchair onto her knees, with her legs underneath her on the floor of the van. The report indicated Staff A and CNA B were in the facility van with Resident #1. A clinical assessment fall report dated 05/21/16 at 1:47 p.m. indicated Resident #1 had a witnessed fall in which Resident #1 slid out of her wheelchair during transport in the facility van. The report indicated Resident #1 had bruising to her right ankle measuring 5 cm x 5 cm that was blue/purple in color, and an abrasion to her right ankle measuring 3 cm x 2 cm. The report indicated Resident #1 complained of pain. A nursing progress note dated 05/21/16 at 2:03 p.m., indicated Resident #1 was in the facility van when the van stopped suddenly at a red light and Resident #1 slid out of wheelchair onto her knees with her legs underneath her. The note indicated her right ankle was swollen, with an abraded area to the right ankle and the physician was notified and provided an order obtained for an x-ray. An x-ray report dated 5/21/16 indicated Resident #1 had fractures of her distal right fibula and tibia (ankle fracture) with medial displacement of both distal fragments (the movement of fractured bone fragments away their normal alignment). During an interview on 06/29/16 at 9:20 a.m., the DON said Resident #1 no longer resided in the facility. She moved to another facility on 06/27/16. During an interview on 06/29/16 at 10:35 a.m. and 1:46 p.m., CNA B said she put Resident #1 in the van, securing the back wheels of the wheelchair, while Staff A put the seatbelt around the resident. CNA B said she did not secure the front wheels of the wheelchair. She said she came to a traffic light, hit her brakes, and heard Resident #1 screaming to stop the van. She saw Resident #1 slipped out of the wheelchair, which was tipped over on top of the resident. Resident #1 was positioned on her knees. She said they returned Resident #1 to the facility. CNA B said the transportation aide showed her how to secure the wheelchair and the resident, but she did not demonstrate for the transportation aide. She was in-serviced on the van after the incident. During an observation on 06/29/2016 at 9:25 a.m., Staff A attempted to demonstrate how to put a wheelchair into the van, securing all four wheels to the van floor. As Staff A secured the wheelchair; the administrator intervened and told Staff A to ensure the wheelchair wheels were locked. Staff A locked the wheelchair wheels, then reached for a seatbelt attached to the top of the van; the administrator intervened again and corrected Staff A on which strap to use. Staff A then threaded the black strap that was attached to the floor of the van through the arms of the wheelchair. During an observation and interview on 06/29/16 at 11:15 a.m., Resident #1 was observed at another facility. She had a splint on her right foot that extended up to below her knee. Resident #1 said on 05/21/16, during transport in the facility van, she noticed Staff A could not secure the front left wheel of her wheelchair to the van. She said during transport, she already felt as if she was sitting halfway out of the chair. She said when CNA B slammed on the brakes, Resident #1 fell forward onto her knees, with the wheelchair on top of her. Resident # 1 said her ankle swelled immediately, and she felt pain in her right ankle and leg. Resident #1 was doing therapy before the incident, and was able to take a couple of steps, but was currently unable to walk because she could not bear weight on her foot, and the ankle was still painful. During an interview on 06/29/16 at 10:17 a.m. and 12:35 p.m., Staff A said on the day of the incident, he used the shoulder strap from the passenger seat belt of the van to secure Resident #1 into the wheelchair, but did not use the black waist belt. He did not secure the front wheels of the wheelchair to the van. He said CNA B slammed on the brakes, and Resident #1 screamed for them to stop the van. Resident #1 fell out of the wheelchair to her knees. Staff A said he had not been in-serviced on how to use the straps in the van, until after the incident. During an interview on 06/29/16 at 9:30 a.m., the administrator said he in-serviced the staff on how to secure wheelchairs and residents in the van. The administrator said he did not know why Staff A was trying to use the shoulder strap. The administrator said he was not previously aware Staff A used the incorrect strap to secure Resident #1 into the van. During an interview on 06/29/16 at 1:48 p.m., the van driver said she was not in-serviced on the van involved in the incident, until after the incident. She said she showed CNA B how to secure the resident in the van. She said CNA B did not demonstrate how to secure a wheelchair into the van, but said she understood. During an interview on 06/29/16 at 1:50 p.m., the maintenance man said he had not in-serviced the staff on the new van until after the incident. He said he demonstrated how the wheelchair was to be strapped in and resident secured with the seat belt. He said he did not ask staff to return the demonstration. An undated Transportation Policy indicated that drivers go through a checklist of proficiency that meets the company standards. This checklist includes wheelchair lift operation, occupant restraint system, road test, vehicle inspection and a list of driver operating rules. A patient list report provided on 06/29/16 by administrator indicated there were 17 residents in wheelchairs who used the van for transportation.

Based on observation, interview, and record review, the facility failed to ensure residents who entered the facility without pressure sores did not develop pressure sores and failed to ensure residents having pressure sores received the necessary treatment and services to promote healing and prevent new sores from developing for 2 of 3 residents reviewed for pressure sores. (Resident #s 6 and 39) 1. The facility did not prevent Resident #6 from developing an unstageable pressure ulcer to her sacrum. The area was documented as being present on 2/8/16, but was not assessed until 2/10/16. 2. The facility did not prevent Resident #39 from developing an unstageable pressure sore to her right heel and two Stage II pressure sores to her right buttock. The facility indicated the right heel and right buttock were healed. These failures could place 6 residents with pressure sores at risk for the development of new pressure sores and worsening of existing pressure sores. Findings included: 1. February 2016 physician orders [REDACTED]. February 2016 physician orders [REDACTED]. A quarterly MDS dated [DATE] indicated Resident #6 had a BIMS score of 6. The resident required extensive assistance of one person for bed mobility and was dependent on one person for transfers. The MDS indicated the resident was at risk for developing pressure ulcers but did not have one at that time. A Braden Scale for Predicting Pressure Sore Risk dated 12/21/15 indicated Resident #6 scored 18, which indicated she was at low risk for development of pressure ulcers. An Admission/Readmission assessment dated [DATE] indicated Resident #6 had a 1 cm (centimeter) stage II pressure ulcer to the coccyx with an order for [REDACTED].