Every finding on record at Avir at Citizens Trail

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed.The facility did not ensure:1. Food items were labeled and dated.2. The microwave was clean and free of food debris.3. The toaster was clean and free of food debris 4. The juice machine spigot was free from a red gooey substance where the juice was dispersed. 5. The deep fryer was clean and had clear grease.6. [NAME] Q personal cell phone was stored properly.7. A personal drink was stored properly. These failures could place residents at risk for foodborne illness.Findings included: During the initial tour observation and interview with the Dietary Manager on 09/22/25 beginning at 9:31 a.m. until 10:00 a.m. the following was revealed: 1. Two bags of frozen zucchini that were identified by the Dietary Manager unlabeled and undated. 2. Three bags of frozen tater tots that were identified by the Dietary Manager unlabeled. 3. One bag of frozen steak fries that was identified by the Dietary Manager unlabeled and undated. 4. Three frozen dish pie shells undated. 5. Three frozen chocolate creme pies undated. 6. One frozen pecan pie undated. 7. Inside the microwave was a brown buildup. 8. The toaster had brown buildup. 9. The deep fryer had golden food crumbs of various sizes observed on the inside surfaces. 10. The juice machine spigot with a thick gooey red substance. 11. A cell phone was observed next to the toaster charging. [NAME] Q stated the cell phone belonged to her and it should be stored in her bag. [NAME] Q stated it could put residents at risk for food borne illness and contamination. 12. A blue vitamin water was observed in the stand-alone refrigerator without a name and date. During an interview on 09/24/25 at 12:35 p.m., Dietary Aide W stated all staff were responsible for labeling and dating. Dietary Aide W stated the aides were responsible for cleaning the microwave, and juice nozzles after every use. Dietary Aide W stated personal drinks could be stored in the walk-in cooler, but it must be labeled and dated. Dietary Aide W stated personal cell phones should be stored away from the work area. Dietary Aide W stated these failures put residents at risk for food borne illness and cross contamination. During an interview on 09/24/25 at 12:57 p.m., [NAME] V stated all staff were responsible for labeling and dating food products. [NAME] V stated the cooks were responsible for cleaning the fryer and changing the grease once a week. [NAME] V stated the cooks should clean the toaster after every use. [NAME] V stated personal drinks should be stored in the walk-in fridge with date and name. [NAME] V stated personal cell phones should be stored in their personal bag away from the work area. [NAME] V stated these failures could possibly cause food borne illness and cross contamination. During an interview on 09/24/25 at 2:31 p.m., the Dietary Manager stated cleanliness was important in the kitchen so staff were not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager stated all food should be labeled and dated by the date received and the date it was opened. The Dietary Manager stated the aides were responsible for cleaning juice nozzles after every use. The Dietary Manager stated all staff were responsible for cleaning the microwave after every use. The Dietary Manager stated the cooks were responsible for cleaning the dryer weekly and toaster after every use. The Dietary Manager stated cell phones should be stored in the room that was at the back of the kitchen in their personal bag. The Dietary Manager stated personal drinks should be stored in the walk-in refrigerator labeled and dated. The Dietary Manager stated she was responsible for monitoring and overseeing daily walk throughs and when there was an isolated issue that staff were verbally in serviced and if a widespread issue a paper in service was completed. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination and food borne illness. During an interview on 09/24/25 at 4:51 p.m., the Administrator stated food items should be labeled and dated to effectively manage spoilage. The Administrator stated kitchen equipment should be cleaned daily for sanitization purposes. The Administrator stated personal drinks should be kept in the employee break room or in their personal vehicle. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing the kitchen. The Administrator stated phones should be stored on the person or in their personal vehicle. The Administrator stated these failures could potentially put residents at risk for cross contamination, and food borne illness. Record review of the facility's policy titled, Food Receiving and Storage revised 11/2022 reflected. Food shall be received and stored in a manner that complies with safe food handling practices.Refrigerated/Frozen Storage. 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date) . Record review of the facility's policy titled, Sanitation revised 11/2022 reflected. the food service area is maintained in a clean and sanitary manner. 2. All utensils, counter, shelves, and equipment are kept clean, maintained in good repair.

Based on observation, interview and record review the facility failed to effectively 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 3 of 5 (Resident's #2, #31, and Resident #3) residents and 1 of 1 linen cart reviewed for infection control. 1. The facility did not ensure RN A had prepared a barrier to place supplies on when checking Resident #2 and 31's blood sugar. The facility did not ensure RN A cleaned the glucometer between Resident #2 and Resident #31's blood sugar. The facility did not ensure RN A performed hand hygiene while checking Resident #2's blood sugar. 2. The facility did not ensure linen carts were covered. 3. The facility did not ensure A/C wing nurses' carts were cleaned. 4. The facility failed to ensure CNA F did not place a black trash bag on the floor in the hallway on A-Wing to collect trash from the residents' rooms on 09/22/2025. 5. The facility failed to ensure LVN L followed enhanced barrier precautions while disconnecting Resident #3's g-tube (tube inserted directly into the stomach through the abdominal wall to provide nutrition, hydration, and medications) on 09/24/2025. These failures could place residents at risk for cross contamination and the spread of infection.Findings included: 1. During an observation on 09/22/25 at 11:35 a.m., RN A performed hand hygiene, applied a set of gloves and prepared to obtain fingerstick blood sugar for Resident #31. RN A gathered a glucometer (measures the amount of sugar in the bloodstream at a specific time), lancet (device used to prick the skin for a small blood sample), 1 test strip, and alcohol wipe and placed them on the dining table where Resident #31 was sitting at. After using the glucometer, RN A placed the glucometer back on top of the medication cart without disinfecting it. During an observation on 09/22/25 at 11:42 a.m., RN A performed hand hygiene, applied a set of gloves and prepared to obtain fingerstick blood sugar for Resident #2. RN A gathered a glucometer (measures the amount of sugar in the bloodstream at a specific time), lancet (device used to prick the skin for a small blood sample), 1 test strip, and alcohol wipe and placed them on the dining table where Resident #2 was sitting at. RN A pricked Resident #2's index finger with a lancet needle but was unable to get blood. RN A doffed (off) and don (on) new gloves without cleansing her hands or using hand sanitizer. RN A gathered another lancet, test strip and alcohol wipe and placed it on the dining table again. RN A pricked Resident #2's middle finger with a lancet needle then wiped off the blood from the finger using a small alcohol wipe. RN A squeezed the pricked finger to collect blood for glucose testing. During an interview on 09/22/25 at 11:50 a.m., RN A stated she should have performed hand hygiene between gloves changes and clean the glucometer between each resident. RN A stated she believed there was not a problem with placing the glucometer, lancet, alcohol wipe and test strip on the resident's dining table without having a barrier. RN A stated this failure was an infection control issue. 2. During an observation on 09/22/25 at 11:29 a.m., the linen cart on wing A was uncovered which included sheets, pillowcases, gowns, under pads, blankets, briefs and wash cloths. During an interview on 09/22/25 at 11:31 a.m., CNA G stated clean linen carts should always be covered when not being used. CNA G stated the cart was not covered this morning when she came in. CNA G stated all staff were responsible for ensuring the cart was covered when not in use. CNA G stated this was important to prevent germs contaminating the linens. During an interview on 09/22/25 at 11:32 a.m., RN A stated clean linen carts should always be covered when not being used. RN A stated all nursing staff were responsible for ensuring the front flap of the linen cart was down when not in use. RN A stated this failure could allow germs to enter and contaminate the linens. 3. During an observation and interview on 09/23/25 at 3:45 p.m., the state surveyor observed wing C medication cart with LVN C. There were multiple brown gooey substances noted in the drawer where the liquid medications were kept. LVN C stated nurses and MAs were responsible for keeping the cart cleaned. LVN C stated the cart should be cleaned whenever they noticed it was dirty. LVN C stated it was important to ensure the cart was cleaned to prevent infection control issues. During an observation and interview on 09/23/25 at 4:03 p.m., the state surveyor observed wing A medication cart with RN A. There were multiple brown gooey substances noted in the drawer where the liquid medications were kept. RN A stated nurses and MAs were responsible for cleaning the cart every shift. RN A stated this failure was an infection control issue. During an interview on 09/24/25 at 3:21 p.m., the Regional Nurse Consultant stated she expected the glucometer to be cleaned before and after each resident use. The Regional Nurse Consultant stated she expected hand hygiene to be performed with every glove change. The Regional Nurse Consultant stated she expected the glucometer, test strip, lancet and alcohol wipe to be on a clean surface that can be achieved with a barrier. The Regional Nurse Consultant stated she expected medication carts to be kept clean and organized daily by the charge nurse and medication aide. The Regional Nurse stated the DON was responsible for ensuring proper cleaning occurs by random observations and education when needed. The Regional Nurse Consultant stated it was important to ensure infection control practices were done to prevent the spread of infection. During an interview on 09/24/25 at 4:16 p.m., the DON stated her expectation was for RN A to wipe off a space and place a barrier (wax paper) and then set the supplies to check the blood sugar on it. The DON stated she expected the glucometer to be cleaned between residents and after each use. The DON stated she expected all staff to wash or sanitize their hands between glove changes. The DON stated RN A's insulin administration check-off should have been completed April 2025. RN A stated she had not been checked off this year. When asked why she had not been checked off for her annual, stated I don't have an answer. The DON stated should be always covered when not in use. The DON stated her expectation was for the nurses/med aides to keep the medication cart by cleaning as needed. The DON stated she was responsible for monitoring by random spot checks and check offs. The DON stated that there had been a change in ownership and not having an ADON in place to assist her had placed a barrier to monitoring these tasks. The DON stated it was important to ensure infection control practice was followed to prevent the spread of infection. The DON stated there was not a policy and procedure regarding linen carts. During an interview on 09/24/25 at 4:51 p.m., the Administrator stated medication carts need to remain clean so that they were provided with sanitary services. The Administrator stated linen carts should be covered when not being accessed. The Administrator stated the glucometer should be cleaned between residents. The Administrator stated there should be a barrier between the tablecloth or place the items on a sanitized surface such as the medication cart. The Administrator stated the DON was responsible for monitoring and overseeing. The Administrator stated these failures were an infection control issue. 4. During an observation on 09/22/2025 starting at 12:32 AM, there was a black trash bag on the floor in the hallway on A-Wing. CNA F was observed coming in and out of the residents' rooms on A-Wing with clear trash bags which contained trash from the residents' rooms including dirty briefs and placing the clear trash bags in the black trash bag on the floor in the hallway. During an interview on 09/22/2025 at 12:38 AM, CNA F said she did not have a barrel to put the trash from the residents' rooms in. CNA F said she should not place trash bags on the floor because the trash was dirty, and the residents could get into it. CNA F said it could also cause spreading of the dirty. CNA F said she should be disposing of the trash in the biohazard room when it was taken out of the residents' rooms. During an interview on 09/22/2025 at 12:45 AM, RN E said the CNAs should not have trash bags on the floor in the hallway. RN E said the CNAs were supposed to take the trash from the residents' rooms to the biohazard room. RN E said she had not noticed CNA F had the trash bag in the hallway. RN E said the bags with trash should not be on the floor for infection control. 5. Record review of Resident #3's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and gastrostomy status (creation of an external opening into the stomach to provide nutrition). Record review of Resident #3's Comprehensive MDS assessment dated [DATE] indicated she was rarely/never understood and sometimes understood others. The MDS assessment indicated Resident #3 had a short-term and long-term memory problem. The MDS assessment indicated Resident #3 was dependent on staff for all ADLs, and she had a feeding tube. The MDS assessment indicated Resident #3 had one or more unhealed pressure ulcers/injuries and received pressure ulcer/injury care. Record review of Resident #3's Order Summary Report dated 09/23/2025 indicated she had an order for enhanced barrier precautions with high contact resident care due to gastrostomy tube (tube inserted directly into the stomach through the abdominal wall to provide nutrition, hydration, and medications) with a start date of 09/08/2025. Record review of Resident #3's care plan reviewed 07/24/2025, did not address the use of enhanced barrier precautions. During an observation on 09/24/2025 at 9:06 AM, LVN L put on gloves, uncovered Resident #3, and disconnected Resident #3's feeding from her g-tube. LVN L failed to put on a gown while providing direct care to Resident #3. During an interview on 09/24/2025 at 9:57 AM, LVN L said she was not aware of the requirement for enhanced barrier precautions when accessing a feeding tube. LVN L said she did not remember receiving any training regarding enhanced barrier precautions. LVN L said standard and isolation precautions should be followed when providing care to residents for infection control. During an interview on 09/24/2025 at 5:18 PM, the DON said the CNAs should not place trash bags on the floor. She said the CNAs should have a barrel with a bag inside of the barrel so they could place the trash inside the barrel and then place the barrel in the soiled utility room until the end of their shift. The DON said the charge nurse was responsible for ensuring the CNAs were disposing of the trash properly. The DON said placing dirty things, like bags with trash, on the floor was an infection control issue. The DON said LVN L should have followed enhanced barrier precautions when providing care to Resident #3. The DON said a gown and gloves were required when disconnecting a feeding tube. The DON said she was responsible for ensuring the staff were following enhanced barrier precautions, and she conducted random spot checks to ensure they were being followed. The DON said she had not noticed any issues with the staff not wearing the appropriate PPE. The DON said she had conducted an in-service with the staff regarding enhanced barrier precautions, and she would provide it. The DON said not wearing the appropriate PPE for enhanced barrier precautions placed the residents at risk for transmission of different infections. During an interview on 09/24/2025 at 5:58 PM, the Administrator said he expected for the trash to be disposed of properly. The Administrator said bags with trash should not be on the floor. The Administrator said the charge nurse was responsible for ensuring the CNAs handled trash properly. The Administrator said putting bags with trash on the flood was unsanitary and it could result in the spread of infection. The Administrator said he expected for the staff to wear the appropriate attire, such as gown and gloves, when performing procedures. The Administrator said the DON was responsible for ensure the staff were doing this. The Administrator said not wearing the appropriate attire could cause infections to be spread. Record review of an Inservice Form dated 03/04/2025 presented by the DON for all staff with subject Enhanced Barrier Precautions indicated LVN L's signature. Record review of the facility's Enhanced Barrier Precautions policy revised February 2025, indicated, Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include. device care or use (feeding tube). During an interview with the Regional Nurse Consultant on 09/24/2025 at 7:09 PM, the policy regarding proper disposal of trash was requested and not received upon exit of the facility.

Based on interviews and record reviews, the facility failed to develop and implement an infection prevention and control program to include antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for antibiotic stewardship. The facility failed to utilize an antibiotic tracking log for the months of August 2025 through September 2025. This failure could place residents at risk for inappropriate antibiotic useFindings included: Record review of the facility's antibiotic tracking log, the last month the tracking and trending on antibiotic usage was completed in July 2025. The tracking logs for August 2025 and September 2025 were not completed. During an interview on 09/23/25 at 9:15 a.m., the DON stated infection control for August 2025 and September 2025 were not completed yet. The DON stated she was responsible for completing August 2025 and September 2025 infection control log but due to transition of changing companies/EHR system, and the ADON leaving two months ago the log had not been completed within a timely manner. The DON stated usually the ADON was responsible for ensuring the log was completed and she monitored it by reviewing the logs weekly via email. The DON stated it was important to keep up with the antibiotic stewardship program and tracking/trending of infections to identify and intervene for any negative patterns. During an interview on 09/24/25 at 3:21 p.m., the Regional Nurse Consultant stated that the ICP, which was the DON now, was responsible for completing the infection control log with the applicable tracking and trending. The Regional Nurse Consultant stated the infection control log should be completed monthly. The Regional Nurse Consultant stated typically it was ADON's duty however, the facility was between ADONs so the DON and Regional Nurse Consultant should be ensuring it was completed. The Regional Nurse Consultant stated she did require the log be sent to her monthly for review but with the changes of the EHR system transition, no ADON in place, and transcribing physician orders to ensure accuracy took precedence. The Regional Nurse Consultant stated it was important for tracking and trending to be completed timely so the facility can identify and intervene as needed for any negative trends. During an interview won 09/24/25 at 4:51 p.m., the Administrator stated he expected tracking and trending logs to be completed timely to ensure negative trends were addressed. The Administrator stated that due to the transition of changing companies, EHR system and a vacant ADON position made this a challenge. The Administrator stated the ADON was responsible for completing the log and the DON was responsible for monitoring and overseeing. The Administrator stated it was important for tracking and trending to be completed timely to manage and correct any negative trends. Record review of the facility's policy Antibiotic Stewardship, revised on 12/2016, reflected. Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. 1. The purpose of our antibiotic's stewardship program is to monitor the use of antibiotics in our residents.