>A Skin Alteration Record for Resident #6 indicated not to use the document for pressure ulcers. The type of alteration was written as stage II. The first entry was documented on 12/21/15 and was located on the sacrum. The length was 1 cm, width 1 cm and no depth. There was no drainage. The next entry was documented on 12/28/15 and measured 0.5 cm length, 0.5 cm width and no depth without drainage. The last entry was 1/05/16 and measured 0.5 cm length, 0.5 cm width and no depth without drainage. This was the last documentation on this area. Weekly Skin Assessments for Resident #6 indicated there were no areas of skin impairment on 1/13/16, 1/20/16, 1/28/16, 2/01/16, and 2/08/16. A Daily-Skilled Nurses' Note dated 2/08/16 at 16:57 (4:57 p.m.) indicated Resident #6 had a pressure ulcer. The nurse documented there was a wound to the coccyx. There was no description or staging of the wound. A Daily-Skilled Nurses' Note dated 2/09/16 at 20:40 (8:40 p.m.) indicated Resident #6 had a pressure ulcer. The nurse documented there was an open area to the coccyx. A Progress Note dated 2/10/16 at 5:53 a.m. indicated a CNA called the nurse to Resident #6's room. The resident was noted to have a pressure ulcer to the coccyx with slough noted in the middle of it. The DON was present in the building at that time and was informed along with the oncoming nurse. The resident was left in bed to help relieve pressure. A Progress Note dated 2/10/16 at 10:11 a.m. indicated Per DON, cleaned coccyx area with ns (normal saline) and applied skin barrier around edges. Applied saccral (sic) dressing . A Daily-Skilled Nurses' Note dated 2/10/16 at 10:14 a.m. indicated Resident #6 had a pressure ulcer. The nurse documented that the coccyx was cleaned with normal saline, barrier cream was applied, and the area was covered with a sacral dressing. A Skin Assessment Flow Sheet-Pressure Ulcer for Resident #6 indicated the first entry was dated 2/10/16. The ulcer was assessed as a stage II. The length was documented as 2.0 cm; width 2.0 cm and depth as 0.2 cm. Drainage was noted; however, there was no description of the drainage. The next entry was 2/15/16. The ulcer was assessed as stage II. There were no measurements recorded on this document. Drainage and slough were noted to the ulcer. The next entry was 2/19/16. The ulcer was assessed as stage II. The length was documented as 3.2 cm and the width was 3.4 cm. There was no measurement for depth documented. Drainage, slough, and necrotic tissue were noted to the ulcer. The documented noted that the resident was sent to the wound care clinic this day for debridement. The next entry was 2/22/16. The ulcer was assessed as stage II. The length was documented as 3.0 cm; width 3.0 cm and depth 2.0 cm. Drainage, slough, and necrotic tissue were noted to the ulcer. The flow sheet contained a code key for pressure ulcers. This key indicated stage II was a Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without sloughing or bruising. The flow sheet defined a stage III as Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle us not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The flow sheet defined a stage IV as Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some portion of the wound bed. Often includes undermining and tunneling. The flow sheet defined an unstageable pressure ulcer as Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. A telephone order dated 2/11/16 indicated Resident #6 was to receive pressure ulcer treatment to the coccyx. The pressure ulcer was to be cleaned with normal saline, covered with an Allevyn dressing and changed every 5 days and as needed. A Progress Note dated 2/19/16 at 7:26 a.m. written by the DON indicated that Resident #6's ulcer that was noted on 2/10/16 was a stage III. A Weekly-Ulcer assessment dated [DATE] indicated Resident #6 had an unstageable pressure ulcer to the coccyx that was identified 2/10/16. The length was 3.2 cm, width 3.4 cm and depth undetermined. The wound bed was described as gray. Eschar was also noted as being present. The amount of necrosis was documented as being 100%. There was a moderate amount of tan exudate that had a strong odor. Turning and repositioning was noted as every 2 hours. The pressure reducing devices in place was noted as a wheelchair cushion. The physician was notified of the decline in the wound. A Progress Note dated 2/19/16 at 10:45 a.m. indicated Resident #6 had a PRN (as needed) dressing change to the wound on the coccyx. The wound had declined and measured 3.4 cm wide, 3.2 cm long with grayish slough to the wound bed and walls, black necrosis to edges especially from 7 o'clock to 10 o'clock. There was a moderate amount of tan drainage with very foul odor. The physician was notified and ordered to send the resident to the ER for further evaluation. A telephone order dated 2/19/16 indicated Resident #6 was to be sent to the emergency room for further eval (evaluation) and tx (treatment) of wound to coccyx- possible sacrum xray, poss (possible) wound culture, wound care clinic. A telephone order dated 2/19/16 indicated Resident #6 would go to outpatient wound center to evaluate and treat an open wound to the sacrum. A telephone order dated 2/19/16 indicated Resident #6's pressure ulcer was to be cleansed daily with wound cleanser, pat dry, repack loosely with ½ inch Nugauze and cover with foam dressing. A Hydrotherapy Wound/Pressure Ulcer Initial Evaluation dated 2/19/16 from the wound care clinic indicated Resident #6 had an irregular, oval-shaped sacral decubitus with black base and gray sides. The therapist documented that the sacrum could be palpated beneath the necrosis. The resident denied pain. The wound measured 2.9 cm length, 2.9 cm width, and 1.2 cm depth to the necrotic base. There was 0.8 cm of undermining (necrotic tissue) at the 12 o'clock position and 1.4 cm of undermining (necrotic tissue) at the 3 o'clock position. The therapist performed sharp debridement of the wound. During an observation and interview on 2/25/16 at 9:05 a.m., Resident #6's mattress was a Medline Advantage Select Me mattress. At this time, LVN D said they called it a scoop mattress. During an interview on 2/25/16 at 9:41 a.m., the DON said they did not have a manual on Resident #6's mattress, so she printed off a sheet from the internet. The ADON said that they were putting an air mattress on the bed as we speak. A product information sheet printed by the facility on 2/25/16 indicated the Medline Advantage Me mattress was recommended for prevention of pressure ulcers up to a stage II. A care plan initiated on 7/03/13 and revised on 12/09/15 for Resident #6 indicated a focus of alteration in skin integrity related to incontinence. The interventions included offering a diet per the physician's orders [REDACTED]. A care plan initiated on 2/12/16 for Resident #6 had focus of The resident has 1 pressure ulcer or potential for pressure ulcer development r/t disease process. The interventions included administering medications as ordered and documenting side effects and effectiveness. Treatments were to be administered as ordered with monitoring of effectiveness. Assessment of the wound was to be made weekly and any decline reported to physician. The last intervention was to educate the resident/family/caregivers about the causes of skin breakdown. During an observation and interview on 2/25/16 at 1:04 p.m., LVN D performed wound care for Resident #6. LVN D said the wound was unstageable. She measured the ulcer and said it was 3.0 cm long, 2.4 cm wide and 2.0 cm deep. There was pale-pink granulation observed from the 12 