Based on observations, and interviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 16 of 16 confidential residents reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 09/23/25. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.Findings included: During an interview on 09/22/2025 at 12:21 PM, Resident #58's family member said the food was served cold. During an interview on 09/23/2025 at 9:29 AM, Resident #2 said the food tasted bad.During an observation and interview on 09/23/25 at 12:30 p.m., lunch tray was sampled by the Dietary Manager and five surveyors. The sample tray consisted of a smothered pork chop, green beans, black eyed peas, peach pie and a roll. The Dietary Manager stated the smothered pork chop was lukewarm, green beans were lukewarm/bland, black-eyed peas were lukewarm/bland, and the pie was tart. The surveyors agreed. During an interview on 09/24/25 at 12:05 p.m., CNA U stated no residents complained to her about food being cold or bland but if so, she would offer the resident an alternative. CNA U stated all food complaints would be reported to the nurse and dietary staff. CNA U stated residents not eating their food could potentially cause weight loss. During an interview on 09/24/25 at 12:07 p.m., LVN O stated she had not had any residents complained about food being cold or bland. LVN O stated she would offer an alternative and report to the Dietary Manager. LVN O stated residents not eating their food could potentially cause weight loss and skin breakdown.During an interview on 09/24/25 at 2:31 p.m., the Dietary Manager stated she had not had any complaints regarding food being cold or bland. The Dietary Manager stated she told the residents before if there were any issues to come directly to her and she would try her best to fix it. The Dietary Manager stated she monitored meal service including food quality daily by interviewing residents and tray sampling. The Dietary Manager included there were no issues found with food quality during her tray sampling. The Dietary Manager stated it was important to ensure food was palatable and had an appetizing temperature to prevent weight loss. During an interview on 09/24/25 at 4:51 p.m., the Administrator stated he expected food to be the appropriate temperature and seasoned for palatability. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing. The Administrator stated he has not experienced a test tray that was not palatable. The Administrator stated he has not had any complaints when serving residents in the dining room regarding temperature and palatability. The Administrator stated that typically he assisted in delivering trays but not collecting them to observe any concerns. The Administrator stated it was important to ensure food was palatable and had an appetizing temperature for managing weight and quality of life. Record review of the facility's policy titled, Food and Nutrition Services revised 10/2017 reflected. each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional. needs.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 8 residents (Resident #30, Resident #2, and Resident #31) reviewed for resident rights. 1.The facility failed to ensure Resident #30 was treated with respect and dignity when Resident #30 asked an unknown staff member to take him to the restroom before he ate his lunch and the staff member failed to comply with Resident #30's request during lunch on 09/22/25.2. The facility did not ensure RN A provided privacy when administering Resident #2 and #31's insulin. These failures could place residents at risk for diminished quality of life, loss of dignity, and self-worth. Findings included: 1.Record review of Resident #30's face sheet dated 09/15/25 indicated he was a [AGE] year-old-male who admitted to the facility on [DATE] with the diagnoses chronic systolic congestive heart failure (disease in which the heart muscle cannot pump blood effectively), sleep apnea (sleep disorder in which breathing stops and starts repeatedly), atrial fibrillation (an irregular often rapid heart rate that causes poor blood flow), and high blood pressure. Record review of Resident #30's admission MDS assessment dated [DATE] indicated he was understood by others and made himself understood. The MDS also indicated he had a BIMS score of 7 which meant he had severe cognitive impairment. The MDS also indicated he required moderate assistance with transfers and bed mobility, maximal assistance with toileting and bathing, and setup for eating. Record review of Resident #30's care plan dated 09/23/25 did not indicate his ADL care. During an observation and interview on 09/22/25 at 12:20 PM Resident #30 was laying in his bed with his lunch tray untouched on top of his bedside table. He said an unknown facility staff member brought him his tray and told him they would be back to take him to the restroom. He said he tried to wait but had already had an accident and did not want to eat while he was covered in urine. he said he felt unclean. During an interview on 09/22/25 at 12:35 PM CNA B said that she was unaware of Resident #30 needed to go to the restroom because the department heads passed the trays on the hall daily. She said no one notified her that he needed to use the restroom. She said if she had known she would have taken him because it was his right. CNA B grabbed her cart and immediately went to his room and changed him and set him up for his lunch. During an interview on 09/24/25 at 6:25 PM the DON said the department heads passed trays on the hall, but she expected the unknown staff to notify nursing when Resident #30 expressed the need to use the restroom to ensure he made it to the restroom and prevented him from urinating on himself. The DON said the failure placed a risk for Resident #30 having skin breakdown as well as Resident #30 being upset that he is wet and not be able to eat his food in a timely manner. During an interview on 09/24/25 at 7:08 PM The administrator said he expected the staff to ensure to meet the resident care needs timely regardless of meal service. He said he expected the unknown staff to notify the correct staff member to ensure Resident #30 was taken to the restroom. He said the failure placed a risk for Resident #30's health, safety, and dignity being compromised. 2. Resident #31 Record review of Resident #31's face sheet, dated 09/23/25, reflected Resident #31 was an [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included diabetes mellitus ((lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) due to underlying condition with diabetic chronic kidney disease (a complication of diabetes that damages the kidneys). Record review of Resident #31's quarterly MDS assessment, dated 09/01/25, reflected Resident #31 made himself understood, and understood others. Resident #31's BIMS score was 9, which reflected her cognition was moderately impaired. Record review of Resident #31's comprehensive care plan dated 06/03/25 reflected Resident #31 had a diagnosis of diabetes mellitus. The care plan interventions included administer medications/insulin as ordered and monitor/document for side effects and effectiveness. Record review of the physician order summary report, dated 09/23/25, reflected Resident #31 had an order for Novolog Injection Solution 100 unit/ml, inject as per sliding scale, 4 units. subcutaneous before meals and at bedtime related to diabetes mellitus with a start date 09/11/25. During an observation on 09/22/25 at 11:35 a.m., revealed Resident #31 was sitting at the dining table when RN A walked over and told him she was about to give him insulin. RN A raised Resident #31 shirt up and administered 4 units to Resident #31's RLQ. There were 13 residents sitting in the dining room ready for lunch to be served. Resident #2 Record review of Resident #2's face sheet, dated 09/23/25, reflected Resident #2 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Type 2 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) with diabetic nephropathy (complication of diabetes mellitus that affects the kidneys) and legal blindness. Record review of Resident #2 quarterly MDS assessment, dated 07/14/25, reflected Resident #2 made herself understood, and understood others. Resident #2's BIMS score was 12, which reflected her cognition was moderately impaired. Record review of Resident #2's comprehensive care plan, dated 07/16/25, reflected Resident #2 had Diabetes Mellitus. The care plan interventions included diabetes medication as ordered by the doctor, monitor/document for side effects/effectiveness and fasting serum blood sugar as ordered by the doctor. Record review of the physician order summary report, dated 09/23/25, reflected Resident #2 had an order for Humalog KwikPen, inject as per sliding scale, 14 units. subcutaneous before meals and at bedtime related to diabetes mellitus with a start date 09/23/25. During an observation on 09/22/25 at 11:42 a.m., revealed Resident #2 was sitting at the dining table when RN A walked over and told her she was about to give her insulin. RN A raised Resident #2 shirt up and administered 14 units to Resident #2's RLQ. There were 12 residents sitting in the dining room ready for lunch to be served. During an interview on 09/24/25 at 2:30 p.m., Resident #2 stated she was not aware RN A raised her shirt up and administered insulin in the dining room. Resident #2 stated she would have said something to her. During an interview on 09/22/25 at 11:32 a.m., RN A stated it was standard practice to administer insulin in the abdomen in an open area. RN A stated she always did that and was never told not to. During an interview on 09/24/25 at 3:21 p.m., the Nurse Consultant stated her expectation was insulin to be administered in a private area. The Nurse Consultant stated the DON was responsible for ensuring privacy was given through random observations and education as needed. The Nurse Consultant stated it was important to provide privacy to protect the residents' dignity. During an interview on 09/24/25 at 4:16 p.m., the DON stated insulin administration should be given in the resident room or in a private area. The DON stated she monitored by random spot checks and check offs. The DON stated she has never noticed RN A administering insulin in the dining room. The DON stated it was important to provide privacy to protect the residents' dignity and privacy. During an interview on 09/24/25 at 4:51 p.m., the Administrator stated insulin administration should be given in a private location out of view of other residents or non-clinical staff. The Administrator stated the DON was responsible for monitoring and overseeing. The Administrator stated it was important to provide privacy when administering insulin to protect the residents' dignity. Record review of the facility's Dignity policy, revised 02/2021, reflected . each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 4 of 20 residents (Resident #3, Resident #5, Resident #17, and Resident #30) reviewed for care plans. 1. The facility failed to develop a care plan to address Resident #3's wounds and the use of enhanced barrier precautions. 2. The facility failed to develop a care plan to address Resident #17's g-tube. 3. The facility failed to ensure a care plan was developed to address Resident #30's smoking. 4. The facility failed to ensure a comprehensive care plan was developed for Resident #5. These failures could place residents at risk of not having their individual needs met and a decreased quality of life.Findings included: 1. Record review of Resident #3's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and gastrostomy status (creation of an external opening into the stomach to provide nutrition). Record review of Resident #3's Comprehensive MDS assessment dated [DATE] indicated she was rarely/never understood and sometimes understood others. The MDS assessment indicated Resident #3 had a short-term and long-term memory problem. The MDS assessment indicated Resident #3 was dependent on staff for all ADLs, and she had a feeding tube. The MDS assessment indicated Resident #3 had one or more unhealed pressure ulcers/injuries and received pressure ulcer/injury care. Record review of Resident #3's care plan reviewed 07/24/2025, did not address Resident #3's wounds, wound care, and enhanced barrier precautions. Record review of Resident #3's Order Summary Report dated 09/23/2025, indicated the following orders enhanced barrier precautions with high contact resident care due to gastrostomy tube (tube inserted directly into the stomach through the abdominal wall to provide nutrition, hydration, and medications) with a start date of 09/08/2025. Cleanse abrasion on right buttock with normal saline and apply anasept gel (gel applied to wounds to help prevent/treat infections) and collagen sheet or powder (powder or sheet applied to wounds to help tissue regeneration). Cover with border gauze island one time a day with a start date of 09/11/2025. Cleanse Stage I pressure wound on right buttock with normal saline apply triad paste (a paste that sticks to wet skin, absorbs fluid, moisture, protects, and promotes wound healing) and cover with border gauze island one time a day with a start date of 09/11/2025. Unstageable deep tissue injury to coccyx clean with normal saline or wound cleanser apply anasept and collagen sheet or powder to wound. Cover with border gauze island one time a day may change if dressing becomes soiled or saturated with a start date of 09/11/2025. During an observation on 09/24/2025 starting at 9:06 AM, LVN L did not follow enhanced barrier precautions when disconnecting Resident #3's g-tube from her feeding. The Treatment Nurse entered the room, put on a gown and gloves to follow enhanced barrier precautions, and prompted LVN L to put on a gown. The Treatment Nurse provided wound care to Resident #3's right buttock and coccyx as ordered with the assistance of LVN L. 2. Record review of a face sheet dated 09/15/2025 indicated Resident #17 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and gastrostomy (creation of an external opening into the stomach to provide nutrition). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #17 was usually understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 5, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #17 required partial/moderate assistance with toileting and personal hygiene, showering/bathing self and set-up or cleanup assistance for eating. The MDS assessment did not indicate Resident #17 had a feeding tube. Record review of Resident #17's care plan reviewed 07/31/2025 did not address Resident #17's g-tube. Record review of Resident #17's Order Summary Report dated 09/23/2025 indicated: As needed complete tube site care every shift and as needed start date 09/11/2025. Verify enteral tube placement by checking for residual gastric volume (check the stomach contents) prior to medication administration and feedings every shift with a start date of 09/11/2025. Isosource 1.5 (liquid nutrition tube-feeding formula) at 50 ml/hr via g-tube with a start date of 09/11/2025 May use Diabetisource 1.2 (tube feeding formula designed for individuals with diabetes) at 50 ml/hr until Isosource 1.5 arrives with an order date of 09/22/2025. During an observation on 09/24/2025 at 10:32 AM, Resident #17 had Diabetisource 1.2, feeding, connected to her g-tube at 50 ml/hr. During an interview on 09/24/2025 at 6:02 PM, the MDS Coordinator said she was responsible for completing the care plans. The MDS Coordinator said Resident #3's plan of care for her wounds and the use of enhanced barrier precautions and Resident #17's g-tube were not included in the residents' care plans because she had not had time to put them in. The MDS Coordinator said due to the change in companies for the facility she did not have access to put in the residents' care plans. The MDS Coordinator said it was important to put these things in the care plan because they needed to follow the plan of care. During an interview on 09/24/2025 at 6:28 PM, the Administrator said care plans should be completed timely, and they should include care of the g-tube, any wounds, and the use of enhanced barrier precautions. The Administrator said the MDS Coordinator was responsible for completing the care plans. The Administrator said it was important for the care plans to be completed to ensure the residents received the best quality of care. 3. Record review of Resident #30's face sheet dated 09/15/25 indicated he was a [AGE] year-old-male who admitted to the facility on [DATE] with the diagnoses chronic systolic congestive heart failure (disease in which the heart muscle cannot pump blood effectively), sleep apnea (sleep disorder in which breathing stops and starts repeatedly), atrial fibrillation (an irregular often rapid heart rate that causes poor blood flow), and high blood pressure. Record review of Resident #30's admission MDS assessment dated [DATE] indicated he was understood by others and made himself understood. The MDS also indicated he had a BIMS score of 7 which meant he had severe cognitive impairment. The MDS also indicated he required moderate assistance with transfers and bed mobility, maximal assistance with toileting and bathing, and setup for eating. Record review of Resident #30's care plan dated 09/23/25 did not indicate him being a smoker. During an interview on 09/24/25 at 5:27 PM the MDS Nurse said Resident #30 should have had a care plan for smoking, but she guessed she forgot to add the care plan for smoking. The MDS Nurse said the failure placed a risk for the nursing staff not being able to care for the Resident #30 correctly while smoking. During an interview on 09/24/25 at 6:11 PM the DON said Resident #30 should have had a care plan when he admitted and the MDS nurse was responsible for completing those care plans. The DON said the failure placed a risk for the staff not knowing what measures were needed for care for Resident #30 while smoking. 4. Record review of Resident #5's face sheet, dated 06/23/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #5 had diagnoses which included vascular dementia (disease in which there is a decline in memory and thinking related to blocked blood flow to the brain), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), high blood pressure, and aphasia (language disorder that affects the ability to communicate). Record review of Resident #5's admission MDS assessment, dated 08/21/25, indicated she sometimes made herself understood and she sometimes understood others. Resident #5 had a BIMS score of 1, which indicated she was severely cognitively impaired. Resident #5 required moderate assistance with toileting, baths, and dressing. Resident #5 was independent with transfers and bed mobility and required supervision with eating. Record review of Resident #5's EMR, on 09/23/25, indicated she did not have a care plan implemented. Resident #5 had a care plan for a previous stay, dated 07/10/23. During an interview on 09/24/25 at 4:50 PM, LVN C said she was not sure who was responsible for completing care plans but Resident #5 should have had a care plan for the charge nurses to know how to provide care and interventions. During an interview on 09/24/25 at 5:22 PM, the MDS Nurse said she was responsible for all residents' comprehensive care plans and the DON and ADON were responsible for the acute care plans. The MDS Nurse said Resident #5 should have a care plan, but she did not have access to the systems the facility used, and she was just now completing the care plans. She said she looked at the admission assessment and all assessments. She said without the care plan the staff could have been missing the risks she added and diagnoses for Resident #5. During an interview on 09/24/25 at 6:11 AM, the DON said she expected the care plan for Resident #5 to be in place. She said the care plan should have been completed within 14 days after the admission MDS was completed. The DON said the MDS Nurse was responsible for Resident #5's care plan. The DON said the failure placed a risk for staff not knowing the care provided to Resident #5. During an interview on 09/24/25 at 6:59 PM, the Administrator said his expectation was for all residents to have care plans to meet their needs. He said the failure placed a risk for patient care being compromised. Record review of the facility's policy titled, Care Planning- Interdisciplinary Team, revised 2024, indicated The interdisciplinary team is responsible for the development of resident care plans Resident care plans are developed according to the timeframes and criteria established by 483.21.Comprehensive, person-centered care plans are based on resident assessments.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 4 of 6 residents (Resident #2, Resident #22, Resident #29, and Resident #51) reviewed for accidents and supervision. 1. The facility failed to ensure 2-person assistance was used when Resident #2 was transferred from her bed to the wheelchair by CNA K with the use of a mechanical lift on 09/24/2025. 2. The facility failed to ensure Resident #22 did not have fingernail clippers on her dresser and hand sanitizer and hair spray on her bedside table. 3. The facility failed to ensure Resident #29 did not have a can of hairspray on her dresser, nail polish remover in her caddy, another can of hairspray on her table by the window, and nail polish remover on her dresser by the television in a caddy. 4. The facility failed to ensure Resident #53 did not have a blue razor in the trash can in her room. 5. The facility failed to ensure RN A disposed of the lancet properly. 6. The facility failed to ensure the razor in wing B medication cart had a cover on it. These failures could place residents at an increased risk for falls and injuries. Findings included: 1. Record review of Resident #2's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder depressive type (mood disorder with symptoms such as feelings of sadness, worthlessness, and depression), legal blindness, muscle weakness, and muscle wasting and atrophy (thinning or wasting of muscle tissue). Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated she was understood and understood others. The MDS assessment indicated Resident #2's vision was severely impaired, and she had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 required substantial/maximal assistance with toileting, showering/bathing, lower body dressing and partial/moderate assistance with personal hygiene and upper body dressing. The MDS assessment indicated Resident #2 was dependent on staff for transfers. Record review of Resident #2's care plan reviewed 07/16/2025 indicated, she had a potential for injury related to previous falls, unsteady gait, visual deficits, attempted to stand unassisted and lost balance easily. Interventions included 2 staff to assist resident during transfers. Resident #2's care plan indicated she had an ADL self-care performance deficit and limited physical mobility. Resident #2's care plan did not address the use of the mechanical lift. Record review of Resident #2's Order Summary Report dated 09/23/2025 did not indicate the use of the mechanical lift. During an observation and interview on 09/24/2025 at 9:01 AM, CNA K was observed coming out of Resident #2's room with the mechanical lift. There were no other staff members observed in Resident #2's room. Resident #2 said CNA K transferred her from her bed to the wheelchair, and she was not comfortable in her wheelchair. CNA K said she transferred Resident #2 with the use of the mechanical lift by herself. During an interview on 09/24/2025 at 9:49 AM, CNA K said the use of the mechanical lift probably required 2 staff, but she was not sure because at some facilities only one staff was required. CNA K said she thought they may have trained her on the use of the mechanical, but it had been a while. CNA K said she transferred Resident #2 on her own because the nurse had to step out of the room, and she did not wait for her to come back to help her. CNA K said it was important for the adequate number of staff to be used for transfers for safety. During an interview on 09/24/2025 at 10:28 AM, LVN L said Resident #2 should be transferred with 2 staff with the mechanical lift. LVN L said the CNAs should not use one staff to transfer residents with the mechanical that CNA K should have waited for her to come assist her or for other staff to help her. LVN L said one person should not perform the transfer for the residents' safety. During an interview on 09/24/2025 at 5:23 PM, the DON said transferring with the mechanical lift required 2 staff. The DON said CNA K should have asked another staff member for assistance with Residents #2's transfer. The DON said CNA K could have been injured or the resident could have been injured. During an interview on 09/24/2025 at 6:05 PM, the Administrator said he expected for 2 staff to use the mechanical lift to transfer the residents. The Administrator said the DON was responsible for ensuring the staff were transferring the residents properly. The Administrator said not using 2 staff when required could result in the resident being harmed. 2. Record review of Resident #22's face sheet, dated 09/24/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included Alzheimer's disease (progressive disease that destroys memory and important mental functions), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), and high blood pressure. Record review of Resident #22's quarterly MDS assessment, dated 07/09/25, indicated she was able to make herself understood and understood others. Resident #22 had a BIMS score of 3, which indicated she had severe cognitive impairment. Resident #22 required maximal assistance with bathing and dressing, supervision with toileting, bed mobility, and transfers, and setup with eating. Record review of Resident #22's care plan did not address items she could not keep in her room. During an observation on 09/22/2025 at 11:07 AM revealed Resident #22 had fingernail clippers on her dresser and hand sanitizer and hair spray on her bedside table. 3.Record review of Resident #29's face sheet, dated 09/15/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included dementia (cognitive function severe enough to interfere with daily life), anxiety (intense, excessive, and persistent worry and fear about everyday situations), high blood pressure, and depression (lowering of a person's mood). Record review of Resident #29's admission MDS assessment, dated 06/14/25, indicated she was able to make herself understood and she was able to understand others. Resident #29 had a BIMS score of 6, which indicated she had severe cognitive impairment. Resident #29 required moderate assistance with toileting, bathing, and transfers, and she required for bed mobility, and setup for eating. Record review of Resident #29's care plan, dated 06/23/25, indicated she had impaired visual functioning, ADL self -care deficits, and cognitive impairment with interventions in place to reorient her as needed and provide simple instructions with care. During an observation on 09/22/2025 at 3:43 PM revealed Resident #29 was out in the hallway in her wheelchair but had a can of hairspray on her dresser, nail polish remover in her caddy, another can of hairspray on her table by the window, and nail polish remover on her dresser by the television in a caddy. During an observation on 09/23/2025 at 10:35 AM revealed Resident #29 was out of the room and the door was opened, there continued to be a can of hairspray on her dresser, nail polish remover in her caddy, another can of hairspray on her table by the window, and nail polish remover on her dresser by the television in a caddy. During an interview on 09/24/25 at 4:30 PM CNA E she said the hairspray, fingernail polish remover, or the nail clippers were not supposed to be left out. She said she had completed a round and removed the items when she began her shift. CNA E said the failure placed a risk for injury for all residents in the unit. During an interview on 09/24/25 at 4:39 PM, LVN C said hairspray, fingernail polish remover, and nail clippers probably were not supposed to be out. She said the failure placed a risk for any of the residents harming themselves. LVN C said all staff were responsible for ensuring the items were not in the residents' rooms. LVN C said the items were always out so she figured it was ok. During an interview on 09/24/25 at 6:01 PM, the DON said hairspray, nail clippers, and nail polish remover were not supposed to be out in the locked unit. The DON said the nursing staff were all responsible for ensuring those items were not out in the unit. She said the failure placed a risk for residents ingesting, placing in their eyes, and using the items inappropriately. During an interview on 09/24/25 at 6:53 PM, the Administrator said the hairspray, nail clippers, and nail polish remover should be kept in the medication room or the carts and used by a nurse, CNA, or med aide. The Administrator said nurse aides and the charge nurse were responsible for ensuring items were not in the room. He said the failure placed a risk for residents ingesting or using inappropriately. 4. Record review of Resident #51's face sheet, dated 09/15/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #51 had diagnoses which included senile degeneration of the brain (progressive decline in cognition), impulse disorder (mental health disorder that makes it difficult to resist urges and behaviors), depressive disorder (group of conditions that lower a person's mood), and chronic pain. Record review of Resident #51's quarterly MDS assessment, dated 02/25/25, indicated she sometimes made herself understood and usually understood others. Resident #51 had a BIMS score of 0, which indicated she had severe cognitive impairment. Resident #51 was dependent on staff for all her ADLs. Record review of Resident #51's care plan, dated 07/09/25, indicated she had cognitive loss related to senile degeneration of the brain with interventions to provide the residents with a homelike environment. During an observation on 09/22/2025 at 10:55 AM revealed Resident #51 was lying in bed, but she had a blue razor in the trash can in her room. During an interview on 09/24/25 at 5:15 PM, LVN R said her expectation was for the aides to place used razors in the sharp's container. LVN R said the failure placed a risk of someone getting cut. During an interview on 09/24/25 at 6:05 PM, the DON said the razors should not be in the room. They should be locked in an area to where no other residents would have access to them. The risk was injury. The nurse's staff should ensure the items were not in the rooms. The razors should be placed in sharps containers after use. During an interview on 09/24/25 at 6:56 PM, the Administrator said he expected personal care items to be stored out of resident reach except when in use. The nurse and CNAs were responsible for ensuring the items should not be in the rooms. The risk was patient health and safety risk. 5. During an observation on 09/22/25 at 11:42 a.m., RN A performed hand hygiene, applied a set of gloves and prepared to obtain a fingerstick blood sugar for Resident #2. RN A gathered a glucometer (measures the amount of sugar in the bloodstream at a specific time), lancet (device used to prick the skin for a small blood sample), 1 test strip, and alcohol wipe and placed them on the dining table where Resident #2 was sitting. RN A pricked Resident #2's index finger with a lancet needle but was unable to get blood. RN A doffed (off) and don (on) new gloves without cleansing her hands or using hand sanitizer. RN A gathered another lancet, test strip and alcohol wipe and placed it on the dining table again. RN A pricked Resident #2's middle finger with a lancet needle then wiped off the blood from the finger using a small alcohol wipe. RN A squeezed the pricked finger to collect blood for the glucose testing. Once RN A picked up the supplies which included the lancet needle and disposed of the used lancet in the trash can on her medication cart. During an interview on 09/22/25 at 11:50 a.m., RN A stated lancets and test strips should be disposed of in the sharp container. When asked why she did not dispose the lancet and test strip properly, RN A stated, I wasn't thinking properly. RN A stated disposing of the lancet and test strip could possibly cause an injury or transmission of blood borne pathogens. 6. During an observation and interview on 09/23/25 at 10:58 a.m., a razor was in the bottom drawer uncovered in wing B nurse's cart. LVN D stated the razor should have a protective cover. LVN D stated it was important for the razor to have a protective cover to prevent an injury. During an interview on 09/24/25 at 3:21 p.m., the Regional Nurse Consultant stated she expected lancets were disposed of in the sharp container and razors were stored properly by ensuring the safety cover was in place. The [NAME] Nurse Consultant stated the DON was responsible for monitoring by random observations and education as needed. The Regional Nurse Consultant stated it was important to dispose of sharps properly to residence the risk of a needle stick or transmission of blood borne pathogens. The Regional Nurse Consultant stated it was important to properly store razors to reduce the risk of injury. During an interview on 09/24/25 at 4:16 p.m., the DON stated the lancets should be discarded in the sharp container after every use and razors should not be stored without the cover on the blade. The DON stated she monitored by random spot checks. The DON stated there had not been any issues in the past. The DON stated it was important to dispose of lancets and store razors properly to prevent an injury and transmission of blood borne pathogens. During an interview on 09/24/25 at 4:51 p.m., the Administrator stated he expected lancets to be discarded in the sharp container and razors covers should remain on razors unless they are in use. The Administrator stated the DON was responsible for monitoring and overseeing. The Administrator stated it was important to dispose of lancets and store razors properly to prevent an injury/accidents and transmission of blood borne pathogens. Record review of the Obtaining a Fingerstick Glucose Level policy, revised 10/2011, reflected .the purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Steps in the Procedure. 6. Discard lancet into the sharp's container. Record review of the facility's undated, Sharps Disposal policy, reflected .this facility shall discard contaminated sharps into designated containers. 2. Contaminated sharps will be discarded into containers that are: b. puncture resistant. Record review of the facility's policy revised, July 2017, titled, Lifting Machine, using a Mechanical, indicated, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility.

Based on interview and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 3 residents (Resident #1, Resident #8, and Resident #58) reviewed for dialysis. 1. The facility failed to keep ongoing communication with the dialysis facility for Resident #58. 2. The facility failed to obtain a dialysis contract for Resident #58's dialysis clinic. 3. The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #1 and Resident #8. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs.Findings included: 1. Record review of Resident #58's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included end stage renal disease (final stage of chronic kidney disease, the kidneys no longer function adequately to maintain the body's needs and dialysis or a kidney transplant required for survival). Record review of Resident #58's Comprehensive MDS assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #58 had a BIMS score of 13, which indicated her cognition was intact. The MDS assessment indicated Resident #58 required dialysis while a resident of the facility. Record review of Resident #58's Order Summary Report dated 09/24/2025 indicated dialysis check shunt (provides access to the bloodstream for dialysis) for signs and symptoms of infection or bleeding every shift with a start date of 09/11/2025. Record review of Resident #58's care plan revised 09/23/2025 indicated she required hemodialysis (a type of dialysis that filters the blood since the kidneys cannot) related to renal failure. Interventions included to encourage resident to go for the scheduled dialysis appointments and to check and change dressing daily at access site. During an interview on 09/22/2025 at 12:21 PM, Resident #58's family member said Resident #58 went for dialysis every Tuesday, Thursday, and Saturday. During an interview on 09/23/2025 at 1:49 PM, the Administrator said the facility did not have a dialysis contract for Resident #58's dialysis clinic. During an interview on 09/24/2025 at 10:18 AM, LVN L said Resident #58 went to the dialysis clinic on Tuesday, Thursday, and Saturday. LVN L said she was sending dialysis communication forms to Resident #58's dialysis clinic, but she had not received any back from the dialysis clinic. LVN L said she had not attempted to contact the clinic to communicate with them regarding the dialysis communication forms or obtaining treatment information. LVN L said it was important for them to have ongoing communication with the dialysis clinic to know if Resident #58 was declining, any changes were made, and she was tolerating her dialysis treatments and to have ongoing collaboration with the clinic. During an interview on 09/24/2025 at 11:48 AM, the charge nurse at the dialysis clinic said the facility had not been sending communication forms for the dialysis clinic to fill out for Resident #58. The charge nurse at the dialysis clinic said the communication form was for the facility and the dialysis clinic to communicate, and it was important for them to have ongoing communication and for the facility to know if the resident had any adverse effects during her treatment. During an interview on 09/24/2025 at 5:31 PM, the DON said the nurses should be completing the top portion of the dialysis communication form and sending it with the resident to the dialysis clinic, and then when the resident returned to the facility the communication form should be returned with the bottom portion completed by the dialysis clinic. The DON said there was currently no monitoring in place to ensure communication with the dialysis clinic was completed. The DON said it was important for communication and so if there were any changes at the facility, the dialysis clinic was aware, and if there were any changes at the dialysis clinic, the facility was aware. During an interview on 09/24/2025 at 6:12 PM, the Administrator said the facility's communication system between the dialysis clinic and the facility should be adhered to. The Administrator said the charge nurses were responsible for maintaining ongoing communication with the dialysis clinic. The Administrator said not maintaining ongoing communication with the dialysis clinic could result in the residents' health being compromised. The Administrator said they did not have the dialysis contract for the dialysis clinic Resident #58 went to because it was his first survey at the facility. The Administrator said he was responsible for obtaining the dialysis contracts, and it had been an oversight. The Administrator said it was important to have dialysis contracts to be clear on expectations from both parties and to establish protocols to protect the resident.

Based on observation and interview, the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 6 medication carts (A-Wing nurse's medication cart) and 4 of 8 residents (Resident #24, Resident #27, Resident #28, Resident #50) observed for medication storage. 1. The facility failed to ensure Resident #24 did not have remedy cream on her room table. 2. The facility failed to ensure Resident #27 did not have triple antibiotic ointment at her bedside. 3. The facility failed to ensure Resident #28 did not have Preparation H cream (a cream used for hemorrhoids) and lantiseptic (a barrier cream used for skin breakdown) on plastic drawers next to her chair. 4. The facility failed to ensure Resident #50 did not have and unknown white cream in a specimen cup on his bedroom shelf. 5. The facility failed to ensure RN E secured the A-Wing Nurse Medication Cart when it was not in use and unattended on 09/22/2025. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion. Findings included: 1.Record review of Resident #24's face sheet, dated 09/23/25, indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease causing too much sugar in the blood), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), dementia (cognitive function severe enough to interfere with daily life), tremors, and high blood pressure. Record review of Resident #24's admission MDS, dated [DATE], indicated she was able to make herself understood and she was able to understand others. The MDS also indicated she had a BIMS score of 3 which meant she had severe cognitive impairment. The MDS also indicated she required maximal assistance with bathing, dressing, and personal hygiene and she required setup for bed mobility, transfer, and eating. Record review of Resident #24's care plan, dated 07/09/25, indicated she had impaired cognitive function with interventions to administer medications as ordered. Record review of Resident #24's order summary report, dated 09/23/25, indicated she had an order: May apply barrier cream as needed with a start date of 08/24/2025 and no end date. During an observation on 09/22/2025 at 11:14 AM, Resident #24 was out of the room but had a tube of Remedy Prevent ointment on her dresser table. During an observation on 09/23/2025 at 10:23 AM, Resident #24 was lying in her bed and had a tube of Remedy Prevent ointment on her dresser table and she was not interviewable. 2. Record review of Resident #27's face sheet, dated 09/24/25, indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses Alzheimer's disease (progressive disease that destroys memory and important mental functions), psychotic disorder (mental disorder characterized by disconnection from reality), depression (lowering of a person's mood), heart failure (disease in which the heart does not pump blood as it should), and high blood pressure. Record review of Resident #27's quarterly MDS assessment, dated 07/25/25, indicated she usually understood others and was usually able to make herself understood. The MDS also indicated she had a BIMS score of 7 which indicated she had severe cognitive impairment. The MDS also indicated she required supervision for transfers, and bathing, moderate assistance for toileting, setup for eating and independent with bed mobility. Record review of Resident #27's care plan, dated 06/05/25, indicated she had impaired cognitive function with interventions to administer medications as ordered. Record review of Resident #27's order summary report, dated 09/24/25, did not indicate she had an order for triple antibiotic ointment. During an observation on 09/23/2025 at 10:33 AM, Resident #27 had a tube of triple antibiotic ointment in her caddy sitting on her bedside table and she was not interviewable. 3. Record review of Resident #28's face sheet, dated 09/23/25, indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses dementia (cognitive function severe enough to interfere with daily life), heart failure (disease causing the heart difficulty pumping enough blood), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and major depression (excessive lowering of a person's mood). Record review of Resident #28's annual MDS, dated [DATE], indicated she could make herself understood and she understood others. The MDS also indicated she had a BIMS score of 6 which indicated she had severe cognitive impairment. The MDS also indicated she required supervision for bathing, toileting, and dressing and she was independent with eating, transfers, and bed mobility. Record review of Resident #28's care plan, dated 05/07/25, indicated she had impaired cognitive function and impaired visual functioning with interventions to administer medications as ordered. Record review of Resident #28's order summary report, dated 09/23/25, indicated she had an order for: Preparation H Rectal Ointment 0.25-14-74.9% (Phenylephrine-mineral oil-petroleum) insert 1 application rectally every 6 hours as needed for hemorrhoids with a start date of 09/16/25 and no end date. During an observation on 09/22/2025 at 12:10 PM, Resident #28 had a tube of Preparation H rectal ointment and a 1-ounce packet of lantiseptic cream lying on top of her plastic drawers next to the chair in her room. During an observation and interview on 09/23/2025 at 10:37 AM, Resident #28 was sitting on her bed and had a tube of Preparation H rectal ointment and a 1-ounce packet of laniseptic cream lying on top of her plastic drawers next to the chair in her room. Resident #28 said she used it when she needed to. She said rubbed a little bit of the Preparation H rectal ointment on her butt at a time when it hurt. 4.Record review of Resident #50's face sheet, dated 09/30/25, indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), dementia (cognitive function severe enough to interfere with daily life), hearing loss, and high blood pressure. During an observation on 09/22/2025 at 11:24 AM, Resident #50 was sitting in his chair watching wrestling and had an unknown white cream in a specimen cup on his shelf. During an observation and interview on 09/24/25 at 4:30 PM, CNA E said the medications that were out were not supposed to be left out on the unit. She said the family brought the white cream that was located in Resident #50's room. She said the family did not specify what the cream was supposed to be but told her to use it for his mouth. CNA E said the staff should not have left the creams out because its harmful for the residents on the unit. CNA E said the failure could place a risk for any of the residents potentially drinking or eating the creams. CNA E said the medications were out but she made rounds upon her coming in to work and ensured it was all put away as it was supposed to be. During an interview on 09/24/25 at 4:39 PM, LVN C said the medication and creams should not have been out. She said the failure placed a risk for all the residents harming themselves. LVN C said all staff were responsible for ensuring the medications and creams were not in the residents' rooms. LVN C said the charge nurses normally completed rounds in the rooms, but she had been working at the facility for a month and thought it was okay for the creams and medications to be out because the creams and medications had always been out in the residents' rooms. During an interview on 09/24/25 at 6:01 PM, the DON said the lantiseptic, hemorrhoid cream, or barrier creams were not supposed to be out in the locked unit. The DON said all the nursing staff were responsible for ensuring medication and creams were not out in the locked unit. The DON said the failure placed a risk for residents ingesting, placing in their eyes, and using the cream or medications inappropriately. The DON said it all should have been stored on the nurse's carts or medication rooms. During an interview on 09/24/25 at 6:53 PM, the Administrator said the medications should have been kept in the medication room or the nurse's carts and administered by a nurse or medication aide. The Administrator said the nurse aides and the charge nurse were responsible for ensuring medications and creams were not in the residents' room. He said the failure placed risks for residents ingesting or using inappropriately. 5. During an observation and interview on 09/22/2025 starting at 12:30 AM, there was an unlocked, unattended medication cart on A-Wing. RN E said it was the A-Wing Nurse Medication Cart, and she was responsible for it. RN E said she did not realize she left it unlocked. RN E said the medication carts should be locked at all times because somebody could get into it. During an interview on 09/24/2025 at 5:39 PM, the DON said the medication cart should be locked when it was not in use. The DON said the nurse or medication aide whomever was using the medication cart was responsible for ensuring it was locked. The DON said she monitored to ensure the medication carts were locked when unattended by conducting random spot checks. The DON said an unlocked medication cart could result in a resident, visitor, or unauthorized personnel getting into the medication cart. During an interview on 09/24/2025 at 6:26 PM, the Administrator said he expected for the medication cart to be locked when out of the nurses' sight. The Administrator said the DON was responsible for ensuring the this happened. The Administrator said the medication cart being unlocked could compromise the residents' safety. Record review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 1 of 7 residents (Resident #2) reviewed for services provided to meet professional standards. The facility failed to ensure RN A administered Resident #2's Humalog KwikPen (insulin medication) according to the manufacturer's instructions. This failure could place residents at risk of inaccurate drug administration and not receiving the care and services to meet their individual needs. Findings included:Record review of Resident #2's face sheet, dated 09/23/25, reflected Resident #2 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Type 2 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) with diabetic nephropathy (complication of diabetes mellitus that affects the kidneys). Record review of Resident #2 quarterly MDS assessment, dated 07/14/25, reflected Resident #2 made herself understood, and understood others. Resident #2's BIMS score was 12, which reflected her cognition was moderately impaired. Record review of Resident #2's comprehensive care plan, dated 07/16/25, reflected Resident #2 had a diagnosis which included Diabetes Mellitus. The care plan interventions included diabetes medication as ordered by the doctor, monitor/document for side effects/effectiveness and fasting serum blood sugar as ordered by the doctor. Record review of Resident #2's physician order summary report, dated 09/23/25, reflected Resident #2 had an order for Humalog KwikPen, inject as per sliding scale, 14 units. subcutaneous before meals and at bedtime related to diabetes mellitus with a start date 09/23/25. During an observation and interview on 09/22/25 at 11:42 a.m., revealed RN A prepared Resident #2's Humalog KwikPen by removing the pen cap, placed a needle onto the pen, and turned the dose knob to 14 units. RN A administered the medication to Resident #2's RLQ. RN A did not prime (removing the air from the needle and cartridge) the insulin pen by turning the dose knob into 2 units before turning the dose knob to 14 units. RN A stated priming the insulin was not required before administering Resident #2's insulin. RN A stated it was important to ensure insulin was administered per the manufacturer's instructions because the resident may not get the correct dosage of insulin which could have led to uncontrolled diabetes. During a telephone interview on 09/23/25 at 9:49 a.m., the Pharmacy Consultant stated the insulin pen should be primed 2 units prior to each dose to ensure the resident was getting the correct dose. The Pharmacy Consultant stated she did a random medication pass which included insulin administration and she did not notice any issues. The Pharmacy Consultant stated it was important to prime the insulin pen to bring the insulin to the tip of the needle so the resident could receive the correct dose of insulin. During an interview on 09/24/25 at 3:21 p.m., the Regional Nurse Consultant stated her expectation was for an insulin pen to have the needle primed with 2 units prior to drawing up the dose before administration. The Regional Nurse Consultant stated the DON was responsible for ensuring insulin was properly administered through random observation and education as needed. The Regional Nurse Consultant stated it was important to properly prime the needle, so the resident got the complete dose. During an interview on 09/24/25 at 4:16 p.m., the DON stated insulin pens were to be primed with 2 units prior to administration to ensure the residents received the accurate dose. The DON stated she monitored insulin administration during check offs. The DON stated RN A insulin administration check-off should have been completed April 2025. When the DON was asked why RN A had not been checked off for her annual, she stated, I don't have an answer. The DON stated she had not noticed any issues with insulin administration in the past. The DON stated it was important to properly prime the needle to prevent hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). During an interview on 09/24/25 at 4:51 p.m., the Administrator stated insulin pens should be primed per manufacturer instructions before administration. The Administrator stated the DON was responsible for monitoring and overseeing insulin administration. The Administrator stated it was important to properly prime the needle to ensure the accurate dose was given. Record review of the manufacture's guidelines titled Humalog KwikPen, revised 05/2025, reflected . Priming your Pen. Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.Record review of the Insulin Administration policy, revised 09/2014, reflected .to provide guidelines for the safe administration of insulin to residents with diabetes. 5. The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system (s) prior to their use.

Based on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 2 residents (Resident #2 and Resident #51) reviewed for reasonable accommodations. 1. The facility failed to ensure Resident #2's call light was within reach on 09/23/2025. 2. The facility failed to ensure Resident #51's call light was in reach for her to use when assistance was needed on 09/22/25 and 09/23/25. These failures could place residents at risk for a delay in assistance and a decreased quality of life.Findings include: 1. Record review of Resident #2's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder depressive type (mood disorder with symptoms such as feelings of sadness, worthlessness, and depression), legal blindness, muscle weakness, and muscle wasting and atrophy (thinning or wasting of muscle tissue). Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated she was understood and understood others. The MDS assessment indicated Resident #2's vision was severely impaired, and she had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 required substantial/maximal assistance with toileting, showering/bathing, lower body dressing and partial/moderate assistance with personal hygiene and upper body dressing. The MDS assessment indicated Resident #2 was dependent on staff for transfers. Record review of Resident #2's care plan reviewed 07/16/2025 indicated, she was at risk for falls, was very impatient and impulsive when she asked for care to encourage resident to use call light to gain assistance. Resident #2's care plan indicated she had a potential for injury related to previous falls, unsteady gait, visual deficits, attempted to stand unassisted and loses balance easily. Interventions included to place frequently needed articles within reach, and to place call light within reach. During an observation and interview on 09/23/2025 starting at 9:29 AM, Resident #2 was in her wheelchair by the end of the foot of her bed. Resident #2 said she was blind and asked for her call light. Resident #2 said the staff had issues with giving her, her call light. She said sometimes she had to yell, Hey, I need my call light. Resident #2's call light was on her bed by the head of the bed. During an interview on 09/23/2025 at 9:55 AM, CNA G said she rushed out of Resident #2's room and forgot to give her, the call light. CNA G said everybody should ensure the call light was within reach of the resident, and if they noticed it was not, they should put it within reach. CNA G said it was important for the call light to be within the residents reach because they could fall and need help. During an interview on 09/24/2025 at 5:41 PM, the DON said the call lights should be in reach for all residents. The DON said all staff should ensure the call lights were within reach, and if they noticed it was not, they should give it to them. The DON said if the call light was not within reach the residents could need assistance and not be able to get the assistance they required. During an interview on 09/24/2025 at 6:27 PM, the Administrator said the call lights should be kept within the residents' reach. The Administrator said the DON was responsible for ensuring this happened. The Administrator said the call light not being within the residents' reach could compromise their safety. 2. Record review of Resident #51's face sheet dated 09/15/25 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses senile degeneration of the brain (progressive decline in cognition), impulse disorder (mental health disorder that makes it difficult to resist urges and behaviors), depressive disorder (group of conditions that lower a person's mood), and chronic pain. Record review of Resident #51's quarterly MDS assessment dated [DATE] indicated she sometimes made herself understood and usually understood others. The MDS also indicated she had a BIMS score of 0 which indicated she had severe cognitive impairment. The MDS also indicated she was dependent on staff for all of her ADLs. Record review of Resident #51's care plan dated 07/09/25 indicated she had cognitive loss related to senile degeneration of the brain with interventions to provide resident with a homelike environment. During an observation on 09/22/2025 at 10:55 AM Resident #51 was lying in bed and her call light was in the dresser drawer next to her bed. During an observation on 09/23/2025 at 9:41 AM Resident #51 was lying in her bed yelling loudly and her call light was on the floor under the bed. During an interview on 09/24/25 at 6:27PM the DON said Resident #51's call light should have always been in reach. The DON said all staff were responsible for ensuring the call light remained in resident's reach, and the failure placed a risk for Resident #51 not getting the help she needed. During an interview on 09/24/25 at 7:05 PM the Administrator said he expected the call lights to always be in reach for all residents. He said the failure placed a risk of timely care being compromised. Record review of the facility's policy titled, Call System, Residents, revised January 2025, indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. 1.Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.2. Call system communication may be audible or visual. The system may be wired or wireless.3. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 2 of 8 residents (Resident #51 and Resident #2) reviewed for a homelike environment. 1. The facility failed to ensure Resident #51's pillow had a pillowcase on it on 09/22/25 and 09/24/25. 2. The facility failed to ensure Resident #2's fitted sheet did not have reddish-brownish particles and multiple brown stains on it on 09/23/2025 and 09/24/2025. These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: 1. Record review of Resident #51's face sheet, dated 09/15/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #51 had diagnoses which included senile degeneration of the brain (progressive decline in cognition), impulse disorder (mental health disorder that makes it difficult to resist urges and behaviors), depressive disorder (group of conditions that lower a persons mood), and chronic pain. Record review of Resident #51's quarterly MDS assessment, dated 02/25/25, indicated she sometimes made herself understood and usually understood others. Resident #51 had a BIMS score of 0, which indicated she had severe cognitive impairment. Resident #51 was dependent on staff for all of her ADLs. Record review of Resident #51's care plan, dated 07/09/25, indicated she had cognitive loss related to senile degeneration of the brain with interventions to provide the resident with a homelike environment. During an observation on 09/22/2025 at 10:55 AM revealed Resident #51 was lying in bed and did not have a pillowcase on her pillow. During an observation and interview on 09/24/25 at 5:15 PM, LVN R said she was unsure of why Resident #51 did not have a pillowcase on her pillow, but she said she should have had a pillowcase. She said the CNAs were responsible for ensuring Resident #51 had a pillowcase. LVN R said Resident #51 not having a pillowcase placed a risk for being uncomfortable. LVN R said she would not want to lay on a pillow without a pillowcase covering it. During an interview on 09/24/25 at 5:30 PM LVN R said she spoke with the CNAs that worked with Resident #51 and the CNAs said Resident #51 had a habit of fidgeting and taking her pillowcase off, so they left it off. During an interview on 09/24/25 at 6:29 PM, the DON said she expected the CNAs to put the pillowcase on for Resident #51 and if the resident removed the pillowcase the CNAs should place it back on. The DON said the failure placed a risk for discomfort for Resident #51. During an interview on 09/24/25 at 7:08 PM with the Administrator revealed he expected the CNAs to put the pillowcases on and if removed he expected staff to replace it. The Administrator said the failure placed a risk for improper sanitation and decreased dignity for Resident #51. 2. Record review of Resident #2's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder depressive type (mood disorder with symptoms such as feelings of sadness, worthlessness, and depression), legal blindness, muscle weakness, and muscle wasting and atrophy (thinning or wasting of muscle tissue). Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated she was understood and understood others. The MDS assessment indicated Resident #2's vision was severely impaired, and she had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 required substantial/maximal assistance with toileting, showering/bathing, lower body dressing and partial/moderate assistance with personal hygiene and upper body dressing. Record review of Resident #2's care plan reviewed 07/16/2025 indicated, she had an ADL self-care performance deficit and limited physical mobility. During an observation and interview on 09/23/2025 at 9:29 AM, Resident #2 said she was blind. Resident #2 said the CNAs did not change her sheets yesterday, she was not able to provide the names of the CNAs. Resident #2 said she did not remember when the last time her sheets were changed. Resident #2's fitted sheet had multiple brown stains on it and there were reddish-brownish particles in the bed. Resident #2's bed pad had a dried light tan stain on it. During an observation and interview on 09/23/2025 at 4:28 PM, Resident #2 said she did not know if her sheets were changed. Observed Resident #2's sheets and the top sheet and bed pad were clean, but the fitted sheet had multiple brown stains on it. During an observation and interview on 09/24/2025 at 9:53 AM, CNA K said she made Resident #2's bed and changed the sheets. CNA K removed the blanket and top sheet, and the fitted sheet still had multiple brown stains on it and there were reddish-brownish particles in the bed. CNA K said she changed the top sheet, but did not change the fitted sheet. She said she did not change it because she did not notice it was stained. CNA K said the residents' sheets were changed every other day on their shower days and if they were dirty, they should be changed. CNA K said it was the responsibility of the CNAs to ensure the residents had clean linens. She said it was important for them to have clean linens so they would feel clean. During an interview on 09/24/2025 at 9:57 AM, LVN L said the nurses were supposed to check to ensure the CNAs were changing the residents' sheets. LVN L said the residents' sheets should be changed when they were up and out of their room. LVN L said it was important for the residents' sheets to be clean for infection control and to prevent bed bugs. During an interview on 09/24/2025 at 5:22 PM, the DON said the residents' sheets should be changed every day when they were assisted out of their bed and as needed. The DON said the CNAs should be ensuring the sheets were changed and clean. The DON said it was important for the residents' sheets to be changed because it could cause the resident discomfort and it could be an infection control issue. During an interview on 09/24/2025 at 6:31 PM, the Administrator said he expected for the residents to have clean linen, and the CNAs were responsible for ensuring they had clean linens. The Administrator said it was important for sanitation and for the residents' dignity. Record review of the facility's policy titled, Homelike Environment, revised February 2021, indicated, Residents are provided with a safe, clean, comfortable and homelike environment. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. e. clean bed and bath linens that are in good condition.