o'clock to 3 o'clock position and 5 o'clock to 7 o'clock position. Gray/yellow slough was observed to the wound bed along with an odor. LVN D performed wound care according to the order. During an interview on 2/24/16 at 2:45 p.m., LVN D said Resident #6 came back from the hospital on [DATE] with a small area to the coccyx. After reading the progress notes from 12/21/15-2/07/16 and noting no mention of pressure ulcer, LVN D said she could see how looking at the whole picture it looked bad. During an interview on 2/25/16 at 12:55 p.m., the DON said she was first aware of Resident #6's pressure ulcer on the morning of 2/10/16. She said it was about the size it was now, but it was deeper now since debridement. She said when she first saw the ulcer it had gray tissue and granulation. The wound deteriorated in a couple of days. The DON said she had been trying to do the pressure ulcer assessments. She said one of the nurses got the treatment order for Resident #6. She said originally the ulcer was a stage II but it deteriorated to a stage III about last Thursday. The DON said she made an error in documenting the ulcer as a II on the assessment sheet beginning with the 2/19/16. It should have been a III. The DON said she felt the mattress on the resident's bed was sufficient. She was not aware the mattress was being changed to an air mattress. During an interview on 2/25/16 at 2:22 p.m., LVN E said Resident #6 had a small place which she came back with from the hospital. LVN E said the wound was back and forth. It would heal some and come back. When showed her documentation beginning on 2/08/16, LVN E said that was the area she currently had. When shown that her documentation on 2/07/16 reflected Resident #6 did not have a pressure ulcer, LVN E said she failed to document it. 2. Physician orders [REDACTED].#39 was [AGE] years old, readmitted from the hospital 08/20/15. The orders included the following wound care, start date 01/31/16: Clean skin alteration to right buttock. Apply PeriGuard (barrier cream) every shift til healed and Clean wound to right heel with wound cleanser, cover with dry 4 x 4 gauze daily and as needed until healed. The orders also included ProMod (protein supplement) 30 milliliters daily for wound health, order date 09/11/15. A treatment record dated February 2016 indicated the right heel and right buttock were treated as ordered. The most recent MDS dated [DATE] indicated Resident #39 had intact cognition, required extensive assist of two staff for bed mobility, was totally dependent on two staff for transfers, was totally bowel and bladder incontinent, and had one unstageable pressure sore. A care plan updated 02/19/16 indicated Resident #39 had a pressure ulcer to her right heel related to non-weight bearing boot friction. Interventions included,Float heels as able and Special cushion on bed/wheelchair (specify location.) A care plan updated 02/19/16 indicated Resident #39 was at risk for further alteration in skin integrity. An intervention was Pressure redistributing device on bed. There were no care plans for Stage II pressure sores to Resident #39's right buttock. During an interview on 02/25/16 at 3:55 p.m., the ADON MDS coordinator said there were no other care plans for Resident #39. A skilled nursing note dated 11/08/15 at 5:41 p.m. indicated Resident #39's right foot had a pillow in place for heel pressure prevention. A weekly skin assessment dated [DATE] indicated Resident #39 had no pressure sores. There were no other weekly skin or pressure sore assessments in the computer or on the chart. There were no dietary recommendations or progress notes from 8/20/15-2/25/16 on Resident #39's chart or computerized records. During an interview on 02/25/16 at 8:30 a.m., the ADON MDS coordinator said Resident #39' right heel was scabbed-over and healed. During an interview on 02/25/16 at 2:55 p.m., the ADON MDS coordinator said the company who previously owned the facility came in December 2015 and removed all resident and staff records, so they had no prior records for Resident #39. During an interview on 02/25/16 at approximately 3:20 p.m., the DON brought hand-written skin assessments and documentation for Resident #39 as follows: Skin Assessment Flow Sheet -- Non-Pressure Ulcer Conditions 01/13/16 (onset date): Altered skin integrity right buttock skin shear. Treatment: PeriGuard every shift. There were no measurements. 02/13/16: 1.0 x 1.0 x 0.1 cm. Continue current treatment -- healing. 02/18/16: 1.0 x 1.0 x 0.1 cm. Continue current treatment -- healing. Skin Assessment Flow Sheet -- Pressure Ulcer (no onset date) 01/12/16: 1.0 x 1.0 x ?, unstageable, eschar; continue current treatment 01/19/16: 1.0 x 1.0 x ?, unstageable, eschar, continue current treatment 01/26/16: 1.0 x 1.0 x ?, unstageable, eschar; continue current treatment 02/05/16: 1.0 x 1.0 x ?, unstageable, eschar; continue current treatment 02/13/16: 1.0 x 1.0 x ?, unstageable, eschar; continue current treatment 02/18/16: 1.0 x 1.0 x ?, unstageable, eschar; continue current treatment 02/25/16: 1.0 x 1.0 x ?, unstageable, eschar; continue current treatment A Braden Scale for Predicting Pressure Sore Risk dated 02/19/16 indicated Resident #39 was at low risk for pressure sore development. It noted friction and shear were both potential problems. During an observation on 02/24/16 at 12:50 a.m., Resident #39 was sitting in her wheel chair. She had socks on and her feet were on the foot pedals. She did not have pillows or other pressure relieving devices to her feet. There was no cushion in her wheel chair. During an observation and interview on 02/25/16 at 10:02 a.m., LVN A said she was not sure about a pressure sore to Resident #39's buttock. She stated, I think it's healed. I don't have a treatment. Resident #39 was sitting in her wheel chair. She had socks on and her feet were on the foot pedals. She did not have pillows or other pressure relieving devices to her feet. There was no cushion in her wheel chair. The linens were off and the bed had a Medline Select Me mattress. LVN A removed the dressing. Black eschar covered the wound bed with thick, hard yellow tissue surrounding the eschar. The pressure sore was round and measured 1.0 x 1.0 cm (centimeters.) LVN A said the treatment record just called it a wound and they were not staging it. LVN A said weekly skin assessments were done by the nurses on Fridays. She said the DON and ADON assigned residents to each shift. A product information sheet printed by the facility on 2/25/16 indicated the Medline Advantage Me mattress was recommended for prevention of pressure ulcers up to a stage II. During an interview on 02/25/16 at 3:15, LVN B said Resident #39 had no pressure sores or treatment to her right buttock. LVN B did not comment when shown the February 2015 treatment record that indicated to Clean skin alteration to right buttock. Apply PeriGuard (barrier cream) every shift til healed. During an observation and interview on 02/25/16 at 3:43 p.m., Resident #39 had two open areas to her right buttock. LVN B said there had been two areas on her right buttock. She stated, They open and close. LVN B said she did not know if the wounds were being staged or measured. The open pressure sores measured 0.8 x 0.5 cm and 1.0 x 0.5 cm and wound beds were red tissue. LVN B said she did not know the stage of the pressure sores. During an interview on 02/25/16 at 3:47 p.m., CNA C said she applied PeriGuard barrier cream all over Resident #39's buttocks, including the open areas. An undated Pressure Ulcer, Care and Prevention Of policy and procedure indicated the following: Purpose: To prevent and treat further breakdown of pressure sores. Procedures .9. Off load heels if resident is unable to move lower extremities with out assistance .20. If resident is noncompliant with prevention and/or treatment recommendations, complete an Informed Consent detailing recommendations and possible consequences of noncompliance. Include such information into resident's Interdisciplinary Plan of Care. A Pressure Ulcer: Prevention, Assessment, and Treatment policy and procedure dated 2003 noted the following: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity .to prevent breakdown . 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs . 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse designee will .2. Notify .dietary department . Document notification. 3. Assess site daily and sign off on treatment sheet any treatment completed . 4. Causes of Pressure Ulcers: 1. Unrelieved pressure over a bony prominence resulting in ischemia at the area of pressure. 2. Shearing of tissue . Skin Integrity Management General Guidelines 1. If pressure causes changes in the resident's skin, it is the responsibility of the charge nurse to .do an assessment and initiate a treatment plan as soon as possible. Document in resident's chart, area of change, who you notified, and treatment applied .3 .Notify dietician of a resident at risk or who has known skin breakdown .10. Positioning of chair-bound individuals should include consideration of postural alignment, distribution of weight, balance and stability, and pressure relief. 11. The Treatment Nurse/designee and the DON should add a written plan for the use of positioning devices and schedules to the care plan .13. Skin injury due to friction and shear forces should be minimized through proper positioning, transferring, and turning techniques .20. Additional heel protection may be needed even if a resident is on a pressure reducing/relieving device. Use pillows to off-pressure heels. 21. If eschar or necrotic tissue is present, debridement may be indicated .Treatment Nurse/designee will determine type of debridement indicated and will notify physician for recommendations. 22 .Care planning in response to the presence of pressure sores must be completed. The Director of Nurses or designee does this. 23. The Braden Assessment must be completed on every resident .and as needed. (If conditions change a new one must be completed.) A General Guidelines for Treatment revised March 7, 2007 noted the following: .8 .If the ulcer does not show any evidence of healing following 2 weeks or more of conservative management, notify the physician . The National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 02/25/16 noted the following: Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. A sheet provided by the DON on 2/25/16 indicated 6 residents had pressure ulcers.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care for 1 of 5 residents reviewed for changes in condition. (Resident #1) Resident #1 experienced a change in condition. RN A recognized the resident had slurred speech, but did not thoroughly assess the resident or notify the physician. Approximately thirty minutes later, Resident #1 was found unresponsive on the floor and died . An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training with additional staff and evaluate the effectiveness of the corrective systems. This failure could place the census of 55 residents at risk for lack of medical treatment in the event of a change in condition. Findings included: A face sheet (undated) indicated Resident #1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated glucose checks were ordered, The A DNR (Do Not Resuscitate) was in place for Resident #1. The most recent MDS dated [DATE] indicated Resident #1 had clear speech with distinct intelligible words and had clear comprehension. He was without an altered level of consciousness or a decreased level of psychomotor skills. The resident was without falls since admission. A care plan dated [DATE] indicated Resident #1 required supervision when transferring from one position to another and verbal cues or minimal physical assistance was needed for mobility. The provider investigation report dated [DATE] indicated on [DATE] Resident #1 was found lying on the floor unresponsive, taking agonal breaths (an abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, accompanied by strange vocalizations). The nurse (unnamed) was unable to obtain a blood pressure reading or a palpable radial pulse and the resident was without a heart rate. A small hematoma was noted on the right side of the resident's forehead. Resident #1 had a DNR in place. The nurse spoke with the resident about 30 minutes prior and checked his blood sugar. The resident was visually assessed by the nurse and found to have slurred speech, but the nurse attributed it to him just waking up as he did not show any visual signs of any or distress. The investigation summary indicated the physician concluded the resident likely had a stroke and collapsed. An Incident Reporting Form dated [DATE] indicated the following: *4:45 p.m., Resident #1 with slight slurred speech noted, but resident rolled to his right side to prepare to get out of bed, *5:17 p.m., CNA (unidentified) found resident on the floor and called the nurse, *5:20 p.m., RN (unidentified) assessment (no details were indicated), *5:20 p.m., RN found Resident #1 without a heart rate or a blood pressure or breaths, *5:25 p.m., the physician was notified. During a telephone interview on [DATE] at 11:42 a.m., RN A said shortly after she arrived for her shift on [DATE], she started passing medications and she noticed Resident #1 was asleep. She said around 4:45 p.m., she entered Resident #1's room to check his blood sugar levels which was within normal limits. She could not confirm the resident was asleep, but said he was in bed with his eyes closed. RN A said she knew the resident was in pain earlier in the day, so she asked how he was doing and he said he was doing better. She said when the resident spoke, it sounded as if he had a speech impediment as his speech was slurred. RN A said while she checked his (routine) blood sugar levels, she only checked the resident visually and did not find any visual indicators of concern and felt the resident was coherent. She indicated no vital signs or other assessments of the resident were completed. RN A said she could not recall all she asked of the resident as she did not talk much, but remembered asking the resident if he was going to dinner to eat. She said Resident #1 said he was and rolled over from his left side to his right side. RN A said she still had three more residents' blood sugar levels to check and to give medications with only 15 to 20 minutes until dinner. RN A said approximately 30 minutes later, after she left Resident #1's room, CNA C informed her Resident #1 was on the floor. She said she immediately went to the room where the resident was taking deep, agonal breaths. She said she instructed CNA C to retrieve her blood pressure cuff and stethoscope from her nurse cart which was on the given hall. RN A said when the CNA returned with the requested items, she (RN A) checked Resident #1's vital signs; however, he did not have a pulse, heart rate or blood pressure. RN A said she then sent CNA C to get the resident's chart and noted a DNR in the resident's file. RN A said she immediately called the doctor and explained the chain of events. She said the doctor informed her Resident #1 must have had a massive stroke or [MEDICAL CONDITION]. She said although the resident had some pain earlier in the day, the doctor did not feel the reported pain was related to the events which caused his death. Since the incident, she said the staff was trained on the FAST Stroke Assessment. She did not report she was given any other training. (For example - assessment for a change in condition, recognizing changes in condition and what to do) RN A said the only thing she felt she could have done differently was get some water for the resident as she thought his mouth may have been dry. The one-on-one in-service record revealed RN A was in-serviced on [DATE] on the topic of documentation. The record indicated the following were reviewed with RN A: Complete Assessment and Fast Stroke Assessment Documentation. The record did not include training on recognizing changes in condition. The one-on-one in service was presented by DON and was provided as a verbal review. The record was signed by the presenter, but the signature line for RN A was blank. During a telephone interview on [DATE] at 12:20 p.m., CNA C said Resident #1 required supervision with transfers, but was quite independent. She said Resident #1 was easily understood and she never heard the resident with slurred speech when she spoke to him. She said on the day of the incident, when she first checked Resident #1 at the beginning of her shift, she assisted the resident with putting on some sweats. She did not note any speech slurring, but found the resident to present as tired. CNA C said as dinner time approached, Resident #1 still presented more tired than usual as she found him lying in bed. She said Resident #1 usually ate in the dining hall, but she thought she would bring him a tray. CNA C said she was heading back down the hall and noticed Resident #1 on the floor as she passed his room. CNA C said she immediately got RN A and the nurse immediately went to the resident's room. CNA C said the resident was found to be unresponsive upon RN A's assessment of the resident and explained he was breathing as if he were taking his last breath. She said since the incident, the staff completed in-service training on [MEDICAL CONDITION]. During an interview on [DATE] at 8:56 a.m., the administrator said during the investigation, she was told RN A went into Resident #1's room to check his blood sugar and noted the resident had slurred speech. She denied knowing of any prior instances of Resident #1 with slurred speech. She said RN A attributed the slurred speech to the resident just waking up, so she only completed a visual assessment. The administrator said RN A noted the resident was moving and did not have facial drooping, so she thought the resident to be okay. The administrator said CNA C checked on Resident #1 later and found him on the floor and unresponsive with agonal breaths. She explained the nurse was retrieved and assessed the resident, but could not get any vitals. She said the doctor was called immediately and said the resident had a possible stroke or [MEDICAL CONDITION]. She said she did not feel the nurse failed the resident in this event as she attributed the slurred speech to the resident waking from his sleep. The administrator said since the event, the nursing staff completed training on FAST Stroke Assessment and one-on-one training was completed with RN A. She said although she did not feel the nurse failed the resident in this event; she said the training and one-on-one was completed as the doctor indicated Resident #1 likely sustained a stroke. The administrator said they did not have a written policy on how to recognize and report a change of condition, but only the steps in notifying the physician when a change of condition occurred. During an interview on [DATE] at 10:37 a.m., the DON said the chain of events involving Resident #1as reported by the administrator. She said RN A failed to assess the resident and document that an assessment was completed on the incident report. She said when she questioned RN A about this failure, RN A told her she visually assessed the resident and also documented such on her witness statement. She said, I wasn't in the room so I can't say if I would have done differently. The DON denied feeling RN A did anything wrong. During an interview on [DATE] at 9:28 a.m., LVN F said she knew about the chain of events relating to Resident #1 and said she would have completed vitals and fully assessed the resident once slurred speech was noted. LVN F said she worked with Resident #1 several times and never found him to have slurred speech in the past. She confirmed attending the FAST Training provided since the incident and denied learning anything new from the training. The in-service training log revealed CNAs and nurses attended the stroke training presented on [DATE]. The in-service did not indicate training was provided on recognizing and reporting changes in condition. The administrator was notified on [DATE] at 11:14 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on [DATE] at 2:34 p.m. and included: 1. The facility will continue to strive to assess residents as indicated with any change in condition. 2. The facility is providing education to Licensed Nursing staff regarding Change in Condition using INTERACT II material to include the use of the INTERACT SBAR tool as well as the implementation of a policy on Change of Condition detailing what to observe, report and document. 3. The facility is providing education to C.N.A.s on the use of the INTERACT Stop and Watch Early Warning Tool. The C.N.A.s will use the tool when any change in a resident is identified. The tool will be given to the charge nurse and the DON. The DON will follow-up to ensure the charge nurse has responded appropriately to the possible change. ALL employees (not just direct care) were in-serviced on this assessment tool. 4. The facility has installed document holders throughout the facility to hold the Stop and Watch Early Warning Tool to provide accessibility for staff. The assessment tool is printed in bright orange paper. The DON/Designee will monitor the holders to ensure the tool remains available. 5. The Administrative Nursing staff are conducting chart audits to review for any documented resident changes to ensure proper follow up from the charge nurse. Any concerns identified will be addressed by the Administrative Nurses immediately. 6. The DON/Designee will review Nurses Notes and the 24 hour report daily to monitor for any identified changes and for the proper follow up. The DON/Designee will provide additional education to staff as indicated from the monitoring. 