Based on interview and record review the facility failed to ensure the transfer or discharge of a resident was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for 2 of 4 residents (Resident #8, Resident #54) reviewed for discharge. The facility failed to provide transfer and discharge documentation in the EMR for Resident #8 and Resident #54 to include a physician's orders, reason for discharge or a discharge summary. This failure could place residents at risk of an unsafe discharge.The findings include: 1. Record review of Resident #8's electronic face sheet, dated 09/23/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with hospitalizations on 07/28/2025, 08/05/2025, 08/26/2025, and 09/18/25 and re-admissions on 07/30/2025, 08/06/2025, 08/29/2025, and 09/20/2025. Resident #8 had diagnoses which included: End stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), Vitamin B12 deficiency anemia (a condition that occurs when the body does not have enough vitamin B12), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), heart failure, atrial fibrillation (an irregular, often rapid heart rate that commonly caused poor blood flow), major depressive disorder, seizures, and personal history of pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest) and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Record review of Resident #8's comprehensive MDS assessment, dated 06/14/2025, revealed a BIMS score of 15, which indicated she was cognitively intact. Record review of Resident #8's care planning notes, dated 09/23/2025, did not identify reasons for multiple hospitalizations. Record review of Resident #8's EMR, on 09/23/2025, revealed there were no discharge orders, discharge assessments, progress notes reflecting change of condition, MD or family notification or discharge summary for 07/28/2025, 08/05/2025, 08/26/2025 or 09/18/2025. Record review of Resident #8's hospital paperwork after readmission on [DATE] revealed the resident was admitted due to complaints of nausea and vomiting and was treated for gallstones which resulted in a cholecystectomy (surgical removal of gallbladder). Record review of Resident #8's hospital paperwork after readmission on [DATE] revealed the resident admitted to the hospital due to complaints of nausea and vomiting, received a new order for Ondansetron and returned to the facility.Record review of hospitalization on 08/26/2025 was attempted however, the facility was unable to provide hospital paperwork. Record review of Resident #8's hospital paperwork after readmission on [DATE] revealed the resident was admitted to the hospital due to complaints of nausea and coffee ground emesis although hospital paperwork was minimal, and treatment provided was not indicated. 2. Record review of Resident #54's electronic face sheet, dated 09/24/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 07/31/2025 to an acute care hospital. Resident #54 had diagnoses which included: peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), discitis (a condition that involves inflammation and infection of the spine) of cervical region, urine retention, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of the bones wears down), hypertension (high blood pressure), anemia (a condition in which the blood does not have enough healthy red blood cells and protein to carry oxygen all through the body), dementia (a group of thinking and social symptoms that interferes with daily functioning), right leg atherosclerosis (a condition characterized by hardening of the arteries and restriction of blood flow). Record review of Resident #54's discharge MDS assessment, dated 07/31/2025, revealed intact short-term memory and cognitive skills for daily decision making. Record review of SLUMS (St. Louis University Mental Status Examination for detecting mild cognitive impairment and dementia) test results (assessment date unknown) indicated score of 12 which indicated dementia. Record review of Resident #54's care planning notes, dated 09/24/25, did not identify reasons for hospitalization. Record review of Resident #54's EMR on 09/24/25 revealed there were not discharge orders, discharge assessments, progress notes reflecting change of condition or need for hospitalizations, MD or family notification or discharge summary for 07/31/2025. Record review of NP progress noted, dated 07/25/25, revealed a vascular consult (date not identified) was pending for on-going management of chronic disease.During an interview on 09/23/2025 at 3:23 p.m., Resident #8 stated she recalled going to the hospital multiple times due to nausea and vomiting and one time, I had a surgery. Resident #8 did not recall what paperwork was sent with her to the hospital. An interview as attempted but not completed on 9/24/25 at 11:45 a.m. with Resident #54. The resident did not return to the facility after his hospitalization. During an interview on 09/23/25 at 10:29 a.m., RN A stated for resident's transferred to the hospital, she would document vital signs, reason for transfer and what hospital the resident was sent to. The RN could not recall if she documented this information consistently for all resident transfers. During an interview on 09/23/2025 at 10:50 a.m., with Medical Records Staff Employee T stated she did not have any Discharge Summaries for Resident #38 or Resident #54. During an interview on 09/24/2025 at 3:56 p.m., the DON stated she expected nursing staff to complete a physical assessment of residents prior to discharge and indicate findings in a progress note to include reason for discharge, notification of responsible party, physician and DON, indication of vital signs and complete a progress note with SBAR data. The DON stated she would provide in-services to nursing staff regarding expected documentation for discharges. During an interview on 09/24/2025 at 4:51 p.m., the Administrator stated he expected nursing staff to complete full nursing assessments, notify appropriate personnel which included the DON, provide on-site interventions and document these tasks. The Administrator stated he was not aware the nursing staff were not completing full documentation for discharges. The Administrator acknowledged that failure to complete full documentation could place residents at risk for improper discharges. Record review of the facility's Nursing Policy and Procedure, titled Transfer or discharge, Facility-Initiated, dated October 2022, revealed Facility-initiated transfers and discharges must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy, and Documentation of Facility-Initiated Transfer or Discharge, 1.the following information is documented in the medical record: a. The basis for the transfers or discharge; c. the date and time of the transfer or discharge; d. The new location of the resident; e. The mode of transportation; f. A summary of the resident's overall medical, physical, and mental condition.

Based on observation, interview, and record review the facility failed to ensure based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 2 (Resident #41) residents reviewed for quality of care. The facility failed to ensure the Treatment Nurse conducted a skin assessment on 09/22/2025, after she was notified that Resident #41 had newly identified redness under both breasts. This failure could place residents at risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers. Findings included: Record review of Resident #41's face sheet dated 09/15/2025 indicated she was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), cerebral palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination), legal blindness, and excoriation skin-picking disorder (compulsive picking of one's skin). Record review of Resident #41's Comprehensive MDS assessment dated [DATE] indicated she was understood and understood others. The MDS assessment indicated Resident #41's vision was highly impaired, and her BIMS score was 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #41 required partial/moderate assistance with personal hygiene, showering/bathing, and toileting. The MDS assessment indicated Resident #41 did not have any ulcers, wounds, or skin problems. Record review of Resident #41's Order Summary Report dated 09/23/2025 did not indicated any orders to be applied to her skin or any wound treatments. Record review of Resident #41's Skin Assessments indicated the following: 09/17/2025 no alterations in skin integrity noted. completed by the Treatment Nurse. 09/24/2025 (conducted after surveyor intervention) moisture associated skin damage under both breast, NP notified, new order for area to be cleaned with wound cleanser or normal saline antifungal powder to be applied daily and as needed. Completed by the Treatment Nurse. - Record review of Resident #41's care plan indicated she required limited to extensive assistance of 1-2 staff with personal hygiene. Resident #41's care plan indicated she was at risk for pressure ulcers due to moisture, impaired mobility, and scratching self. Interventions included to assess for moisture problem areas such as under the breasts. During an observation and interview on 09/22/2025 at 10:45 AM, Resident #41 was in her room, and she said she had an open area on her breast that bothered her. Resident #41 tried to lift her breast to show the state surveyor but was unable to. CNA B walked into the room, and the state surveyor asked CNA B to assist Resident #41 with lifting her breast for an observation to be made. Resident #41 had redness and irritation under both breasts. The left breast had increased irritation and redness. CNA B applied powder and said she would notify the Treatment Nurse. During an interview on 09/24/2025 at 12:01 PM, CNA B said when a resident had redness, or a new skin condition identified they charted it in the electronic record and notified the treatment nurse. CNA B said she charted Resident #41's redness under her breasts in the electronic record and verbally notified the Treatment Nurse on 09/22/2025. CNA B said it was important for the nurse to be notified of newly identified skin conditions and a skin assessment be completed for it to be monitored, and because it could worsen and turn into a sore. During an interview on 09/24/2025 at 12:31 PM, the Treatment Nurse said CNA B reported to her on Monday, 09/22/2025, that Resident #41 had redness under her breasts. The Treatment Nurse said she had not completed a skin assessment to assess Resident #41. She said she had not done the skin assessment because it slipped my mind. The Treatment Nurse said when she completed the skin assessment on Resident #41 last week, she did not notice any redness underneath Resident #41's breasts. The Treatment Nurse said when she was notified by the staff of a skin issue, she should complete a skin assessment. The Treatment Nurse said it was important to complete a skin assessment to monitor the skin issue and see if it was healing or if it was worsening and so they could report it to the doctor. During an interview on 09/24/2025 at 5:27 PM, the DON said the Treatment Nurse was responsible for conducting skin assessments and treatments. The DON said if the Treatment Nurse was not available the charge nurses were responsible. The DON said the Treatment Nurse should have assessed Resident #41's skin, after she was notified by CNA B of an abnormal skin finding and notified the doctor to get orders for treatment. The DON said it was important for a skin assessment to be completed to maintain skin integrity. The DON said not completing a skin assessment after an abnormal skin finding was reported could have ill effects and the skin issue could worsen. During an interview on 09/24/2025 at 6:08 PM, the Administrator said he expected for any redness or abnormal skin finding to be assessed, treated appropriately, and for the doctor to be notified. The Administrator said if the Treatment Nurse was in the facility, it was her responsibility, if not, the charge nurses were responsible. The Administrator said unaddressed skin issues could worsen or cause more serious problems. Record review of the facility's policy titled, Prevention of Pressure Injuries, revised April 2020, indicated, .Inspect the skin on a daily basis when performing or assisting with personal care or ADLs.Evaluate, report and document potential changes in the skin.

Based on observation, interview, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise for 2 of 14 residents (Resident #4 and Resident #57) reviewed for nutrition and hydration. 1. The facility failed to provide fluids for Resident #57 to ensure adequate nutrition. 2. The facility failed to ensure Resident #4's RD recommendation for Boost VHC (nutritional supplement) four times a day was implemented, after it was recommended due to weight loss on 08/22/2025. These failures could place residents at risk for compromised hydration, malnourishment, illness, skin breakdown, and decreased quality of life.Findings include: 1. Record review of Resident #57's electronic face sheet, dated 09/24/25, revealed an [AGE] year-old male originally admitted to the facility on [DATE]. Resident #57's diagnoses included Alzheimer's dementia (most common form of dementia (most common form of dementia characterized by progressive cognitive decline), atherosclerotic heart disease (a condition characterized by build-up of plaque in the arteries), hypertension (high blood pressure), hyperlipidemia (a condition where there ar high levels of fat particles in the blood), SIADH (Syndrome of Inappropriate antidiuretic Hormone Secretion, a condition when the body produces excess amounts of antidiuretic hormone leading ot water retention and low sodium levels in the blood), and diabetes mellitus ( a metabolic disorder characterized by high blood sugar levels over a prolonged period). Record review of the admissions BIMS assessment, dated 09/16/25, revealed Score 99 which indicated severe cognitive impairment. Record review of Resident #57's physician's orders dated 09/10/25 revealed an order for a regular texture diet and regular consistency liquids. Record review of physician's diet order, dated 09/24/25, revealed a new order for pureed texture diet, nectar consistency liquids. Record review of care plan, dated 09/10/25, revealed resident was totally dependent in all areas of ADL concern including eating and drinking. Observation of Resident #57 on 09/22/2025 at 10:02 a.m. and 2:15 p.m. revealed resident noted with dry oral cavity and cracked, dry lips. No fluids or mouth swabs were present at bedside. Observation of Resident #57 on 09/23/25 at 8:45 a.m. revealed the resident with dry mucous membranes and lips appeared chapped, cracked. Noted water pitcher with approximately 18 ounces of clear, thin liquid on bedside table. The pitchere was full to the lid with clear, thin liquid. Observation of Resident #57 on 09/24/25 at 9:35 a.m. revealed an opened packet of lemon oral swabs located on nightstand. Observed resident's oral cavity to be less dry, lips remained cracked with no emollient cream observed to have been utilized. Observed 18 ounces of clear, thin liquid in water pitcher with a straw in the same location as was observed on 09/23/25 and 4.23 ounces of thin apple juice which was unopened. During an interview on 09/24/25 at 9:00 a.m. with CNA U, CNA U stated she checked Resident #57 this morning but did not notice fluids at the bedside. CNA U stated she was told the resident was now on thickened liquids, but she was unable to identify what type of thickened liquids. During an interview on 09/24/2025 at 9:05 a.m. with LVN L, LVN L stated she was off for two days, and prior to her days off, she notified hospice that Resident #57 was not eating well and noted an overall decline in care. LVN L stated she was not aware of any changes in the diet order for this resident. During an interview on 09/24/2025 at 3:56 p.m. with the DON, the DON stated she expected staff to identify residents who were non-verbal or physically unable to provide his/her own hydration and assist with fluid intake routinely throughout each shift. The DON stated water-based emollient was available as a nursing measure for any resident with chapped / cracked lips. The DON stated she expected oral care to be provided as a nursing measure as indicated. The DON stated adverse effects of not providing adequate hydration could result in complications related to dehydration.During an interview on 09/24/2025 at 4:51 p.m. with the Administrator, the Administrator stated he expected nursing management to monitor residents at risk for hydration and ensure needs of residents were being met. 2. Record review of Resident #4's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included multiple fractures of the pelvis and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #4's Comprehensive MDS assessment dated [DATE] indicated she understood others and was understood. The MDS assessment indicated Resident #4 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #4 required partial/moderate assistance with dressing, personal hygiene, and setup or clean-up assistance with eating. The MDS assessment did not indicate Resident #4 had weight loss. Record review of Resident #4's Order Summary Report dated 09/23/2025 indicated an order for Boost VHC (nutritional supplement) give 60 ml by mouth two times a day with a start date of 09/12/2025. Record review of Resident #4's Medication Flowsheet dated 09/01/2025-09/30/2025 indicated, Boost VHC 60 ml twice a day with a start date of 06/12/2025. The Medication Flowsheet indicated she was receiving the Boost VHC twice a day. Record review of a progress note for Resident #4 dated 08/22/2025 indicated: RD consult for resident with a significant weight loss. Resident returned from hospital stay with weight loss.weight loss -7.32% x30d (30 days) . will recommend increasing Boost VHC to further support nutrition adequacy and promote replenishing weight lost.Increase Boost VHC 60 ml QID (four times a day) . signed by the RD. Record review of Resident #4's care plan reviewed 07/31/2025 did not address the use of nutritional supplements or her weight loss. During an interview on 09/23/2025 at 4:52 PM, RN A said Resident #4 was receiving her Boost twice a day. RN A said she was not aware of an order for Resident #4 to receive Boost four times a day. RN A said the ADON was responsible for monitoring weight loss and the RD's recommendations, but the ADON left last month, and she was not sure who took over the role. RN A said the DON monitored the residents' weights. RN A said since Resident #4 was not receiving the Boost four times a day as recommended by the RD, she was not receiving the proper nutrients, and she could lose more weight. During an interview on 09/24/2025 at 5:30 PM, the DON said she was responsible for making the changes the RD recommended. The DON said she was not aware of the RD's recommendation to increase Resident #4's Boost VHC to four times a day. The DON said she may have missed that one. The DON said since the Boost VHC was not increased, Resident #4's nutrition could be affected. During an interview on 09/24/2025 at 6:11 PM, the Administrator said the RD's recommendations should be followed and addressed appropriately. The Administrator said the DON and Dietary Manager were responsible for following up on the RD's recommendations. The Administrator said if the RD's recommendations were not followed the resident's body weight or health could be compromised. Record review of the Nutrition Recommendation Form completed by the RD on 08/22/2025, indicated, Resident #4 Dietician Recommendations Boost VHC 60 ml four times a day. Record review of the facility's Dietitian Consultants undated policy, indicated, .Significant Weight Changes a. RD to assess resident with significant weight changes on a monthly basis.e. It is recommended to have a weight meeting with RD and nursing staff during the second week of the month, subsequent to RD's weight report review and analysis. Fortified [additional calories and protein for weight loss, underweight, increased nutrient needs] . Record review of the facility's policy titled, Resident Hydration and Prevention of Dehydration, revised October 2017, revealed the following: 6. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. 7. If potential inadequate intake and/or signs .dehydration are observed .monitoring will be initiated and incorporated into the care plan.

Based on observation, interview and record review the facility failed to ensure, based on a resident's comprehensive assessment, a resident was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents (Resident #17) reviewed for enteral nutrition. The facility failed to ensure Resident #17 received Isosource 1.5 (liquid nutrition tube-feeding formula) as ordered by the physician on 09/22/2025. This failure could place residents at risk of weight loss, nutritional imbalances, and health complications.Findings included: Record review of a face sheet dated 09/15/2025 indicated Resident #17 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and gastrostomy (creation of an external opening into the stomach to provide nutrition). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #17 was usually understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 5, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #17 required partial/moderate assistance with toileting and personal hygiene, showering/bathing self and set-up or cleanup assistance for eating. The MDS assessment did not indicate Resident #17 had a feeding tube. Record review of Resident #17's Order Summary Report dated 09/23/2025 indicated: Isosource 1.5 (liquid nutrition tube-feeding formula) at 50 ml/hr via g-tube with a start date of 09/11/2025 May use Diabetisource 1.2 (tube feeding formula designed for individuals with diabetes) at 50 ml/hr until Isosource 1.5 arrives with an order date of 09/22/2025. Record review of Resident #17's undated Medication Administration Record indicated, may use diabetisource 1.2 50 ml/hr until Isosource 1.5 arrives dated 09/22/2025 signed completed for the 6 PM-6 AM shift. There was no signature for the 6 AM-6 PM shift. Resident #17's MAR did not indicate the order for Isosource 1.5 (liquid nutrition tube-feeding formula) at 50 ml/hr via g-tube with a start date of 09/11/2025. Record review of Resident #17's care plan reviewed 07/31/2025 indicated she had a cerebral vascular accident (stroke) if resident was unable to swallow, give enteral feeding (nutrition delivered into the gut through a tube inserted through the abdominal wall) as ordered by the physician. During an observation on 09/24/2025 at 10:32 AM, Resident #17 had Diabetisource 1.2, feeding, connected to her g-tube at 50 ml/hr dated 09/22/2025. During an interview on 09/23/2025 at 3:41 PM, RN H said when she arrived to her shift (6 PM-6AM) yesterday (09/22/2025) she went to Resident #17's room and noticed Diabetisource was running. RN H said there was not any Isosource, so she called the doctor, and he said they could use the Diabetisource until the Isosource was available. RN H said prior to yesterday (09/22/2025) her last shift worked was Thursday (09/18/2025), and on Thursday (09/18/2025) Resident #17 had Isosource. RN H said it was important for Resident #17 to have the correct feeding because she may not get the correct minerals and vitamins that she needed, and she could get sick and start losing weight. During an interview on 09/24/2025 at 3:36 PM, LVN D said the Diabetisource for Resident #17 was changed by the night nurse, LVN N, prior to the start of her shift at 6 AM on 09/22/2025. LVN D said LVN N reported to her there was no more Isosource. LVN D said she had not notified the doctor of the incorrect feeding being administered because she did not catch it until RN H arrived for her shift at 6 PM. LVN D said if they ran out of a feeding formula, they should notify the doctor and get the order to use a different formula. LVN D said Resident #17 having the incorrect formula could result in her having an allergic or negative reaction, and she may not receive the right amount of calories she needed. During an interview on 09/24/2025 at 4:24 PM, LVN N said she did not know why the Diabetisource was administered. She said she worked Sunday night (6 PM-6 AM), and Resident #17's feeding should have been Isosource. LVN N said she thought she administered the correct feeding. LVN N said it was important for the correct feeding to be administered so the resident could get the correct nutrients. During an interview on 09/24/2025 at 5:43 PM, the DON said she was notified there was no more Isosource by the nurses over the weekend. The DON said because of the transition of companies they had issues ordering the Isosource. The DON said it was between Sunday, 09/21/2025, and Monday, 09/22/2025, Resident #17 was switched to the Diabetisource. The DON said if they did not have the Isosource available the nurses should have called the doctor to obtain an order for the Diabetisource until the Isosource was available. The DON said Resident #17 not having the correct feeding formula could result in nutritional deficiencies. During an interview on 09/24/2025 at 6:29 PM, the Administrator said he expected the feeding formulas to be followed per the doctor's orders, and the DON was responsible for ensuring this happened. The Administrator said Resident #17 having the incorrect feeding could compromise her nutritional requirements. Record review of the facility's policy titled, Enteral Nutrition, revised November 2018, indicated, Adequate nutritional support through enteral nutrition is provided to residents as ordered.

Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #30) reviewed for respiratory care. 1. The facility failed to ensure Resident #30's oxygen filter was clean in the back of the concentrator on 09/22/25-09/24/25. 2. The facility failed to ensure Resident #30's oxygen tubing and water was dated, on 09/22/25. 3. The facility failed to ensure Resident #30 had an order in place to ensure oxygen tubing and water were changed and dated, and the filter was cleaned weekly on Sundays. These failures could place residents at risk for respiratory infections and exacerbation of respiratory disease. Findings included:1. Record review of Resident #30's face sheet, dated 09/15/25, indicated a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included chronic systolic congestive heart failure (disease in which the heart muscle cannot pump blood effectively), sleep apnea (sleep disorder in which breathing stops and starts repeatedly), atrial fibrillation (an irregular often rapid heart rate that causes poor blood flow), and high blood pressure. Record review of Resident #30's admission MDS assessment, dated 08/25/25, indicated he was understood by others and made himself understood. Resident #30 had a BIMS score of 7, which meant he had severe cognitive impairment. Resident #30 required moderate assistance with transfers and bed mobility, maximal assistance with toileting and bathing, and setup for eating. Record review of Resident #30's care plan, dated 09/23/25, did not indicate his oxygen use. Record review of Resident #30's order summary report did not indicate an order for changing and cleaning the oxygen tubing, water and filter. During an observation and interview on 09/22/25 at 10:32 AM revealed Resident #30 was lying in the bed with oxygen on set at 2L/M. The oxygen filter was dirty with thick gray fuzzy matter and no dates on oxygen water or tubing. During an observation and interview on 09/23/2025 at 9:37 AM Resident was lying in bed asleep with oxygen on set at 2L/M. He said he was feeling better today. Resident #30's oxygen water and tubing was dated 9/22/25 but the oxygen filter continued to be dirty with thick gray fuzzy matter. During an observation and interview on 09/24/25 at 5:05 PM, LVN R and the state surveyor looked at the oxygen filter and LVN R said the filter was dirty and the charge nurses were supposed to change the oxygen filters and tubing out on Sundays and clean the filters as well. She said the failure placed a risk for Resident #30 not getting accurate air supply and risk for him breathing in bacteria. During an interview on 09/24/25 at 6:08 PM, the DON said the nurses were responsible for cleaning and changing the filters and the water weekly. She said Resident #30 should have had an order in place when the oxygen order was placed to ensure those things were being completed. The DON said the failures placed a risk for Resident #30 not getting the accurate percentage of the oxygen and not breathing in clean air which could have caused upper respiratory infections. During an interview on 09/24/25 at 7:12 PM, the Administrator said the concentrators should have been maintained appropriately. He said the charge nurses should have been cleaning and changing the filters as ordered. The Administrator said the failures placed a risk for health and safety concerns. He said he would think Resident #30 would not be getting the accurate amount of oxygen with the filter being that dirty. Record review of the facility's policy Oxygen Administration, revised October 2010, indicated: PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident.3. Assemble the equipment and supplies as needed.General Guidelinesl. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter.Weekly Documentation1. Oxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record.