7. The DON/Designee will report findings to the Administrator weekly for results and follow up. 8. The results will be presented to the QA Committee and any identified issues will be addressed. On [DATE], the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: *Observed COO providing INTERACT Stop and Watch Early Warning Tool Training with staff present on the given shift and approximately 9 additional staff who were able to come to the facility specifically for the training at the request of the managerial staff. COO explained a second training would be provided later in the day with those unable to attend the first training. *One LVN, one CNA, one floor tech and one housekeeper were interviewed at random and were able to identify the purpose of the Stop and Watch Early Warning Tool, what they should do with residents who had a change of condition or status, where to locate the Stop and Watch Early Warning Tool and who to give the tool to and within what time-frame. In addition, the LVN was able to identify the steps she would take if a resident's status has changed, which included but was not limited to ensuring vitals were checked and notification to appropriate parties. She explained she would forward any information given to her to the DON for follow-up. *During an interview on [DATE] at 2:40 p. m., the ADM said the QA Committee met monthly and consisted of herself, DON, housekeeping supervisor, dietary supervisor, medical director and they would be adding a CNA to the committee. She explained in addition to their normal areas of business, they would be adding the Stop and Watch Tool sheets to their agenda to ensure they were following up with the residents identified to have changes and monitoring appropriately. *A document holder had been installed on each hall, including the secured hall and several copies of the Stop and Watch Early Warning Tool had been printed on bright orange paper and placed in the holders for staff use. After surveyor intervention, on [DATE], the facility added procedures and policies relating to reporting, communication and documentation for Change in Condition. On [DATE] at 3:16 p.m., the administrator, corporate RN, and COO were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training with additional staff and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated the census was 55.

Based on observation, interview, and record review, the facility failed to ensure services that were provided met professional standards of quality for for 1 of 5 residents reviewed for changes in condition. (Resident #1) Resident #1 experienced a change in condition. RN A recognized the resident with slurred speech, but did not thoroughly assess the resident or notify the physician. Approximately thirty minutes later, Resident #1 was found unresponsive on the floor and died . An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training with additional staff and evaluate the effectiveness of the corrective systems. This failure could place the census of 55 residents at risk for lack of medical treatment in the event of a change in condition. Findings included: The Texas Board of Nursing Website, http://www.bne.state.tx.us, accessed [DATE], indicated the following: The Texas Nursing Practice Act <laws_and_rules_nursing_practice_act.asp> (NPA) defines the legal scope of practice for professional registered nurses (RNs). Professional nursing means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. Professional nursing involves: - the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes; A face sheet (undated) indicated Resident #1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated glucose checks were ordered, The A DNR (Do Not Resuscitate) was in place for Resident #1. The most recent MDS dated [DATE] indicated Resident #1 had clear speech with distinct intelligible words and had clear comprehension. He was without an altered level of consciousness or a decreased level of psychomotor skills. The resident was without falls since admission. A care plan dated [DATE] indicated Resident #1 required supervision when transferring from one position to another and verbal cues or minimal physical assistance was needed for mobility. The provider investigation report dated [DATE] indicated on [DATE] Resident #1 was found lying on the floor unresponsive, taking agonal breaths (an abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, accompanied by strange vocalizations). The nurse (unnamed) was unable to obtain a blood pressure reading or a palpable radial pulse and the resident was without a heart rate. A small hematoma was noted on the right side of the resident's forehead. Resident #1 had a DNR in place. The nurse spoke with the resident about 30 minutes prior and checked his blood sugar. The resident was visually assessed by the nurse and found to have slurred speech, but the nurse attributed it to him just waking up as he did not show any visual signs of any or distress. The investigation summary indicated the physician concluded the resident likely had a stroke and collapsed. An Incident Reporting Form dated [DATE] indicated the following: *4:45 p.m., Resident #1 with slight slurred speech noted, but resident rolled to his right side to prepare to get out of bed, *5:17 p.m., CNA (unidentified) found resident on the floor and called the nurse, *5:20 p.m., RN (unidentified) assessment (no details were indicated), *5:20 p.m., RN found Resident #1 without a heart rate or a blood pressure or breaths, *5:25 p.m., the physician was notified. During a telephone interview on [DATE] at 11:42 a.m., RN A said shortly after she arrived for her shift on [DATE], she started passing medications and she noticed Resident #1 was asleep. She said around 4:45 p.m., she entered Resident #1's room to check his blood sugar levels which was within normal limits. She could not confirm the resident was asleep, but said he was in bed with his eyes closed. RN A said she knew the resident was in pain earlier in the day, so she asked how he was doing and he said he was doing better. She said when the resident spoke, it sounded as if he had a speech impediment as his speech was slurred. RN A said while she checked his (routine) blood sugar levels, she only checked the resident visually and did not find any visual indicators of concern and felt the resident was coherent. She indicated no vital signs or other assessments of the resident were completed. RN A said she could not recall all she asked of the resident as she did not talk much, but remembered asking the resident if he was going to dinner to eat. She said Resident #1 said he was and rolled over from his left side to his right side. RN A said she still had three more residents' blood sugar levels to check and to give medications with only 15 to 20 minutes until dinner. RN A said approximately 30 minutes later, after she left Resident #1's room, CNA C informed her Resident #1 was on the floor. She said she immediately went to the room where the resident was taking deep, agonal breaths. She said she instructed CNA C to retrieve her blood pressure cuff and stethoscope from her nurse cart which was on the given hall. RN A said when the CNA returned with the requested items, she (RN A) checked Resident #1 ' s vital signs; however, he did not have a pulse, heart rate or blood pressure. RN A said she then sent CNA C to get the resident's chart and noted a DNR in the resident's file. RN A said she immediately called the doctor and explained the chain of events. She said the doctor informed her Resident #1 must have had a massive stroke or [MEDICAL CONDITION]. She said although the resident had some pain earlier in the day, the doctor did not feel the reported pain was related to the events which caused his death. Since the incident, she said the staff was trained on the FAST Stroke Assessment. She did not report she was given any other training. (For example - assessment on change in condition, recognizing the changes in condition and what to do) RN A said the only thing she felt she could have done differently was get some water for the resident as she thought his mouth may have been dry. The one-on-one in-service record revealed RN A was in-serviced on [DATE] on the topic of documentation. The record indicated the following were reviewed with RN A: Complete Assessment and Fast Stroke Assessment Documentation. The record did not include training on recognizing changes in condition. The one-on-one in service was presented by DON and was provided as a verbal review. The record was signed by the presenter, but the signature line for RN A was blank. During a telephone interview on [DATE] at 12:20 p.m., CNA C said Resident #1 required supervision with transfers, but was quite independent. She said Resident #1 was easily understood and she never heard the resident with slurred speech when she spoke to him. She said on the day of the incident, when she first checked Resident #1 at the beginning of her shift, she assisted the resident with putting on some sweats. She did not note any speech slurring, but found the resident to present as tired. CNA C said as dinner time approached, Resident #1 still presented more tired than usual as she found him lying in bed. She said Resident #1 usually ate in the dining hall, but she thought she would bring him a tray. CNA C said she was heading back down the hall and noticed Resident #1 on the floor as she passed his room. CNA C said she immediately got RN A and the nurse immediately went to the resident's room. CNA C said the resident was found to be unresponsive upon RN A's assessment of the resident and explained he was breathing as if he were taking his last breath. She said since the incident, the staff completed in-service training on [MEDICAL CONDITION]. During an interview on [DATE] at 8:56 a.m., the administrator said during the investigation, she was told RN A went into Resident #1's room to check his blood sugar and noted the resident had slurred speech. She denied knowing of any prior instances of Resident #1 with slurred speech. She said RN A attributed the slurred speech to the resident just waking up, so she only completed a visual assessment. The administrator said RN A noted the resident was moving and did not have facial drooping, so she thought the resident to be okay. The administrator said CNA C checked on Resident #1 later and found him on the floor and unresponsive with agonal breaths. She explained the nurse was retrieved and assessed the resident, but could not get any vitals. She said the doctor was called immediately and said the resident had a possible stroke or [MEDICAL CONDITION]. She said she did not feel the nurse failed the resident in this event as she attributed the slurred speech to the resident waking from his sleep. The administrator said since the event, the nursing staff completed training on FAST Stroke Assessment and one-on-one training was completed with RN A. She said although she did not feel the nurse failed the resident in this event; she said the training and one-on-one was completed as the doctor indicated Resident #1 likely sustained a stroke. The administrator said they did not have a written policy on how to recognize and report a change of condition, but only the steps in notifying the physician when a change of condition occurred. During an interview on [DATE] at 10:37 a.m., the DON said the chain of events involving Resident #1as reported by the administrator. She said RN A failed to assess the resident and document that an assessment was completed on the incident report. She said when she questioned RN A about this failure, RN A told her she visually assessed the resident and also documented such on her witness statement. She said, I wasn't in the room so I can't say if I would have done differently. The DON denied feeling RN A did anything wrong. During an interview on [DATE] at 9:28 a.m., LVN F said she knew about the chain of events relating to Resident #1 and said she would have completed vitals and fully assessed the resident once slurred speech was noted. LVN F said she worked with Resident #1 several times and never found him to have slurred speech in the past. She confirmed attending the FAST Training provided since the incident and denied learning anything new from the training. The in-service training log revealed CNAs and nurses attended the stroke training presented on [DATE]. The in-service did not indicate training was provided on recognizing and reporting changes in condition. The administrator was notified on [DATE] at 11:14 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on [DATE] at 2:34 p.m. and included: 1. The facility will continue to strive to assess residents as indicated with any change in condition. 2. The facility is providing education to Licensed Nursing staff regarding Change in Condition using INTERACT II material to include the use of the INTERACT SBAR tool as well as the implementation of a policy on Change of Condition detailing what to observe, report and document. 3. The facility is providing education to C.N.A.s on the use of the INTERACT Stop and Watch Early Warning Tool. The C.N.A.s will use the tool when any change in a resident is identified. The tool will be given to the charge nurse and the DON. The DON will follow-up to ensure the charge nurse has responded appropriately to the possible change. ALL employees (not just direct care) were in-serviced on this assessment tool. 4. The facility has installed document holders throughout the facility to hold the Stop and Watch Early Warning Tool to provide accessibility for staff. The assessment tool is printed in bright orange paper. The DON/Designee will monitor the holders to ensure the tool remains available. 5. The Administrative Nursing staff are conducting chart audits to review for any documented resident changes to ensure proper follow up from the charge nurse. Any concerns identified will be addressed by the Administrative Nurses immediately. 6. The DON/Designee will review Nurses Notes and the 24 hour report daily to monitor for any identified changes and for the proper follow up. The DON/Designee will provide additional education to staff as indicated from the monitoring. 