Based on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (Resident #57) reviewed for pain management. The facility failed to monitor and record pain levels per physician's order for Resident #57. This deficient practice could place residents at risk of experiencing pain, undue pain and mental distress.The findings were: Record review of Resident #57's electronic face sheet, dated 09/24/25, revealed an [AGE] year-old male originally admitted to the facility on [DATE]. Resident #57 had diagnoses which included Alzheimer's dementia (most common form of dementia characterized by progressive cognitive decline), atherosclerotic heart disease (a condition characterized by build-up of plaque in the arteries), hypertension (high blood pressure), hyperlipidemia (a condition where there are high levels of fat particles in the blood), SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion, a condition when the body produces excess amounts of antidiuretic hormone leading to water retention and low sodium levels in the blood), and diabetes mellitus (a metabolic disorder characterized by high blood sugar levels over a prolonged period).Record review of Resident #57's admissions BIMS assessment, dated 09/16/2025, revealed a score of 99, which indicated severe cognitive impairment. Record review of Resident #57's physician's orders, dated 9/10/25, revealed an order for a Pain Assessment to be completed every shift.Record review of Resident #57's September MAR revealed a pain level of 0, assessed and recorded on 09/15/25 on the night shift. No other pain assessment levels were indicated. Record review of Resident #57's nursing progress notes, dated 8/1/25-9/10/25, completed on paper charting did not reveal any documentation which indicated a pain assessment was completed every shift. Record review of Resident #57's care plan revealed the resident was assessed as receiving hospice services with the goal that the resident would be comfortable with no signs or symptoms of pain or distress. Observation of Resident #57 on 09/22/25 at 10:02 a.m. revealed non-verbal communications with strained facial expression and non-sensical calling out. Observation of Resident #57 on 09/23/25 at 8:45 a.m. revealed the resident lying in bed, responsive with groans only to verbal stimuli. Observation of Resident #57 on 09/24/25 at 9:35 a.m. revealed the resident lying in bed, eyes closed, unlabored breathing and moaning in response to verbal stimuli. Observation of Resident #57 on 09/24/25 at 4:45 p.m. with family member [ at bedside, resident observed with facial grimacing. During an interview on 9/22/25 at 1:36 p.m., the family member of Resident #57 revealed she felt the resident was not getting enough to drink and she wished staff would check on him more often. During an interview on 9/24/25 at 9:05 a.m. with LVN L, LVN L revealed she noticed Resident #57 had an overall decline in health. LVN stated she was not aware there was an order on the MAR that required staff to assess resident's pain level. During an interview on 09/24/25 at 3:56 p.m. with the DON, the DON stated if a resident had orders for every shift pain assessment, she expected nursing staff to complete assessments, record pain level in the MAR or utilize Wong-Baker Assessment Scale for non-verbal residents. The DON stated a blank MAR would indicate the assessment was not completed and adverse effects of not assessing for pain could result in the resident experiencing pain unnecessarily.During an interview on 09/24/25 at 4:51 p.m. with the Administrator, the Administrator stated he expected nursing staff to follow physician's orders and notify the physician of any concerns. The Administrator stated the failure to follow orders could mean a resident experienced unnecessary pain. During an interview on 09/24/25 at 4:51 p.m. with the Administrator, the Administrator stated he expected nursing staff to follow physician's orders and notify the physician of any concerns. The Administrator stated the failure to follow orders could mean a resident experienced unnecessary pain.

Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies, and skill sets necessary to care for resident's needs for 1 of 1 resident (Resident #2) and 2 of 2 nursing staff (RN A and CNA K) reviewed for competencies.1.The facility did not perform RN A's annual skill checkoffs on obtaining a fingerstick glucose level and insulin administration. 2. The facility failed to conduct CNA K's competency assessment to ensure she demonstrated competency in the use of the mechanical lift. These failures could place the residents at risk of receiving care from staff who do not have the training and competency needed for providing care.Findings included: 1.During an observation and interview on 09/22/25 at 11:42 a.m., RN A performed hand hygiene, applied a set of gloves and prepared to obtain fingerstick blood sugar for Resident #2. RN A gathered a glucometer (measures the amount of sugar in the bloodstream at a specific time), lancet (device used to prick the skin for a small blood sample), 1 test strip, and alcohol wipe and placed them on the dining table where Resident #2 was seating. RN A pricked Resident #2's index finger with a lancet needle but was unable to get blood. RN A doffed (off) and don (on) new gloves without cleansing her hands or using hand sanitizer. RN A gathered another lancet, test strip and alcohol wipe and placed it on the dining table again. RN A pricked Resident #2's middle finger with a lancet needle then wiped off the blood from the finger using a small alcohol wipe. RN A squeezed the pricked finger to collect blood for glucose testing. RN A picked up the supplies which included lancet needle and disposed of the used lancet in the trash can on her medication cart. RN A then prepared Resident #2's Humalog KwikPen by removing the pen cap, placing a needle onto the pen, and turning the dose knob to 14 units. RN A administered the medication to Resident #2's RLQ. RN A did not prime (removing the air from the needle and cartridge) the insulin pen by turning the dose knob into 2 units before turning the dose knob to 14 units. RN A stated priming the insulin was not required before administering Resident #2's insulin. RN A stated it was ok to place the glucometer, lancet, alcohol wipe and test strip on the resident's dining table without having a barrier between it. RN A stated it was important to ensure insulin was administered per the manufacturer's instructions because the resident may not get the correct dosage of insulin which could lead to uncontrolled diabetes. During an interview on 09/22/25 at 11:50 a.m., RN A stated she should have performed hand hygiene between gloves changes and cleaned the glucometer between each resident. RN A stated it was ok to place the glucometer, lancet, alcohol wipe and test strip on the resident's dining table without having a barrier between it. During an interview on 09/24/25 at 4:16 p.m., the DON stated insulin check offs should be completed upon hire, annually, and as needed. The DON stated RN A's check-off should have been completed April 2025. When asked why she had not been checked off for her annual, the DON stated, I don't have an answer. The DON stated she was responsible for making sure the competencies were completed in a timely manner. The DON stated she had a log where she kept their annual proficiency dates that she reviewed monthly. The DON stated it was important to ensure staff carry out their task appropriately and according to the policies. During an interview on 09/24/25 at 4:51 p.m., the Administrator stated insulin administration competency should be checked annually for compliance. The Administrator stated the DON was responsible for monitoring and overseeing. The Administrator stated it was important that RN A was checked off for insulin administration and blood sugar check off to ensure care was appropriately given. 2. Record review of Resident #2's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder depressive type (mood disorder with symptoms such as feelings of sadness, worthlessness, and depression), legal blindness, muscle weakness, and muscle wasting and atrophy (thinning or wasting of muscle tissue). Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated she was understood and understood others. The MDS assessment indicated Resident #2's vision was severely impaired, and she had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 required substantial/maximal assistance with toileting, showering/bathing, lower body dressing and partial/moderate assistance with personal hygiene and upper body dressing. The MDS assessment indicated Resident #2 was dependent on staff for transfers. Record review of Resident #2's Order Summary Report dated 09/23/2025 did not indicate the use of the mechanical lift (mechanical lift). Record review of Resident #2's care plan reviewed 07/16/2025 indicated, she had a potential for injury related to previous falls, unsteady gait, visual deficits, attempted to stand unassisted and lost balance easily. Interventions included 2 staff to assist resident during transfers. During an observation and interview on 09/24/2025 at 9:01 AM, CNA K was observed coming out of Resident #2's room with the mechanical lift. There were no other staff members observed in Resident #2's room. Resident #2 said CNA K transferred her from her bed to the wheelchair, and she was not comfortable in her wheelchair. CNA K said she transferred Resident #2 with the use of the mechanical lift by herself. During an interview on 09/24/2025 at 9:49 AM, CNA K said the use of the mechanical lift probably required 2 staff, but she was not sure because at some facilities only one staff was required. CNA K said she thought they may have trained her on the use of the mechanical, but it had been a while. During an interview on 09/24/2025 at 11:26 AM, the DON said she did not have a competency check for the mechanical for CNA K. The DON said the competency checks should be completed upon hire. During an interview on 09/24/2025 at 5:23 PM, the DON said transferring with the mechanical lift required 2 staff. The DON said the charge nurse, the therapy director, or herself were responsible for completing the competency checks for the mechanical lift. The DON said completing CNA K's competency check for the mechanical was missed. The DON said it was important for the staff's competency to be assessed to ensure the staff were doing the transfers correctly. During an interview on 09/24/2025 at 6:05 PM, the Administrator said he expected for all training to be completed to ensure compliance. The Administrator said the DON was responsible for ensuring trainings were completed. The Administrator said it was important to ensure the staff had thorough training so they could provide the appropriate care. Record review of the facility's policy revised, July 2017, titled, Lifting Machine, Using a Mechanical, indicated, 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Record review of the facility's policy titled, Staffing Sufficient and Competent Nursing, indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 2 residents (Resident #4) reviewed for ADLs. The facility failed to ensure Resident #4's facial hair was removed. This failure could place residents at risk of not receiving services and care, and a decreased quality of life.Findings included: Record review of Resident #4's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included multiple fractures of the pelvis and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #4's Comprehensive MDS assessment dated [DATE] indicated she understood others and was understood. The MDS assessment indicated Resident #4 had a BIMS score of 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #4 required partial/moderate assistance with dressing, personal hygiene, and setup or clean-up assistance with eating. Record review of Resident #4's task record indicated bathing every shift, with no signatures to indicate bathing was completed on 9/11/2025, 09/18/2025, and 09/23/2025 for the month of September 2025. Record review of Resident #4's care plan reviewed 07/31/2025 indicated she had an ADL self-care performance deficit related to limited physical mobility, and she required assistance of 1 staff for bathing. During an observation and interview on 09/22/2025 at 2:17 PM, Resident #4 was in her bed, she had multiple hairs on her chin and upper lip approximately 1-2 cm long. Resident #4 said she had not removed her facial hair, but she needed to. Resident #4 said she did not know if she was getting her baths and started talking about a different topic. During an observation on 09/24/2025 at 9:38 AM, Resident #4 was in her bed, she had multiple hairs on her chin and upper lip approximately 1-2 cm long. During an interview on 09/24/2025 at 10:13 AM, LVN L said the CNAs were responsible for removing facial hair usually this was done on the residents' shower days. LVN L said Resident #4 sometimes refused her showers because of her dementia, but the CNAs should be offering for her facial hair to be removed because she did allow them to remove it. LVN L said she had noticed Resident #4 had facial hair but had not had time to address it with the CNAs. LVN L said she was not aware of any missed showers for Resident #4. LVN L said it was important for facial hair to be removed for the resident's self-esteem and dignity. During an interview on 09/24/2025 at 4:30 PM, CNA P said she noticed Resident #4 had facial hair. CNA P said Resident #4 allowed them to shave her, and she had no excuse for not doing it. CNA P said it was important for facial hair to be removed for her to be well-groomed and because she was a woman. During an interview on 09/24/2025 at 5:48 PM, the DON said she was not aware of Resident #4 refusing for her facial hair to be removed. The DON said the CNAs were responsible for making sure facial hair was removed. The DON said it was important for the resident's dignity. During an interview with the Regional Nurse Consultant on 09/24/2025 at 7:09 PM, the policy regarding ADLs/shaving was requested and not received upon exit of the facility.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. The facility failed to prevent CNA A from physically and verbally abusing Resident #1 when she intentionally shoved and used derogatory language towards Resident # 1. The noncompliance was identified as PNC. The IJ noncompliance began on 10/7/23 and ended on 10/8/23. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of abuse and neglect. Findings included: Record review of Resident #1's face sheet, dated 07/17/2024, indicated she was admitted to the facility on [DATE] with diagnoses including, Hypertension (A condition in which the force of the blood against the artery walls is too high), Gastro-esophageal reflux disease without esophagitis (a common condition in which the stomach contents move up into the esophagus and inflammation of the esophagus), Gastrostomy infection (a surgical operation for making an opening in the stomach). Record review of Resident #1's Quarterly MDS assessment, dated 10/16/23, reflected Resident #1 usually made herself understood and usually understood others. Resident #1 had severe cognitive impairment with a (BIMS score of 0. Resident #1 had no physical or verbal behaviors symptoms directed towards herself or others. Resident #1 had no behavior of rejecting care. Resident #1 was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. Record review of Resident #1's care plan dated 4/24/24, reflected Resident #1 was incontinent of bowel and bladder. Staff were to provide incontinent care after each episode. The care plan reflected that Resident #1 was totally dependent on staff for all of her activities of daily living. Record review of the facility's provider investigation report dated 10/8/23, reflected CNA B reported she witnessed CNA A shove Resident # 1, tell Resident #1 to, Turn your ass over, don't touch me you be playing in your pussy, and shut the hell up. It was indicated that the police were notified. Record review of CNA A's signed statement, dated 10/8/2023, reflected, I CNA A was taking to the nurse and She was saying that milk was every were in Resident #1 and her roommate She ask who got them I said another CNA had them I was looking for them could not fine them so I got CNA B to help clean them up when I come out I said them to fat motherfucker got them so by ther another CNA and who are you taking to I did not say not me and another CNA going back and for and I told another CNA did you here me call any by name out she no but we the only to white girl her I apologize if they thank I was toke to them.(Sic) Record review of CNA B's signed statement, dated 10/9/23, reflected I CNA B is stating that on 10/7/2023 at approximately 9:45 p.m I witness CNA A actually go in to Resident #1's room and went to the left side of the bed while I was standing on the right side of the bed CNA A actually pushed Resident #1 and told her to turn her ass over as CNA A begin to clean Resident # 1 she reached out to touch CNA A she made a statement don't touch me you be playing in your pussy Resident #1 moaned and CNA A told Resident # 1 to shut the hell up. During an interview on 7/16/24 at 10:35 a.m., Resident #1 said she did not remember someone by the name of CNA A. She said that no one has been mean to her. She said that she cannot remember if anyone had harmed her or said disrespectful words to her. She said she cannot say if anyone has hurt her feeling here. During an interview on 7/16/24 at 11:15 p.m., with the DON she said CNA A came back after the incident and gave a statement, but it had nothing to do with the actual incident. She said CNA A would not talk about the allegations CNA B made. She said the former ADM was in charge during this incident and the current ADM is only acting ADM until one is hired. She said CNA A was terminated as it was confirmed this incident took place. She said CNA B notified her on 10/8/2023 at 1:15 p.m. that on 10/7/2023 at 9:50 p.m. she witnessed CNA A shove and use verbally abusive language to Resident # 1 . She said that she was the first person that the incident was reported to. During an interview on 7/16/24 at 1:34 p.m. with CNA B she said that she remembered the incident with Resident #1 and CNA A. She said she witnessed CNA A shove Resident # 1 hard when turning her over to do peri care. She said she heard CNA A tell Resident # 1 to turn her ass over. She said then Resident # 1 touched CNA A and she told Resident # 1 to not touch her because she plays with her pussy. She said she heard CNA A then tell Resident # 1 to shut the hell up after Resident # 1 made a groaning noise. She said she reported this incident to the DON. During an attempted interview on 7/16/2024 at 2:50 p.m. CNA A was contacted via telephone. A voicemail was not left as the number was disconnected. During an interview on 7/16/2024 at 3:02 p.m., LVN C said that any type of abuse was to be reported immediately to the abuse coordinator, charge nurse, or DON. She said that she has been in-serviced on this topic as well as their abuse policy multiple times including immediately after the incident with Resident #1. She said she would also need to ensure the resident that was allegedly abused was safe after the allegation and remove the alleged perpetrator for access to any resident. During an interview on 7/16/2024 at 3:04 p.m., CNA D said if a resident made an allegation that they were abused then she would need to ensure the resident was safe, report to the abuse coordinator and any other management that was working, keep the resident safe, and prevent the person who allegedly did the abuse away from other residents. She said she has been in-serviced on all these principals multiple times. During an interview on 7/16/2024 at 3:07 p.m., LVN E said that she has been in-services on the facility abuse policy several times. She said that if an allegation of abuse is made, they are to immediately report the allegation to the abuse coordinator. She said she can also report to the charge nurse and the DON as well as call the abuse coordinator. She said that she would also need to ensure that the person who did the abuse did not have access to any resident and have them leave the building. During an interview on 7/16/2024 at 3:09 p.m., LVN F said that the abuse coordinator should be notified immediately after an allegation of abuse is made. She said that she can tell the abuse coordinator in person or call them. She said that she can also tell other management of an allegation of abuse. She said that she has been trained in this topic multiple times. She said the abuse policy is a topic that is trained frequently. She said that when abuse allegedly occurs she would also need to ensure that the resident and other residents are kept safe from the person who allegedly did the abuse. During an interview on 7/16/2024 at 3:20 p.m., with the former ADM he said he vaguely remembers this incident. He said he immediately suspended CNA A on 10/8/2023 before she came back to work. He said he then investigated the incident. He said he doesn't recall any type of statement from CNA A other than what is in the PIR. He said he doesn't recall the resident needing any counseling or showing any type of emotional response to the incident. He said he doesn't remember what time this was reported by CNA B but it will be located on the PIR. He said these were typically reported immediately to himself or the DON. He said he does not recall when he got the self-report for this incident. During an interview on 7/17/24 at 12:53 p.m., the Administrator said CNA A was immediately upon learning of the incident on 10/8/2024 at 1:15 p.m. suspended pending the investigation results. He said CNA A was terminated when it was determined that the allegations made against CNA A were true. He said that all staff were in-serviced over abuse, neglect and exploitation. The Administrator said abuse of residents would not be tolerated at the facility. Record review of a facility in-service dated 10/8/2023 revealed that CNA B was in-services for the facilities abuse policy. Abuse policy educates staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Record review of CNA A's personnel file on 07/17/24 indicated hire date of 9/5/23. The facility had performed background check and employee misconduct search. No concerns were identified. Record review of CNA A's Employee Disciplinary Report, dated 10/10/23, indicated she was terminated on 10/10/2023 for misconduct regarding allegations of Abuse and was not eligible for rehire. The administrator was notified of IJ PNC on 07/16/2024 at 5:16 p.m. due to the above failures. The administrator was provided with the IJ template on 07/16/2024 at 5:17 p.m. The noncompliance was identified as PNC. The IJ noncompliance began on 10/7/23 and ended on 10/8/23 . The facility had corrected the noncompliance before the investigation began. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: Facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC on 10/8/2023. Completion of in-services on abuse. Abuse policy educates staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Termination of confirmed perpetrator on 10/10/2023. Residents of facility interviewed did not indicate that they had been abused and were safe. Safe surveys were conducted with residents and no resident reported feeling unsafe. Record review of the facility's policy and procedure dated January 10th, 2017, titled Abuse/Reportable Events All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians . Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish . Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment and deprivation.

Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse of residents for 1 of 7 Residents (Resident #1) whose records were reviewed for abuse. CNA B failed to report an allegation of resident abuse within 2 hours after learning about the allegation per facility policy. The facility failed to conduct a thorough investigation when the DON completed only 4 safe surveys and did not interview the resident. The facility failed to prevent CNA A from physically and verbally abusing Resident #1 when she intentionally shoved and used derogatory language towards Resident # 1. The noncompliance was identified as PNC. The IJ noncompliance began on 10/7/23 and ended on 10/8/23. The facility had corrected the noncompliance before the investigation began. This deficient practice could affect any resident and contribute to further resident abuse. The findings were: Record review of the facility's policy and procedure dated January 10th, 2017, titled Abuse/Reportable Events All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians . Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish . Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment and deprivation . Reporting: Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. If the allegations involve abuse or result in serious bodily Injury, the report Is to be made within 2 hours of the allegation. Record review of Resident #1's face sheet, dated 07/17/2024, indicated she was admitted to the facility on [DATE] with diagnoses including, Hypertension (A condition in which the force of the blood against the artery walls is too high), Gastro-esophageal reflux disease without esophagitis (a common condition in which the stomach contents move up into the esophagus), Gastrostomy infection (a surgical operation for making an opening in the stomach). Record review of the Resident #1's Quarterly MDS assessment, dated 10/16/23, reflected Resident #1 usually made herself understood and usually understood others. Resident #1 had severe cognitive impairment with a BIMS score of 0. Resident #1 had no physical or verbal behaviors symptoms directed towards herself or others. Resident #1 had no behavior of rejecting care. Resident #1 was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. Record review of Resident #1's care plan dated 4/24/24, reflected Resident #1 was incontinent of bowel and bladder. Staff were to provide incontinent care after each episode. The care plan reflected that Resident #1 was totally dependent on staff for all of her activities of daily living. Record review of the facility's provider investigation report dated 10/8/23, reflected CNA B reported she witnessed CNA A shove Resident # 1, tell Resident #1 to, Turn your ass over, don't touch me you be playing in your pussy, and shut the hell up. It was indicated that the police were notified. Record review of CNA B's signed statement, dated 10/9/23, reflected I CNA B is stating that on 10/7/2023 at approximately 9:45 p.m., I witness CNA A actually go in to Resident #1's room and went to the left side of the bed while I was standing on the right side of the bed CNA A actually pushed Resident #1 and told her to turn her ass over as CNA A begin to clean Resident # 1 she reached out to touch CNA A she made a statement don't touch me you be playing in your pussy Resident #1 moaned and CNA A told Resident # 1 to shut the hell up Record review of CNA A's signed statement, dated 10/8/2023, reflected, I CNA A was taking to the nurse and She was saying that milk was every were in Resident #1 and her roomate She ask who got them I said another CNA had them I was looking for them could not fine them so I got CNA B to help clean them up when I come out I said them to fat motherfucker got them so by ther another CNA and who are you taking to I did not say not me and another CNA going back and for and I told another CNA did you here me call any by name out she no but we the only to white girl her I apologize if they thank I was toke to them.(Sic) During an interview on 7/16/24 at 10:35 a.m., Resident #1 said she did not remember someone by the name of CNA A. She said that no one has been mean to her. She said that she cannot remember if anyone had harmed her or said disrespectful words to her. She said she cannot say if anyone has hurt her feeling here. During an interview on 7/16/24 at 11:15 p.m., with the DON she said CNA A came back after the incident and gave a statement, but it had nothing to do with the actual incident. She said CNA A would not talk about the allegations CNA B made. She said the former ADM was in charge during this incident and the current ADM is only acting ADM until one is hired. She said CNA A was terminated as it was confirmed this incident took place. She said CNA B notified her on 10/8/2023 at 1:15 p.m. that on 10/7/2023 at 9:50 p.m. she witnessed CNA A shove and use verbally abusive language to Resident # 1. She said that she was the first person that the incident was reported to. During an interview on 7/16/24 at 1:34 p.m. with CNA B she said that she remembered the incident with Resident #1 and CNA A. She said she witnessed CNA A shove Resident # 1 hard when turning her over to do peri care. She said she heard CNA A tell Resident # 1 to turn her ass over. She said then Resident # 1 touched CNA A and she told Resident # 1 to not touch her because she plays with her pussy. She said she heard CNA A then tell Resident # 1 to shut the hell up after Resident # 1 made a groaning noise. She said she reported this incident to the DON. During an interview on 7/16/2024 at 2:41 p.m., with the DON she said that all safe surveys were completed during the investigation of the allegations. She said that the safe surveys were also called psychosocial assessments. She said she was the first person the incident was reported to. She said that she thought 4 safe surveys was sufficient to determine if facility residents felt safe. She said that Resident # 1 was not interviewed after the incident, and she did not receive a safe survey. During an interview on 7/16/2024 at 3:02 p.m., LVN C said that any type of abuse was to be reported immediately to the abuse coordinator, charge nurse, or DON. She said that she has been in-serviced on this topic as well as their abuse policy multiple times including immediately after the incident with Resident #1. She said she would also need to ensure the resident that was allegedly abused was safe after the allegation and remove the alleged perpetrator for access to any resident. During an interview on 7/16/2024 at 3:04 p.m., CNA D said if a resident made an allegation that they were abused then she would need to ensure the resident was safe, report to the abuse coordinator and any other management that was working, keep the resident safe, and prevent the person who allegedly did the abuse away from other residents. She said she has been in-serviced on all these principals multiple times. During an interview on 7/16/2024 at 3:07 p.m., LVN E said that she has been in-services on the facility abuse policy several times. She said that if an allegation of abuse is made, they are to immediately report the allegation to the abuse coordinator. She said she can also report to the charge nurse and the DON as well as call the abuse coordinator. She said that she would also need to ensure that the person who did the abuse did not have access to any resident and have them leave the building. During an interview on 7/16/2024 at 3:09 p.m., LVN F said that the abuse coordinator should be notified immediately after an allegation of abuse is made. She said that she can tell the abuse coordinator in person or call them. She said that she can also tell other management of an allegation of abuse. She said that she has been trained in this topic multiple times. She said the abuse policy is a topic that is trained frequently. She said that when abuse allegedly occurs she would also need to ensure that the resident and other residents are kept safe from the person who allegedly did the abuse. During an interview on 7/16/2024 at 3:20 p.m., with the former ADM he said he vaguely remembers this incident. He said he immediately suspended CNA A on 10/8/2023 before she came back to work. He said he then investigated the incident. He said he doesn't recall any type of statement from CNA A other than what is in the PIR. He said he doesn't recall the resident needing any counseling or showing any type of emotional response to the incident. He said he doesn't remember what time this was reported by CNA B but it will be located on the PIR. He said these were typically reported immediately to himself or the DON. He said he does not recall when he got the self-report for this incident. During an interview on 7/16/24 at 4:26 p.m., with the Administrator, he said that he was the acting Administrator until a new Administrator was hired. He said if he became aware of abuse, he would be required to report it within two hours to the state. He said that as soon as he found out there was an alleged perpetrator, he would suspend the alleged perpetrator and remove their access to residents. He said when he is called, he will ask the person who called him to ensure that the resident was safe, what they were currently doing to ensure the safety of the resident and he will then give guidance if additional measures were needed. He said if it was necessary, he would then call the police. He said that he would then ensure there was an assessment completed for the resident to identify any potential issues. He said if the resident can speak, they would be interviewed and safe surveys would be completed, he would talk to family, talk to the physician, and police if necessary. He said if the resident could not tell what occurred, they would then rely on safe surveys and witness statements. He said that the number of residents that they have complete safe surveys depend on what happened, and the residents would be picked at random. During an interview on 7/17/24 at 12:53 p.m., the Administrator said CNA A was immediately suspended pending the investigation results. He said CNA A was terminated when it was determined that the allegations made against CNA A were true. He said that all staff were in-serviced over abuse, neglect and exploitation. The Administrator said abuse of residents would not be tolerated at the facility. He said that all allegations of abuse are reported within two hours after the incident occurred. Record review of CNA A's personnel file on 07/17/24 indicated hire date of 9/5/23. The facility had performed background check and employee misconduct search. No concerns were identified. Record review of CNA A's Employee Disciplinary Report, dated 10/10/23, indicated she was terminated for misconduct regarding allegations of Abuse and was not eligible for rehire. The administrator was notified of IJ PNC on 07/16/2024 at 5:16 p.m. due to the above failures. The administrator was provided with the IJ template on 07/16/2024 at 5:17 p.m. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC. Completion of in-services on abuse on 10/8/2023. Abuse policy educates staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Staff and management recognizing the steps to report abuse and neglect. ADM and DON being able to articulate the steps of an investigation on 7/17/2024. Termination of confirmed perpetrator. The noncompliance was identified as PNC. The IJ noncompliance began on 10/7/23 and ended on 10/8/23. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 6 of 7 residents reviewed for abuse and neglect. (Resident #2, Resident #3, Resident #5, Resident #6, Resident #7, Anonymous Resident) The facility failed to ensure Resident #7 and AR did not suffer physical pain when CNA B provided ADL care to them. The facility failed to ensure Resident #3, Resident #5, Resident #7, and an AR did not suffer verbal and mental abuse, and mistreatment when CNA B would cuss and say hurtful things towards them. The facility failed to ensure CNA B did not remove Resident #5's food from him so he would not have a bowel movement on her. The facility failed to ensure Resident #2 did not experience verbal aggressive behaviors from CNA B. The facility failed to ensure Resident #6 did not experience emotional distress when CNA B would refuse to change her or speak to her in an unprofessional manner. An Immediate Jeopardy (IJ) situation was identified on 02/23/24 at 3:10 p.m. while the IJ was removed on 02/24/24 at 3:45 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #3's face sheet printed 02/15/24 indicated Resident #3 was a [AGE] year-old male and admitted on [DATE] with diagnoses including schizoaffective disorder (is a mental health condition), generalized anxiety disorder (is a condition of excessive worry about everyday issues and situations), cognitive communication (problems with communication that have an underlying cause in a cognitive deficit), and muscle wasting and atrophy (shortening). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3 was understood and had the ability to understand others. The MDS indicated Resident #3 had unclear speech, adequate hearing, and adequate vision. The MDS indicated Resident #3 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #3 did not have psychosis, behavioral symptoms, or rejection of care. The MDS indicated Resident #3 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and partial/moderate assistance (helper does less than half the effort) for oral hygiene, upper body dressing and toilet transfer. The MDS indicated Resident #3 was occasionally incontinent for urine and frequently incontinent for bowel. Record review of Resident #3's care plan dated 06/12/22, edited on 01/11/24 indicated Resident #3 had potential for injury related to falls due to history of previous fall. Intervention included remind/encourage resident to use call light to gain assistance. During an interview on 02/15/24 at 12:04 p.m., Resident #3 said CNA B acted like she was better than him. He said CNA B said mean stuff to him all the time. He said CNA B did cuss at him and recently cussed him out after she helped him in the shower. He said CNA B made him feel like an outcast. 2. Record review of Resident #5's face sheet printed 02/15/24 indicated Resident #5 was a [AGE] year-old male and admitted on [DATE] with diagnoses including hemiplegia (is paralysis that affects only one side of your body) and hemiparesis (is weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction affecting non dominant side, cerebral infarction (stroke), acquired absence of right leg below knee, and end stage renal disease (is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 was understood and had the ability to understand others. The MDS indicated Resident #5 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #5 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #5 had functional limitation range of motion to lower extremities to one side. The MDS indicated Resident #5 required partial/moderate assistance (helper does less than half the effort) for oral and toileting hygiene, shower/bathe self, dressing, and personal hygiene, and substantial/maximal assistance for sit to stand, chair/bed-to-chair, toilet, and tub/shower transfer. The MDS indicated Resident #5 had frequent incontinence for urine and bowel. Record review of Resident #5's care plan dated 01/20/24 indicated Resident #5 had an ADL self-care performance deficit and limited physical mobility. Intervention included the resident required extensive assistance for bed mobility, toilet use and transfer. During an interview on 02/15/24 at 12:00 p.m., Resident #5 said CNA B was not easy to work with. He said the facility wanted CNA B to use the mechanical lift to transfer him, but she did not which made her pick him up from the wheelchair and push him on the bed. He said she sometimes acted like she was afraid to transfer him because she thought he would put poop on her. He said sometimes she put his coat in his wheelchair to sit on so he could poop on it instead of the facility's linen. He said CNA B did not want him eating his snacks because it made him have loose bowels. He said CNA B talked rough to him and kind of turned and cleaned him rough. He said he was not afraid of her. He said sometimes she tells him, Don't talk to me! He said CNA B did not know how to talk to people. He said CNA B put him in hospital gowns instead of shirts, which he would ask for, but was always told gowns were easier. He said CNA B was not very nice to Resident #3, his roommate. He said she throws his clothes in the trash and talked rough to him. 3. Record review of Resident #7's face sheet printed on 02/15/24 indicated Resident #7 was a [AGE] year-old female and admitted on [DATE] and latest return on 02/15/24 with diagnoses including nontraumatic intracranial hemorrhage (brain bleed), flaccid hemiplegia affecting left side non dominant (the affected extremity exhibits decreased muscle tone and cannot be actively moved by the patient), legal blindness, muscle weakness, muscle wasting and atrophy (shortening), body mass index 50.0-59.9 (morbidly obese), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated Resident #7 was understood and had the ability to understand others. The MDS indicated Resident #7 had adequate hearing, clear speech, and severely impaired vision. The MDS indicated Resident #7 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #7 had functional limitation in range of motion to her upper and lower extremities on one side. The MDS indicated Resident #7 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, dressing, personal hygiene, roll left and right and dependent for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The MDS indicated Resident #7 was always incontinent for urine and bowel. Record review of Resident #7's care plan dated 06/10/22, edited 02/14/24 indicated Resident #7 had an ADL self-care performance deficit and limited physical mobility. Intervention included bed mobility, bathing and toilet use required extensive assistance and total assistance required for transfers. Record review of Resident #7's care plan dated 08/02/22, edited 02/14/24 indicated Resident #7 had demonstrated demanding behaviors towards others, yelling out for assistance when request for assistance is not answered immediately, desiring one on one constant help/assist from staff. Intervention included offer an outlet for resident to express feelings, wishes and frustrations. During an interview on 02/14/24 at 10:35 a.m., Resident #7 said she did not get along CNA B. She said CNA B jerked her arm and caused her pain when she got her up and called her fat. She said CNA B said things like I'm [CNA B] a buck 75 and you're [Resident #7] 300 pounds, so you need to help me or You [Resident #7] don't even try to help me [CNA B]. She said her left arm was bad so she could not help from that side. She said when CNA B said mean things to her, it made her sad. During an interview on 02/14/24 at 11:00 a.m., Resident #7's family member #1 said around December 2023, AE #1 called her at home and told her she needed to check on Resident #7 because CNA B was mistreating her. She said AE #1 told her she reported CNA B's mistreatment to the DON. She said when she filed the complaint on 12/26/23, she told the DON that CNA B said rude and hurtful things to her family member. She said she told the DON, CNA B always commented on Resident #7's weight. She said CNA B also told Resident #7, nobody cared if she told her family about things because if her family really cared about Resident #7, they would not have put her in nursing home. She said CNA B also said things like I don't have time to be doing this or I'm busy, so I ain't doing that. During an interview on 02/15/24 at 10:20 a.m., Resident #7's family member #2 said Resident #7 told her CNA B was rough, mean, and talked to her in a demeaning way. She said CNA B's behavior upset Resident #7 and when CNA B was not working, Resident #7 was happy and relieved. During an interview on 02/15/24 at 11:00 a.m., Resident #7's family member #3 said Resident #7 complained CNA B was rude to her and does not treat her right. He said Resident #7 complained CNA B commented on her weight and told him I can't stand her! He said CNA B even mentioned private family matters to Resident #7 causing her to become upset. 4. Record review of Resident #2's face sheet printed 02/15/24, indicated Resident #2 was an [AGE] year-old, female and admitted on [DATE] and 04/22/22 with diagnoses including unilateral primary osteoarthritis (is a chronic condition affecting the joints), depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (is a condition of excessive worry about everyday issues and situations). Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was understood and had the ability to understand others. The MDS indicated Resident #2 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #2 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #2 required set-up or clean-up assistance for oral and toilet hygiene, shower/bathe self, and upper body dressing and supervision or touching assistance for lower body dressing, putting on/taking off footwear, transfers, and personal hygiene. The MDS indicated Resident #2 was occasionally incontinent of urine and bowel. Record review of Resident #2's care plan dated 03/01/22, edited on 01/30/24, indicated Resident #2 had potential for injury related to falls due to unsteady gait, attempted to stand unassisted, and lost balance easily. Intervention included resident educated on importance of using call light to gain assistance. During an interview on 02/14/24 at 12:45 p.m., Resident #2 said CNA B was verbally aggressive to her and other residents. She said the few times CNA B was verbally aggressive to her, it made her mad. 5. Record review of Resident #6's face sheet printed 02/15/24 indicated Resident #6 was an [AGE] year-old, female and admitted on [DATE] with diagnoses including age related cognitive decline (overall slowness in thinking and difficulties sustaining attention, multitasking, holding information in mind and word-finding), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and chronic kidney disease, stage 3 (is a type of kidney disease in which a gradual loss of kidney function occurs over a period of months to years). Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was understood and had the ability to understand others. The MDS indicated Resident #6 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #6 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #6 required partial/moderate assistance for oral hygiene, upper body dressing, and personal hygiene and substantial/maximal assistance for toilet hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident #6 was always incontinent of urine and bowel. During an interview on 02/15/24 at 10:03 a.m., Resident #6 said CNA B spoke to you a nasty way. She said when you asked CNA B for something, she would say, What you want? or Well, I [CNA B} ain't got no time for that! She said CNA B did not say those things in a joking manner. She said CNA B had smarted off at her and a bunch of folks. She said CNA B refused to change her and would get someone else to do it. She said CNA B's actions hurt her feelings and made her feel like she did something wrong. 6. Record review of Resident #4's face sheet printed 02/15/24 indicated Resident #4 was a [AGE] year-old, male and admitted on [DATE] and 03/28/23 with diagnoses including multiple sclerosis (is a potentially disabling disease of the brain and spinal cord (central nervous system)), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and muscle wasting and atrophy (shortening). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4 was understood and had the ability to understand others. The MDS indicated Resident #4 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #4 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #4 required partial/moderate assistance for toileting hygiene, shower/bath self, and dressing. The MDS indicated Resident #4 was occasionally incontinent of urine and frequently incontinent of bowel. Record review of Resident #4's care plan dated 12/26/23, edited on 01/09/24 indicated Resident #4 had potential for injury related to falls due to history of previous falls. Intervention included encourage resident to participate in activities program that encourages exercise and physical activity for strengthening and improved mobility. During an interview on 02/14/24 at 1:15 p.m., Resident # 4 said CNA B intimated the poor, old ladies on her hall. He said CNA B was so mean to AR sometimes, AR would start shaking. He said about 1-2 weeks ago, he heard CNA B tell Resident #3, Now, take your a** back to your room after she helped him take a shower. He said LVN G was standing by the shower door, so he did not know how LVN G did not hear CNA B cussing at Resident #3. 7. During an interview and observation on 02/14/24 at 1:30 p.m., AR said he/she had been putting up with CNA B's behaviors for a while. AR said CNA B got a better attitude for a while then she went back to being bad. AR said she never hit her/him or anything, but CNA tells you to hurry up! AR said CNA B was always in a hurry and rough with cares. AR said she/he had pain in her/his arms and CNA B, who knew she/he had pain in the arms, would pull the arm up and yank her/his clothes off or pull on the hurt arm. AR said CNA B pushes you or throws you in the bed when she's transferring you. AR said she/he was afraid of CNA B. AR's body was shaking in the chair and increased as she/he talked. During an interview on 02/14/24 at 11:22 a.m., AE #1 said CNA B was mean and aggressive with cares. AE #1 said CNA B picked on Resident #7 all the time. AE #1 said CNA B made Resident #7 cry sometimes because of how bad she [CNA B] talked about her [Resident #7]. AE #1 said Resident #7 had behaviors of throwing herself out of the bed or wheelchair, but it was because she [Resident #7] was so mad and frustrated with CNA B picking on her all day long. AE #1 said she/he heard CNA B say things like, wipe your own a**! AE #1 said CNA B took Resident # 5's food away from him after he got back from dialysis, because sometimes he would be hungry and eat a lot of food since he did not eat at dialysis. AE #1 said she complained in front of Resident #5 if he ate too much, he was going to sh** everywhere. AE #1 said another resident [AR] complained CNA B was rude and rough with her/him, but the resident was too scared to report it because of retaliation. During an interview on 02/14/24 at 4:07 p.m., LVN G said she had worked at the facility for [AGE] years. She said she had never been told by a resident or staff CNA B was rough or rude to residents. She said she did not hear CNA B say cuss words to Resident #3. During an interview on 02/14/24 at 4:14 p.m., CNA E said she had worked at the facility for 5 years on the 2pm-10pm shift. She said she had heard residents being yelled at or staff refusing the resident care which she considered verbal abuse. She said it took the choices away from the resident making them feel helpless. She said she never saw who was verbally abusing the resident, just heard it. She said it happened on the 6am-2pm and 2pm-10pm shift. During an interview on 02/14/24 at 4:15 p.m., CNA B said she had been employed at the facility for a year. She said she normally worked the 2pm-10pm shift. She said she did not abuse any residents or was rough with cares. She said she did not have any issues with any of the residents. She said she did not have any issues with Resident #3, but she did try to take another person with her when she dealt with him. During an interview on 02/15/24 at 10:30 a.m., CNA J said she had been working for the facility since June 2022 but had previously worked at the facility for 4 years. She said she worked all shifts at the facility. She said she worked the middle hall (Rooms 201-216) and sometimes the B long hall (room [ROOM NUMBER]-228). She said several residents had complained about CNA B to her. She said Resident #3, Resident #5, Resident #7, and AR had complained about how CNA B talked to and treated them. She said CNA B's treatment of the residents made them feel like she did not like them. She said another resident told her CNA B cussed out Resident #3 and LVN G was there. She said when CNA B treats Resident #3 bad, he always says, I'm not putting with this sh**! During an interview on 02/15/24 at 11:22 a.m., CNA F said she had worked at the facility for [AGE] years on the 6am-2pm shift. She said she normally worked B long hall which were rooms 216-228. She said verbal and mental abuse was happening at the facility by CNA B. She said Resident #5 told her CNA B was too rough during cares and he was afraid of her. She said Resident #5 always asked the 6a-2pm shift to put him back to bed before they left because he did not want CNA B doing it. She said another resident reported to her CNA B was rough, talked harsh, and made them go to bed when she wanted them to. She said Resident #3 told her CNA B cussed at him and was ugly to him. She said the residents being abused probably felt sad, disgusted, or isolated themselves. During an interview on 02/15/24 at 1:20 p.m., the DON said she had known CNA B for a while and sometimes her tone was taken the wrong way. She said sometimes CNA B's tone and demeanor was aggressive. She said CNA B's aggressive tone or demeanor was not directed at the residents. She said it was just how CNA B was. She said she had done an in-service to all staff about their tone in November 2023. She said she had never done a 1:1 with CNA B about her tone and demeanor. She said CNA B had previous allegation of abuse last June (2023). She said staff had not recently told her of any residents complaining about CNA B's care or demeanor. She said recently Resident #3 told her CNA B and him had verbally got into, but he had called her a bit**. She said no formal disciplinary actions or report had been done on CNA B. During an interview on 02/15/24 at 2:09 p.m., the ADM said he was the abuse coordinator. He said CNA B had been verbally counseled a few times regarding how she spoke to residents. He said CNA B had been accused of abuse in June 2023. He said CNA B had employee disciplinary reports on file. He said CNA B had been monitored due to the previous abuse allegations by doing rounds. CNA B's employee disciplinary reports were requested during the interview and not received before exit. CNA B's employee disciplinary reports were received 6 days after exit. Record review of CNA B's proficiency dated 04/11/23 indicated .knowledge of abuse/neglect protocol .satisfactory .communication skills (respect/dignity) .satisfactory . Record review of CNA B's employee disciplinary report dated 02/02/24, indicated .CNA B .verbal counseling .Resident #3 complained that CNA B talked to him disrespectfully while attempting to provide care .reminded CNA B that this was the 2nd complaint regarding her tone with Resident #3 .another complaint would result in her suspension and/or termination .CNA B reported that she was only trying to get Resident #3 to get up and take a shower .Resident #3 needed to be cleaned up and was refusing .signature of supervisor presenting EDR:ADM .employee refused to sign .ADM (supervisor initial) .to be retained in employee's personnel file . The employee disciplinary report did not reveal CNA B's signature or date received and a witness initials of CNA B's refusal to sign. Record review of the facility's 12/23 staff sign in sheet indicated CNA B worked 24 days, 2pm-10pm shift on the hall where Resident #3, Resident #5, and Resident #7 resided. Record review of a facility's Be mindful of your tone and how you say things to and around the residents in-service dated 11/14/23 reflected CNA B's signature was noted on the attendance roster. Record review of a facility's Abuse, Neglect, and reportable events in-service dated 01/30/24 indicated .all resident have the right to be free from abuse, neglect .residents should not be subjected to abuse by anyone .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 . CMA L, LVN G, LVN H, CNA E, CNA F signature was noted on the attendance roster. CNA B signature was not noted on the attendance roster. Record review of a facility's Abuse/Reportable Events policy dated 01/17 indicated .all residents have the right to be free from abuse, neglect .residents should not be subjected to abuse by anyone .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 .abuse: the willful infliction of injury .intimidation .pain or mental anguish .it included verbal abuse, sexual abuse, physical abuse, and mental abuse .mental abuse .includes, but not limited to humiliation, harassment, threats of punishment or deprivation .verbal abuse .any use of oral, written or gestured language that willfully disparaging and derogatory terms to resident . This was determined to be an Immediate Jeopardy (IJ) on 02/23/24 at 3:10 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 02/23/24 at 3:10 p.m. 2/24/2024 Plan of Removal - F 600 Immediate Action Taken Resident Specific CNA B was suspended pending investigation on 2/15/2024 at 3:30pm. CNA B was terminated on 2/21/2024 at 2:21pm. CNA B did not work in the facility after allegations of verbal abuse were brought to the Administrator, by the HHSC surveyor on 2/15/2024. Residents #3, #5, and #7 were interviewed by the Administrator on 2/15/2024. Residents #3, #5, and #7's Responsible Parties notified of the verbal abuse allegation on 2/15/2024. Residents #3, #5, and #7 had head to toe assessments performed by the Treatment Nurse on 2/15/2024. MD notified of the IJ on 2/23/2024 at 4:48pm by Administrator, no new orders received. System Changes All interviewable residents were interviewed by Administrator regarding abuse, safety, who to report concerns to, and complaint resolution on 2/23/2024. All non-interviewable residents received a head-to-toe skin assessment, to assess for any injuries or evidence of abuse, by Charge Nurses, Director of Nursing and Treatment Nurse on 2/23/2024. All residents in the facility received head to toe skin assessments, to assess for any injuries or evidence of abuse, by Charge Nurses, Director of Nursing and Treatment Nurse on 2/23/2024. Direct care staff interviewed on 2/24/2024 by Administrator regarding abuse and whether they have witnessed any abuse. All resident care plans revised to include being at risk for mental/emotional distress on 2/23/2024 by Regional Reimbursement Consultant. Abuse/Reportable Event policy reviewed on 2/23/2024 at 5:15pm by Administrator, Regional Nurse, and Director of Nursing. No changes made to policy at this time. Education Director of Nursing provided education to all staff regarding the Abuse/Reportable Event Policy, including types of abuse, definition of verbal and mental abuse, reporting requirements. All staff present in the facility were educated on 2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Director of Nursing provided education to all staff regarding the Grievance Policy, including how to file a grievance, timely resolution, and that residents are able to voice grievances without fear of reprisal or discrimination. All staff present in the facility were educated on 2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding the Abuse/Reportable Event Policy on 2/23/2024 at 5:45pm. Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding the Grievance Policy on 2/23/2024 at 5:45pm. On 02/24/24 a surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of CNA B's termination letter. CNA B was suspended immediately and was officially terminated by telephone on 02/21/24. Record review of an Abuse Pre/Post test. The administrator said this was the test used for educational purposes concerning the staff. The test consisted of 20 questions covering the different types of abuse and reporting of allegations. There was a situation question at the end of the test. Record review of an In-Service Form indicated an in-service for the Administrator and the DON was held on 02/23/24. The in-service was presented by the Regional Clinical Consultant. The topic was the Grievance - Voicing and Resolution facility policy. The policy included how to file a grievance and promptly attempting to resolve grievances. Record review of an In-Service Form indicated an in-service for the Administrator and the DON was held on 02/23/24. The in-service was presented by the Regional Clinical Consultant The topic was Abuse/Neglect and reportable events. The In-service included definitions of abuse, screening of personnel, training of personnel, prevention of abuse, identification of abuse, reporting, and protection of the residents. Record review of an In-Service Form indicated an in-service for all staff was held on 02/23/24. The in-service was presented by the DON. The topic was the Grievance - Voicing and Resolution facility policy. The policy included how to file a grievance and promptly attempting to resolve grievances. Record review of an In-Service Form indicated an in-service for all staff was held on 02/23/24. The in-service was presented by the DON. The topic was Abuse/Neglect and reportable events. The In-service included definitions of abuse, screening of personnel, training of personnel, prevention of abuse, identification of abuse, reporting, and protection of the residents. Record review of Employee Disciplinary Reports for CNA E, CNA F, LVN G, and CNA J dated 02/24/24 indicated they received verbal counseling for failing to report an allegation of abuse/neglect to the Abuse Coordinator. The report indicated the employees were re-educated on the abuse/reportable events policy/procedure. Each employee had signed their report. During interviews and observations conducted on 2/24/24 beginning at 1:30 p.m. through 2:00 p.m., 12 of 51 residents were observed and they showed no signs of untimely care and there were no signs of abuse. Out of the 12 residents observed, 7 were interviewable. Each said they had been educated in the last 24 hours concerning abuse and who to report any abuse to. Each of the 7 residents denied abuse of any kind. The also said they had been assessed by a nurse. (Residents interviewed and observed were Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14) (Non-interviewable observed were Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19). Record review of the observed residents indicated each had been assessed by a nurse. There were skin assessments dated 2/23/24 for each of the 12 residents. Each of the 12 residents' care plan had been revised to include being at risk for mental/emotional distress on 2/23/2024. During interviews conducted on 02/24/24 beginning at 2:00 p.m. through 3:38 p.m., 19 of 33 of all staff in-serviced (including staff across all shifts that were the Administrator, the DON, the Treatment Nurse, CNAs, LVNs, RNs, Dietary Manager, Medical Records/Housekeeping Supervisor, and Activity Director) were interviewed. All staff said they received education on signs and symptoms of abuse, who and when to report abuse, types of abuse, reporting requirements, how to file a grievance, timely resolution, and resident being able to voice grievances without fear of reprisal or discrimination. The Treatment nurse said she had assisted in completing the head-to-toe assessments and skin assessments of each resident on 02/23/24. CNA E, CNA F, LVN G and CNA J said they had received verbal counseling on reporting abuse to the abuse coordinator immediately if they became aware of any abuse. During an interview on 2/24/24 at 3:27 p.m., the DON said she conducted the initial in-service on 02/23/24 and another on the morning of 02/24/24. She said she planned to in-service every shift as they come on duty, until every staff member was in-serviced. She said she had in-serviced not just nursing staff but all staff in the facility. She said in-services were about the grievance policy, the abuse and neglect policy, reporting of abuse, and signs and symptoms of abuse. The DON said she was in-serviced by the Regional Nurse Consultant. She said she was in-serviced on the different types of abuse and reporting abuse. She said the Administrator was the Abuse Coordinator. The DON said she was in-serviced on grievances and following up on them. She said grievances should be followed up on immediately and at least within 24 hours. She said all abuse should be reported immediately. During an interview on 2/24/24 at 3:34 p.m., Regional Clinical Consultant said she in-serviced the Administ [TRUNCATED]

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 6 of 7 residents (Resident #3, Resident #5, Resident #7, Resident #2, Resident #6, Anonymous Resident) reviewed for abuse/neglect. The facility failed to follow the facility's policy to ensure CNA B did not verbally and mentally abuse Resident #7, Resident #5, Resident #3, and Anonymous Resident. The facility failed to follow the facility's policy to ensure CNA B did not cause Resident #7 and Anonymous Resident pain when providing ADL care. The facility failed to follow the facility's policy to ensure Resident #2 did not experience verbally aggressive behaviors from CNA B. The facility failed to follow the facility's policy to ensure Resident #6 did not experience emotional distress when CNA B would refuse to change her or speak to her in an unprofessional manner. The facility failed to ensure when Resident #3 filed a complaint/grievance on 02/09/24 indicating CNA B treated him like trash, it was investigated by the facility's ADM/ Abuse Preventionist within 24 hours of the complaint/grievance per the facility's policy. The facility ADM/ Abuse Preventionist had not completed the investigation process until surveyor entrance on 02/14/24. The facility failed to ensure when Resident #3 filed a complaint/grievance on 02/09/24 indicating CNA B treated him like trash, it was reported to HHSC within 2 hours of allegation by the facility's ADM/ Abuse Preventionist per the facility's policy. The facility ADM/ Abuse Preventionist had not reported alleged allegations of abuse until surveyor entrance on 02/14/24. The facility failed to ensure the ADM/Abuse Preventionist, followed the facility's policy to identify, correct, and intervene in situations for possible abuse or mistreatment by CNA B when Resident #4 filed a complaint/grievance on 02/09/24 indicating CNA B was mean and he had overhead a CNA being ugly to another resident. The facility failed to ensure the ADM/Abuse Preventionist, CNA E, CNA J, CNA F, LVN G and AE #1, followed the facility's policy to implement measures to protect residents from harm during and following alleged allegations of abuse by CNA B. The facility failed to ensure CNA E, CNA J, CNA F, LVN G and AE #1 immediately verbally reported allegations of abuse and mistreatment to the ADM/Abuse Preventionist per the facility's policy. The facility failed to ensure AR was not afraid of retaliation for reporting abuse by CNA B. An Immediate Jeopardy (IJ) situation was identified on 02/23/24 at 3:10 p.m. while the IJ was removed on 02/24/24 at 3:45 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, neglect, and decreased quality of life. Findings included: Record review of a facility's Abuse/Reportable Events policy dated 01/17 indicated .all residents have the right to be free from abuse, neglect .residents should not be subjected to abuse by anyone .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 .abuse: the willful infliction of injury .intimidation .pain or mental anguish .it included verbal abuse, sexual abuse, physical abuse, and mental abuse .mental abuse .includes, but not limited to humiliation, harassment, threats of punishment or deprivation .verbal abuse .any use of oral written or gestured language that willfully disparaging and derogatory terms to resident .mistreatment: means inappropriate treatment or exploitation of a resident .all reports or suspicion of abuse/neglect .will investigated as facility protocol .investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint .appropriate notification to state and home office will be the responsibility of the administrator .the facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect .facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents .to the facility administrator .the facility administrator or designee will report the allegation to HHSC .if allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation .comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist .the facility will take necessary measure to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of resident . Record review of the facility's Grievance/Complaint log dated 02/24 indicated .02/09/24 .Resident: Resident#3 .Person filing report: Resident #3, Date of Incident: 2/9/24 .Person Investigating: ADM .Date Resident/Family Informed of Findings: 2/9/24 .Disposition of Complaint: CNA treat him like trash . Record review of Resident #3 's Grievance/Complaint Investigation Report dated 02/09/24 indicated .Describe the incident as provided by the resident/individual: Res [Resident #3] states that CNA B treat him like trash .Recommendations/corrective action taken .CNA B have been counseled regarding their care administration and how they address Resident #3 . There was no documented date of when the recommendations/corrective action taken was done. There was no documentation noted for, Describe your findings of the incident, Was grievance/complaint resolved to the satisfaction of all concerned, Date resident/individual received report of findings, or .I, blank, certify that I have received a copy of the documents surrounding the grievance/complaint filed on . Record review of the facility's Grievance/Complaint log dated 02/24 indicated .02/09/24 Resident: Resident #4 .Person filing report: Resident #4 .Date of Incident: 2/9/24 . Person Investigating: ADM .Date Resident/Family Informed of Findings: 2/9/24 .Disposition of Complaint: CNA 's mean . Record review of Resident #4's Grievance/Complaint Investigation Report dated 02/09/24 indicated .Describe the incident as provided by the resident/individual: Res [Resident #4] state CNA's .CNA B .are mean .Res [Resident #4] has overheard CNA being ugly to other Res . There was no documentation noted for, Describe your findings of the incident, Recommendation/corrective action taken, Was grievance/complaint resolved to the satisfaction of all concerned, Date resident/individual received report of findings, or .I, 'blank', certify that I have received a copy of the documents surrounding the grievance/complaint filed on . 1. Record review of Resident #3's face sheet printed 02/15/24 indicated Resident #3 was a [AGE] year-old male and admitted on [DATE] with diagnoses including schizoaffective disorder (is a mental health condition), generalized anxiety disorder (is a condition of excessive worry about everyday issues and situations), cognitive communication (problems with communication that have an underlying cause in a cognitive deficit), and muscle wasting and atrophy (shortening). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3 was understood and had the ability to understand others. The MDS indicated Resident #3 had unclear speech, adequate hearing, and adequate vision. The MDS indicated Resident #3 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #3 did not have psychosis, behavioral symptoms, or rejection of care. The MDS indicated Resident #3 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and partial/moderate assistance (helper does less than half the effort) for oral hygiene, upper body dressing and toilet transfer. The MDS indicated Resident #3 was occasionally incontinent for urine and frequently incontinent for bowel. Record review of Resident #3's care plan dated 06/12/22, edited on 01/11/24 indicated Resident #3 had potential for injury related to falls due to history of previous fall. Intervention included remind/encourage resident to use call light to gain assistance. During an interview on 02/15/24 at 12:04 p.m., Resident #3 said CNA B acted like she was better than him. He said CNA B said mean stuff to him all the time. He said CNA B did cuss at him and recently cussed him out after she helped him in the shower. He said CNA B made him feel like an outcast. 2. Record review of Resident #5's face sheet printed 02/15/24 indicated Resident #5 was a [AGE] year-old male and admitted on [DATE] with diagnoses including hemiplegia (is paralysis that affects only one side of your body) and hemiparesis (is weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction affecting non dominant side, cerebral infarction (stroke), acquired absence of right leg below knee, and end stage renal disease (is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 was understood and had the ability to understand others. The MDS indicated Resident #5 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #5 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #5 had functional limitation range of motion to lower extremities to one side. The MDS indicated Resident #5 required partial/moderate assistance (helper does less than half the effort) for oral and toileting hygiene, shower/bathe self, dressing, and personal hygiene, and substantial/maximal assistance for sit to stand, chair/bed-to-chair, toilet, and tub/shower transfer. The MDS indicated Resident #5 had frequent incontinence for urine and bowel. Record review of Resident #5's care plan dated 01/20/24 indicated Resident #5 had an ADL self-care performance deficit and limited physical mobility. Intervention included the resident required extensive assistance for bed mobility, toilet use and transfer. During an interview on 02/15/24 at 12:00 p.m., Resident #5 said CNA B was not easy to work with. He said the facility wanted CNA B to use the mechanical lift to transfer him, but she did not which made her pick him up from the wheelchair and push him on the bed. He said she sometimes acted like she was afraid to transfer him because she thought he would put poop on her. He said sometimes she put his coat in his wheelchair to sit on so he could poop on it instead of the facility's linen. He said CNA B did not want him eating his snacks because it made him have loose bowels. He said CNA B talked rough to him and kind of turned and cleaned him rough. He said he was not afraid of her. He said sometimes she tells him, Don't talk to me! He said CNA B did not know how to talk to people. He said CNA B put him in hospital gowns instead of shirts, which he would ask for, but was always told gowns were easier. He said CNA B was not very nice to Resident #3, his roommate. He said she throws his clothes in the trash and talked rough to him. 3. Record review of Resident #7's face sheet printed on 02/15/24 indicated Resident #7 was a [AGE] year-old female and admitted on [DATE] and latest return on 02/15/24 with diagnoses including nontraumatic intracranial hemorrhage (brain bleed), flaccid hemiplegia affecting left side non dominant (the affected extremity exhibits decreased muscle tone and cannot be actively moved by the patient), legal blindness, muscle weakness, muscle wasting and atrophy (shortening), body mass index 50.0-59.9 (morbidly obese), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated Resident #7 was understood and had the ability to understand others. The MDS indicated Resident #7 had adequate hearing, clear speech, and severely impaired vision. The MDS indicated Resident #7 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #7 had functional limitation in range of motion to her upper and lower extremities on one side. The MDS indicated Resident #7 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, dressing, personal hygiene, roll left and right and dependent for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The MDS indicated Resident #7 was always incontinent for urine and bowel. Record review of Resident #7's care plan dated 06/10/22, edited 02/14/24 indicated Resident #7 had an ADL self-care performance deficit and limited physical mobility. Intervention included bed mobility, bathing and toilet use required extensive assistance and total assistance required for transfers. Record review of Resident #7's care plan dated 08/02/22, edited 02/14/24 indicated Resident #7 had demonstrated demanding behaviors towards others, yelling out for assistance when request for assistance is not answered immediately, desiring one on one constant help/assist from staff. Intervention included offer an outlet for resident to express feelings, wishes and frustrations. During an interview on 02/14/24 at 10:35 a.m., Resident #7 said she did not get along CNA B. She said CNA B jerked her arm and caused her pain when she got her up and called her fat. She said CNA B said things like I'm [CNA B] a buck 75 and you're [Resident #7] 300 pounds, so you need to help me or You [Resident #7] don't even try to help me [CNA B]. She said her left arm was bad so she could not help from that side. She said her family member filed a grievance about CNA B treatment of her. She said the ADM and DON were aware of CNA B's being mean and saying hurtful things to her. She said when CNA B said mean things to her, it made her sad. She said the DON and CNA B were friends, and nothing seemed to happen when you complained about CNA B. During an interview on 02/14/24 at 11:00 a.m., Resident #7's family member #1 said she complained to the DON and ADM about CNA B being mean to Resident #7, but nothing happened. She said the first time she reported CNA B was probably in November 2023. She said the DON told her CNA B would not be Resident #7's CNA. She said as time went on CNA B still was Resident #7's aide. She said the family kind of dealt with CNA B still being Resident #7's aide because the facility was short staffed. She said around December 2023, AE #1 called her at home and told her she needed to check on Resident #7 because CNA B was mistreating her. She said AE #1 told her she reported CNA B's mistreatment to the DON. She said when she filed the complaint on 12/26/23, she told the DON that CNA B said rude and hurtful things to her family member. She said she told the DON, CNA B always commented on Resident #7's weight. She said CNA B also told Resident #7, nobody care is she told her family about things because if her family really cared about Resident #7, they would not have put her in nursing home. She said CNA B also said things like I don't have time to be doing this or I'm busy, so I ain't doing that. She said the family had been pretty much just accepting any care that was given from CNA B, because nothing was being done. She said CNA N and the DON were pretty cool with each other so maybe that was why nothing happened. During an interview on 02/15/24 at 10:20 a.m., Resident #7's family member #2 said Resident #7 told her CNA B was rough, mean, and talked to her in a demeaning way. She said CNA B behavior upset Resident #7 and when CNA B was not working, Resident #7 was happy and relieved. During an interview on 02/15/24 at 11:00 a.m., Resident #7's family member #3 said Resident #7 complained CNA B was rude to her and does not treat her right. He said Resident #7 complained CNA B commented on her weight and told him I can't stand her! 4. Record review of Resident #2's face sheet printed 02/15/24, indicated Resident #2 was an [AGE] year-old, female and admitted on [DATE] and 04/22/22 with diagnoses including unilateral primary osteoarthritis (is a chronic condition affecting the joints), depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (is a condition of excessive worry about everyday issues and situations). Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was understood and had the ability to understand others. The MDS indicated Resident #2 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #2 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #2 required set-up or clean-up assistance for oral and toilet hygiene, shower/bathe self, and upper body dressing and supervision or touching assistance for lower body dressing, putting on/taking off footwear, transfers, and personal hygiene. The MDS indicated Resident #2 was occasionally incontinent of urine and bowel. Record review of Resident #2's care plan dated 03/01/22, edited on 01/30/24, indicated Resident #2 had potential for injury related to falls due to unsteady gait, attempted to stand unassisted, and lost balance easily. Intervention included resident educated on importance of using call light to gain assistance. During an interview on 02/14/24 at 12:45 p.m., Resident #2 said CNA B was verbally aggressive to her and other residents. She said the few times CNA B was verbally aggressive to her, it made her mad. She said she had not reported CNA B to the ADM because when she was admitted 2 years ago, other residents told her not to talk to the state or corporate people because the staff would retaliate. She said, so I've kept my mouth shut. 5. Record review of Resident #6's face sheet printed 02/15/24 indicated Resident #6 was an [AGE] year-old, female and admitted on [DATE] with diagnoses including age related cognitive decline (overall slowness in thinking and difficulties sustaining attention, multitasking, holding information in mind and word-finding), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and chronic kidney disease, stage 3 (is a type of kidney disease in which a gradual loss of kidney function occurs over a period of months to years). Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was understood and had the ability to understand others. The MDS indicated Resident #6 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #6 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #6 required partial/moderate assistance for oral hygiene, upper body dressing, and personal hygiene and substantial/maximal assistance for toilet hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident #6 was always incontinent of urine and bowel. During an interview on 02/15/24 at 10:03 a.m., Resident #6 said CNA B spoke to you a nasty way. She said when you asked CNA B for something, she would say, What you want? or Well, I [CNA B} ain't got no time for that! She said CNA B did not say those things in a joking manner. She said CNA B had smarted off at her and a bunch of folks. She said CNA B refused to change her and would get someone else to do it. She said CNA B's actions hurt her feelings and made her feel like she did something wrong. 6. Record review of Resident #4's face sheet printed 02/15/24 indicated Resident #4 was a [AGE] year-old, male and admitted on [DATE] and 03/28/23 with diagnoses including multiple sclerosis (is a potentially disabling disease of the brain and spinal cord (central nervous system)), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and muscle wasting and atrophy (shortening). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4 was understood and had the ability to understand others. The MDS indicated Resident #4 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #4 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #4 required partial/moderate assistance for toileting hygiene, shower/bath self, and dressing. The MDS indicated Resident #4 was occasional incontinent of urine and frequently incontinent of bowel. Record review of Resident #4's care plan dated 12/26/23, edited on 01/09/24 indicated Resident #4 had potential for injury related to fall due to history of previous falls. Intervention included encourage resident to participate in activities program that encourages exercise and physical activity for strengthening and improved mobility. During an interview on 02/14/24 at 1:15 p.m., Resident # 4 said CNA B intimated the poor, old ladies on her hall. He said CNA B was so mean to AR sometimes, AR would start shaking. He said about 1-2 weeks ago, he heard CNA B tell Resident #3, Now, take your a** back to your room after she helped him take a shower. He said LVN G was standing by the shower door, so he did not know how LVN G did not hear CNA B cussing at Resident #3. He said he had filed a grievance at the beginning of the month about CNA behavior. He said it did not really do any good to report stuff because nothing happened. 7. During an interview and observation on 02/14/24 at 1:30 p.m., AR said he/she had been putting up with CNA B's behaviors for a while. AR said CNA B got a better attitude for a while then she went back to being bad. AR said she never hit her/him or anything, but CNA tells you to hurry up! AR said CNA B was always in a hurry and rough with cares. AR said she/he had pain in her/his arms and CNA B, who knew she/he had pain in the arms, would pull the arm up and yank her/his clothes off or pull on the hurt arm. AR said CNA B pushes you or throws you in the bed when she's transferring you. AR said she/he was afraid of CNA B. AR body was shaking in the chair and increased as she/he talked. During an interview on 02/14/24 at 11:22 a.m., AE #1 said CNA B was mean and aggressive with cares. AE #1 said CNA B picked on Resident #7 all the time. AE #1 said CNA B made Resident #7 cry sometimes because of how bad she [CNA B] talked about her. AE #1 said Resident #7 had behaviors of throwing herself out of the bed or wheelchair, but it was because she [Resident #7] was so mad and frustrated with CNA B picking on her all day long. AE #1 said she/he heard CNA B say things like, wipe your own a**! AE #1 said CNA B took Resident # 5's food away from him after he got back from dialysis, because sometimes he would be hungry and eat a lot of food since he did not eat at dialysis. AE #1 said she [CNA B] complained in front of Resident #5 if he ate too much, he was going to sh** everywhere. AE #1 said another resident [AR] complained CNA B was rude and rough with her/him, but the resident was too scared to report it because of retaliation. AE #1 said the resident [AR #5] was so scared about reporting CNA B, the resident [AR] was literally shaking from the fear of CNA B. AE #1 said she/he reported the resident [AR] complaint about CNA B's treatment to a nurse and the nurse said CNA B was being investigated. AE #1 said she/he did not want to disclose the nurse's name. During an interview on 02/14/24 at 4:07 p.m., LVN G said she had worked at the facility for [AGE] years. She said she had not heard or seen any abuse at the facility. She said she had never been told by a resident or staff CNA B was rough or rude to residents. She said she did not hear CNA B say cuss words to Resident #3. She said she knew to report abuse and neglect to DON or ADM immediately. During an interview on 02/14/24 at 4:14 p.m., CNA E said she had worked at the facility for 5 years on the 2pm-10pm shift. She said she had heard residents being yelled at or refusing staff the resident care which she considered verbal abuse. She said it took the choices away from the resident making them feel helpless. She said she never saw who was verbally abusing the resident, just heard it. She said it happened on the 6am-2pm and 2pm-10pm shift. She said she knew she was supposed to report abuse allegation but felt it was pointless because nothing happened to the person. She said not reporting abuse risked the abuse to keep happening. She said the verbal abuse made the residents defensive and not ask for help from staff. During an interview on 02/14/24 at 4:15 p.m., CNA B said she had been employed at the facility for a year. She said she normally worked the 2pm-10pm shift. She said she had recently received abuse training. She said she did not abuse any residents or was rough with cares. She said she did not have any issues with any of the residents. She said she did not have any issues with Resident #3, but she did try to take another person with her when she dealt with him. During an interview on 02/15/24 at 10:30 a.m., CNA J said she had been working for the facility since June 2022 but had previously worked at the facility for 4 years. She said she worked all shifts at the facility. She said she worked the middle hall (Rooms 201-216) and sometimes the B long hall (room [ROOM NUMBER]-228). She said several residents had complained about CNA B to her. She said Resident #3, Resident #5, Resident #7, and AR had complained about how CNA B talked to and treated them. She said she had reported the complaints, in the last 1-2 months, to the DON. She said CNA B's treatment of the residents made them feel like she did not like them. She said another resident told her CNA B cussed out Resident #3 and LVN G was there. She said when CNA B treats Resident #3 bad, he always said, I'm not putting with this sh**! During an interview on 02/15/24 at 11:22 a.m., CNA F said she had worked at the facility for [AGE] years on the 6am-2pm shift. She said she normally worked B long hall which were rooms 216-228. She said verbal and mental abuse was happening at the facility by CNA B. She said Resident #5 told her CNA B was too rough during cares and he was afraid of her. She said Resident #5 always asked the 6a-2pm shift to put him back to bed before they left because he did not want CNA B doing it. She said another resident reported to her CNA B was rough, talked harsh, and made them go to bed when she wanted them to. She said Resident #3 told her CNA B cussed at him and was ugly to him. She said she had reported the resident's complaint to LVN G, and she said CNA B treatment to resident had been reported. She said the residents being abused probably felt sad, disgusted, or isolated themselves. She said she had abuse training and knew the ADM was the abuse coordinator. During an interview on 02/15/24 at 1:20 p.m., the DON said she had known CNA B for a while and sometimes her tone was taken the wrong way. She said sometimes CNA B's tone and demeanor was aggressive. She said CNA B's aggressive tone or demeanor was not directed at the residents. She said it was just how CNA B was. She said staff had not recently told her of any residents complaining about CNA B's care or demeanor. She said recently Resident #3 told her CNA B and him had verbally got into, but he had called her a bit**. She said no formal disciplinary actions or report had been done on CNA B. She said she did not know if a safe survey had been done recently because the SW did those. She said staff should first report abuse allegations to the ADM and then her (DON). She said staff should report abuse allegation to the ADM or DON, immediately. During an interview on 02/15/24 at 2:09 p.m., the ADM said he was the abuse coordinator. He said CNA B had employee disciplinary reports on file. He said CNA B had been monitored due to the previous abuse allegations by doing rounds. He said he expected staff to immediately notify him of any allegation of abuse. He said staff were told in orientation and in-serviced on the abuse policy. He said residents were educated on reporting abuse allegations in resident council meetings and he had an open-door policy. He said he had communicated with staff and resident that retaliation would not occur if they reported allegations of abuse. CNA B's employee disciplinary reports were requested during the interview and not received before exit. CNA B's employee disciplinary reports were received 6 days after exit. During an interview on 02/15/24 at 2:26 p.m. the SW said she was responsible for documenting resident's grievances on the grievance/complaint log and report. She said the grievance then went to department heads the complaint was related to. She said she did not remember receiving a complaint/grievance about abuse from a resident. She said she had received a complaint from Resident #4, but it was a CNA but not CNA B. During an interview on 02/15/24 at 2:30 p.m., the ADM said CNA B had been mentioned in February 2024 grievances by Resident #4. He said he had not given February's grievance report when requested at entrance because he was still investigating the allegations. During an interview on 02/23/24 at 3:26 p.m., the ADM said typically Social Services wrote up any grievance or complaints and brought them to him to be resolved. He said he then went to the appropriate department heads for resolution. He said he was working through the grievances and there were 3 - 4 that had not been resolved at the time of the initial complaint investigation. He said it had only been 2 - 3 days since he had received the grievances when the initially investigation started on 02/14/24. Record review of CNA B's proficiency dated 04/11/23 indicated .knowledge of abuse/neglect protocol .satisfactory .communication skills (respect/dignity) .satisfactory . Record review of CNA B's employee disciplinary report dated 02/02/04, indicated .CNA B .verbal counseling .Resident #3 complained that CNA B talked to him disrespectfully while attempting to provide care .reminded CNA B that this was the 2nd complaint regarding her tone with Resident #3 .another complaint would result in her suspension and/or termination .CNA B reported that she was only trying to get Resident #3 to get up and take a shower .Resident #3 needed to be cleaned up and was refusing .signature of supervisor presenting EDR:ADM .employee refused to sign .ADM (supervisor initial) .to be retained in employee's personnel file . The employee disciplinary report did not reveal CNA B's signature or date received and a witness initials of CNA B's refusal to sign. Record review of the facility's 12/23 staff sign in sheet indicated CNA B worked 24 days, 2pm-10pm shift on the hall where Resident #3, Resident #5, and Resident #7 resided. Record review of a facility's Be mindful of your tone and how you say things to and around the residents in-service dated 11/14/23 reflected CNA B's signature was noted on the attendance roster. Record review of a facility's Abuse, Neglect, and reportable events in-service dated 01/30/24 indicated .all resident have the right to be free from abuse, neglect .residents should not be subjected to abuse by[TRUNCATED]