7. The DON/Designee will report findings to the Administrator weekly for results and follow up. 8. The results will be presented to the QA Committee and any identified issues will be addressed. On [DATE], the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: *Observed COO providing INTERACT Stop and Watch Early Warning Tool Training with staff present on the given shift and approximately 9 additional staff who were able to come to the facility specifically for the training at the request of the managerial staff. COO explained a second training would be provided later in the day with those unable to attend the first training. *One LVN, one CNA, one floor tech and one housekeeper were interviewed at random and were able to identify the purpose of the Stop and Watch Early Warning Tool, what they should do with residents who had a change of condition or status, where to locate the Stop and Watch Early Warning Tool and who to give the tool to and within what time-frame. In addition, the LVN was able to identify the steps she would take if a resident's status has changed, which included but was not limited to ensuring vitals were checked and notification to appropriate parties. She explained she would forward any information given to her to the DON for follow-up. *During an interview on [DATE] at 2:40 p. m., the ADM said the QA Committee met monthly and consisted of herself, DON, housekeeping supervisor, dietary supervisor, medical director and they would be adding a CNA to the committee. She explained in addition to their normal areas of business, they would be adding the Stop and Watch Tool sheets to their agenda to ensure they were following up with the residents identified to have changes and monitoring appropriately. *A document holder had been installed on each hall, including the secured hall and several copies of the Stop and Watch Early Warning Tool had been printed on bright orange paper and placed in the holders for staff use. After surveyor intervention, on [DATE], the facility added procedures and policies relating to reporting, communication and documentation for Change in Condition. On [DATE] at 3:16 p.m., the administrator, corporate RN, and COO were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training with additional staff and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated the census was 55.

Based on observation, interview, and record review, the facility failed to ensure each resident received assistance devices to prevent accidents for 2 of 10 residents reviewed for accidents. (Resident #1 and #2) Resident #1 required a sit-to-stand mechanical lift. CNA A did not use a lift and attempted to stand and pivot the resident, causing the resident to fall. Resident #1 sustained a fracture to her left elbow and a tear to her left knee cartilage. Resident #2 required a sit-to-stand mechanical lift. The facility did not use the mechanical lift when attempting to transfer the resident resulting in brasions to both knees. This failure could place 10 residents who required sit-to-stand mechanical lift at risk of injury or harm. Findings included: 1. An undated electronic admission record report indicated Resident #1, admitted [DATE] and was [AGE] years old with [DIAGNOSES REDACTED]. A MDS dated [DATE], indicated Resident #1 had moderate cognitive impairment and required extensive assistance with one-person physical assist on transfers prior to the fall. The care plan dated 9/15/15 indicated Resident #1 required a sit-to-stand lift for transfers. During an interview on 10/21/15 at 10:49 a.m., CNA D said prior to Resident #1's fall, the kiosk, which provided transfer information to CNA's for each resident, indicated Resident #1 required a sit-to-stand mechanical lift CNA D said CNAs would know how a resident should be transferred by referring to the kiosk information. During an interview on 10/21/15 at 12:28 p.m., CNA E said she prior to the fall, the kiosk information indicated Resident #1 required the sit-to-stand mechanical lift. CNA E said she referred to the kiosk if she was unsure of a resident's transfer methods. She said even if a resident requested an alternate transfer method, the CNA should use whatever is noted on the kiosk. Progress notes dated 10/08/15 indicated the following: *2:30 p.m. - Resident #1 was being transferred without the lift by a CNA from the recliner to the shower chair when the resident's legs became weak, both the resident and CNA fell to the floor. *6:00 p.m. - Resident #1 returned from the ER with an order for [REDACTED]. During an observation and interview on 10/21/15 at 10:05 a.m., Resident #1 said CNA A was transferring her from the recliner to the shower chair when CNA A dropped her. Resident #1 wore a sling, a leg immobilizer, and had a grey bruise on her eye. Resident #1said the injuries were sustained from the fall. Resident #1 said before CNA A attempted the transfer she told CNA A to get the lift, but CNA A said the lift was not needed. Resident #1 said the lift or gait belt was not used in this instance. She said CNA A elevated the recliner and as the resident attempted to stand she fell . During an interview on 10/21/15 at 11:47 a.m., LVN C said she witnessed CNA A and other CNAs use a gait belt with Resident #1, approximately 3 or 4 times although the resident required the sit-to-stand mechanical lift. LVN C said she did not feel anything was wrong with the CNAs using the gait belt if the resident felt strong enough and it could be done safely. She said she might have been wrong, but that is what she thought. In a written statement by CNA A dated 10/8/15 at 2:30 p.m. indicated she documented that Resident #1 was sitting in the recliner. CNA A brought in a shower chair and gait belt. CNA A elevated the recliner and attempted to transfer Resident #1 to the shower chair. CNA A documented Resident #1 leaned against the CNA, both fell , and Resident #1's head hit the bed frame. CNA A called for assistance. The resident was assessed and sent to the ER. The statement documented CNA A said they only used the lift when moving the resident from one location to another as Resident #1 complained of pain when using the sit-to-stand mechanical lift and preferred being transferred with the gait belt. In a written statement taken for Resident #1 by the administrator dated 10/9/15 indicated Resident #1 reported CNA A came into the room with a shower chair and gait belt. The gait belt was not used and Resident #1 asked the CNA A to get the lift. CNA A proceeded to elevate the resident's recliner and when Resident #1 stood, the resident's foot turned. The resident fell and her head began to bleed. The resident did not recall the CNA falling. An updated care plan dated 10/9/15 indicated Resident #1was at risk for loss of range of motion related to a sustained fracture to her left elbow and ligament disruption of the left knee. The plan indicated Resident #1 would have a sling applied to her left arm and brace to the left knee. Resident #1's care plan was changed from sit-to-stand lift to Hoyer lift for transfers. During an interview on 10/21/15 at 9:52 a.m., the administrator said after the facility investigation, they concluded the proper transfer procedure was not used to transfer Resident #1, as the resident required sit-to-stand mechanical lift. During an interview on 10/21/15 at 10:31 a.m., LVN B said since the incident, Resident #1 has needed a lot of encouragement and was afraid to get up. LVN B said Resident #1 now required a Hoyer lift though previously using sit-to-stand mechanical lift. 2. An undated electronic admission record report indicated Resident #2 admitted [DATE] and was [AGE] years old with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #2 was cognitively intact and required extensive assistance with one-person physical assist on transfers. The care plan dated 8/7/15 indicated Resident #2 required a mechanical sit-to-stand lift for transfers. An incident report dated 8/13/15 indicated Resident #2 was transferred with a gait belt by a CNA from a bedside commode when the resident's knees gave out and she bumped her knees on the commode causing a small abrasion on each knee. During an interview on 10/21/15 at 3:24 p.m., the DON said Resident #2 was dropped as a CNA used a gait belt even though the resident required sit-to-stand mechanical lift. A handwritten list provided by the administrator on 10/21/15 indicated 10 residents required sit-to-stand mechanical lift for transfers.