Based on interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation is made, if the event that cause the allegation involved abuse to the administrator of the facility and to other officials (including to the State Agency) for 2 of 7 residents (Resident #3 and Resident #4) and 6 of 9 staff members (ADM, CNA E, CNA J, CNA F, LVN G, and AE #1) reviewed for reporting of abuse, neglect and mistreatment. The facility failed to ensure when Resident #3 filed a complaint/grievance on 02/09/24 indicating CNA B treated him like trash, it was reported to HHSC within 2 hours of allegation by the facility's ADM/ Abuse Preventionist. The facility ADM/ Abuse Preventionist had not reported alleged allegations of abuse by CNA B . The facility failed to ensure when Resident #4 filed a complaint/grievance on 02/09/24 indicating CNA B was mean and he had overhead a CNA being ugly to another resident it was reported to HHSC within 2 hours of allegation by the facility's ADM/ Abuse Preventionist. The facility ADM/ Abuse Preventionist had not reported alleged allegations of abuse by CNA B . The facility failed to ensure CNA E reported to the ADM when she heard staff verbally abusing residents. CNA E did not report verbal abuse because it was pointless because nothing would happen. The facility failed to ensure CNA J reported to the ADM when she received multiple complaints of abuse and mistreatment from CNA B. The facility failed to ensure CNA F reported to the ADM when she received multiple complaints of abuse from CNA B. CNA F only informed LVN G of the allegations of abuse and mistreatment from CNA B. LVN G informed CNA F, CNA B's mistreatment to the residents had been reported. The facility failed to ensure LVN G reported to the ADM when CNA F reported allegations of abuse and mistreatment from CNA B. The facility failed to ensure AE #1 reported to the ADM when she received complaints of abuse and witnessed verbal/mental abuse from CNA B. An Immediate Jeopardy (IJ) situation was identified on 02/23/24 at 3:10 p.m. while the IJ was removed on 02/24/24 at 3:45 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for continued alleged violations, diminished quality of life and harm. Findings included: Record review of the facility's Grievance/Complaint log dated 02/24 indicated .02/09/24 .Resident: Resident #3 .Person filing report: Resident #3, Date of Incident: 2/9/24 .Person Investigating: ADM .Date Resident/Family Informed of Findings: 2/9/24 .Disposition of Complaint: CNA treat him like trash . Record review of the facility's Grievance/Complaint log dated 02/24 indicated .02/09/24 Resident: Resident#4 .Person filing report: Resident #4 .Date of Incident: 2/9/24 . Person Investigating: ADM .Date Resident/Family Informed of Findings: 2/9/24 .Disposition of Complaint: CNA 's mean . During an interview on 02/14/24 at 11:22 a.m., AE #1 said CNA B was mean and aggressive with cares. AE #1 said she/he reported the resident [AR] complaint about CNA B's treatment to a nurse, not the ADM, and the nurse said CNA B was being investigated. AE #1 said she/he did not want to disclose the nurse's name. AE #1 said she/he did not report the incident to the ADM because she/he was told it was being investigated. During an interview on 02/14/24 at 4:07 p.m., LVN G said she had never been told by a resident or staff CNA B was rough or rude to residents. She said she did not hear CNA B say cuss words to Resident #3. She said she knew to report abuse and neglect to DON or ADM immediately. During an interview on 02/14/24 at 4:14 p.m., CNA E said she had heard residents being yelled at or staff refusing the resident care which she considered verbal abuse. She said she knew she was supposed to report abuse allegations but felt it was pointless because nothing happened to the person. She said not reporting abuse risked the abuse to keep happening. During an interview on 02/15/24 at 10:30 a.m., CNA J said several residents had complained about CNA B to her. She said she had reported the complaints, in the last 1-2 months, to the DON, not the ADM. During an interview on 02/15/24 at 11:22 a.m., CNA F said verbal and mental abuse was happening at the facility by CNA B. She said another resident reported to her CNA B was rough, talked harsh, and made them go to bed when she wanted them to. She said she had reported the resident's complaint to LVN G but not the DON or ADM, and she said CNA B's treatment to residents had been reported. She said which was why she did not report the complaints to the DON and ADM. She said she had abuse training and knew the ADM was the abuse coordinator. Unable to interview AE #1 due to AE #1 calling from an undisclosed phone number. During an interview on 02/15/24 at 1:20 p.m., the DON said staff had not recently told her of any residents complaining about CNA B's care or demeanor. She said staff should first report abuse allegations to the ADM and then her (DON). She said staff should report abuse allegations to the ADM or DON, immediately. During an interview on 02/15/24 at 2:09 p.m., the ADM said he was the abuse coordinator. He said he expected staff to immediately notify him of any allegation of abuse. He said abuse allegation had been reported to him a couple months ago in November or December 2023. He said he did not recall the resident and staff involved in the allegation, but he had made a self-report. He said CNA B had been verbally counseled a few times regarding how she spoke to residents. He said CNA B had been accused of abuse during full book survey in June 2023. He said he did not know the results of investigation but if CNA B was guilty, she would not still be working at the facility. He said CNA B had employee disciplinary reports on file. He said CNA B had been monitored due to the previous abuse allegations by doing rounds. He said staff were told in orientation and in-serviced on the abuse policy. During an interview on 02/23/24 at 2:50 p.m., LVN G said the abuse coordinator was the ADM. She said any abuse of any kind should be reported to him immediately. She said any staff could get in trouble for not reporting abuse to the Abuse Coordinator. She said not reporting abuse could hurt a resident. During an interview on 02/23/24 at 2:57 p.m., CNA F said the DON was the Abuse Coordinator. She said if she saw anything wrong, she would tell the whole thing. She said, We are there to take care of them. She said she would report any abuse immediately. During an interview on 02/23/24 at 3:17 p.m., CNA E said the ADM was the Abuse Coordinator. She said she would report any kind of abuse to him. This included verbal abuse, financial abuse, physical abuse, and sexual abuse. She said any abuse should be reported immediately. She said not reporting abuse could cause residents to have mood changes and/or depression. During an interview on 02/23/24 at 3:26 p.m., the ADM said typically Social Services wrote up any grievance or complaints and brought them to him to be resolved. He said he then went to the appropriate department heads for resolution. He said he was working through the grievances and there were 3 - 4 that had not been resolved at the time of the initial complaint investigation. He said it had only been 2 - 3 days since he had received them. During an interview on 02/23/24 at 3:40 p.m., CNA J said the ADM and DON were the Abuse Coordinators. She said she would report any form of abuse. She said abuse could be physical, financial, sexual, or verbal. She said she would report anything concerning that was going on with the resident. She said not reporting abuse puts the residents in danger and would make her as bad at the one giving the abuse. Record review of a facility's Abuse, Neglect, and reportable events in-service dated 01/30/24 indicated .it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect . LVN G, CNA E, and CNA F's signatures were noted on the attendance roster. CNA J's signature was not noted on the attendance roster. Record review of a facility's Abuse/Reportable Events policy dated 01/17 indicated .all resident have the right to be free from abuse, neglect . it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect . facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents .to the facility administrator .the facility administrator or designee will report the allegation to HHSC .if allegations involve abuse or result in serious bodily injury, the report is the be made within 2 hours of the allegation . This was determined to be an Immediate Jeopardy (IJ) on 02/23/24 at 3:10 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 02/23/24 at 3:10 p.m. 2/24/2024 Plan of Removal - F 609 Immediate Action Taken Resident Specific Allegations of verbal abuse brought to the Administrator on 2/15/2024 at 3:30pm. Allegations of verbal abuse reported to HHSC by the Administrator on 2/15/2024 at 4:00pm. CNA B was suspending pending investigation on 2/15/2024 at 3:30pm. CNA B was terminated on 2/21/2024 at 2:21pm. CNA B did not work in the facility after allegations of verbal abuse were brought to the Administrator, by the HHSC surveyor on 2/15/2024. Residents #3, #5, and #7 were interviewed by the Administrator on 2/15/2024. Residents #3, #5, and #7's Responsible Parties notified of the verbal abuse allegation on 2/15/2024. Residents #3, #5, and #7 had head to toe assessments performed by the Treatment Nurse on 2/15/2024. MD notified of the IJ on 2/23/2024 at 4:48pm by Administrator, no new orders received. CNA E, CNA J, CNA F, and LVN G were given 1:1 in-service regarding abuse reporting - who to report to and when to report, on 2/24/2024 by Director of Nursing. CNA E, CNA J, CNA F, and LVN G were given documented verbal disciplinary action for failing to follow the facility's abuse policy, on 2/24/2024 by Administrator. System Changes All interviewable residents were interviewed by Administrator regarding abuse, safety, who to report concerns to, and complaint resolution on 2/23/2024. All non-interviewable residents received a head-to-toe skin assessment, to assess for any injuries or evidence of abuse, by Charge Nurses, Director of Nursing and Treatment Nurse on 2/23/2024. All residents in the facility received head to toe skin assessments, to assess for any injuries or evidence of abuse, by Charge Nurses, Director of Nursing and Treatment Nurse on 2/23/2024. All resident care plans revised to include being at risk for mental/emotional distress on 2/23/2024 by Regional Reimbursement Consultant. Abuse/Reportable Event policy reviewed on 2/23/2024 at 5:15pm by Administrator, Regional Nurse, and Director of Nursing. No changes made to policy at this time. Education Director of Nursing provided education to all staff regarding signs and symptoms of abuse, and who/when to report it on 2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Director of Nursing provided education to all staff regarding the Abuse/Reportable Event Policy, including types of abuse, definition of verbal and mental abuse, reporting requirements. All staff present in the facility were educated on2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Director of Nursing provided education to all staff regarding the Grievance Policy, including how to file a grievance, timely resolution, and that residents are able to voice grievances without fear of reprisal or discrimination. All staff present in the facility were educated on2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Director of Nursing provided education to all staff regarding Examples of Mental/Verbal Abuse, how to report those allegations, and that retaliation should never occur. All staff present in the facility were educated on 2/24/2024, at 11:30am. Staff not present for the education will receive the education prior to their next shift. Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding the Abuse/Reportable Event Policy including types of abuse, definition of verbal and mental abuse, and reporting requirements to HHSC, on 2/23/2024 at 5:45pm. Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding the Grievance Policy including how to file a grievance, their responsibility to investigate, assess and resolve, timely resolution of the grievance, and that residents are able to voice grievances without fear of reprisal or discrimination on 2/23/2024 at 5:45pm. On 02/24/24 a surveyor confirmed the facility implemented there plan of removal sufficiently to remove the IJ by: Record review of CNA B's termination letter. CNA B was suspended immediately and was officially terminated by telephone on 02/21/24. Record review of an Abuse Pre/Post test. The administrator said this was the test used for educational purposes concerning the staff. The test consisted of 20 questions covering the different types of abuse and reporting of allegations. There was a situation question at the end of the test. Record review of an In-Service Form indicated an in-service for the Administrator and the DON was held on 02/23/24. The in-service was presented by the Regional Clinical Consultant. The topic was the Grievance - Voicing and Resolution facility policy. The policy included how to file a grievance and promptly attempting to resolve grievances. Record review of an In-Service Form indicated an in-service for the Administrator and the DON was held on 02/23/24. The in-service was presented by the Regional Clinical Consultant The topic was Abuse/Neglect and reportable events. The In-service included definitions of abuse, screening of personnel, training of personnel, prevention of abuse, identification of abuse, reporting, and protection of the residents. Record review of an In-Service Form indicated an in-service for all staff was held on 02/23/24. The in-service was presented by the DON. The topic was the Grievance - Voicing and Resolution facility policy. The policy included how to file a grievance and promptly attempting to resolve grievances. Record review of an In-Service Form indicated an in-service for all staff was held on 02/23/24. The in-service was presented by the DON. The topic was Abuse/Neglect and reportable events. The In-service included definitions of abuse, screening of personnel, training of personnel, prevention of abuse, identification of abuse, reporting, and protection of the residents. Record review of Employee Disciplinary Reports for CNA E, CNA F, LVN G, and CNA J dated 02/24/24 indicated they received verbal counseling for failing to report an allegation of abuse/neglect to the Abuse Coordinator. The report indicated the employees were re-educated on the abuse/reportable events policy/procedure. Each employee had signed their report. During interviews and observations conducted on 2/24/24 beginning at 1:30 p.m. through 2:00 p.m., 12 of 51 residents were observed and they showed no signs of untimely care and there were no signs of abuse. Out of the 12 residents observed, 7 were interviewable. Each said they had been educated in the last 24 hours concerning abuse and who to report any abuse to. Each of the 7 residents denied abuse of any kind. The also said they had been assessed by a nurse. (Residents interviewed and observed were Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14) (Non-interviewable observed were Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19). Record review of the observed residents indicated each had been assessed by a nurse. There were skin assessments dated 2/23/24 for each of the 12 residents. Each of the 12 residents' care plan had been revised to include being at risk for mental/emotional distress on 2/23/2024. During interviews conducted on 02/24/24 beginning at 2:00 p.m. through 3:38 p.m., 19 of 33 of all staff in-serviced (including staff across all shifts that were the Administrator, the DON, the Treatment Nurse, CNAs, LVNs, RNs, Dietary Manager, Medical Records/Housekeeping Supervisor, and Activity Director) were interviewed. All staff said they received education on signs and symptoms of abuse, who and when to report abuse, types of abuse, reporting requirements, how to file a grievance, timely resolution, and resident being able to voice grievances without fear of reprisal or discrimination. The Treatment nurse said she had assisted in completing the head-to-toe assessments and skin assessments of each resident on 02/23/24. CNA E, CNA F, LVN G and CNA J said they had received verbal counseling on reporting abuse to the abuse coordinator immediately if they became aware of any abuse. During an interview on 2/24/24 at 3:27 p.m., the DON said she conducted the initial in-service on 02/23/24 and another on the morning of 02/24/24. She said she planned to in-service every shift as they come on duty, until ever staff member was in-serviced. She said she had in-serviced not just nursing staff but all staff in the facility. She said in-services were about the grievance policy, the abuse and neglect policy, reporting of abuse, and signs and symptoms of abuse. The DON said she was by the Regional Nurse Consultant. She said she was in-serviced on the different types of abuse and reporting abuse. She said the Administrator was the Abuse Coordinator. The DON said she was in-serviced on grievance and following up on them. She said grievances should be followed up on immediately and at least within 24 hours. She said all abuse should be report immediately. During an interview on 2/24/24 at 3:34 p.m., Regional Clinical Consultant said she in-serviced the Administrator and DON on the evening of 2/23/24. She said she in-serviced them on abuse and the reporting abuse. She said she in-serviced them on reporting abuse immediately. She said she in-serviced them on grievances being taken very seriously and following up on them immediately. She said they focused on verbal abuse and mental abuse but did discuss all types of abuse including physical, financial, and sexual abuse. They also discussed neglect. During an interview on 2/24/24 at 3:38 p.m., the Administrator said he was in-serviced the evening of 2/23/24 by Regional Nurse Consultant. He was in-serviced on abuse policy, grievance policy and reporting abuse. He said they went through the whole thing the different types of abuse, reporting of abuse, and following up timely on grievances. The Administrator was informed the Immediate jeopardy was removed on 02/24/24 at 3:45 p.m. the facility remained out of compliance at a severity level of potential harm with a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 3 residents reviewed for accidents. (Residents #7) The facility failed to ensure CNA A provided Resident #7 incontinence care with staff assist x2 per the care plan, which resulted in a fall on 02/08/24. The facility failed to ensure CNA B provided Resident #7 a bed bath with staff assist x2 per the care plan, which resulted in a fall with a laceration to the right foot and probable fracture to the fifth toe on 02/09/24. The facility failed to ensure MR D was trained to operate the mechanical lift for Resident #7's transfer on 02/09/24. These failures could place residents at risk of injury from accident and hazards. Findings included: Record review of Resident #7's face sheet printed on 02/15/24 indicated Resident #7 was a [AGE] year-old female and admitted on [DATE] and latest return on 02/15/24 with diagnoses including nontraumatic intracranial hemorrhage (brain bleed), flaccid hemiplegia affecting left side non dominant (the affected extremity exhibits decreased muscle tone and cannot be actively moved by the patient), legal blindness, muscle weakness, muscle wasting and atrophy (shortening), body mass index 50.0-59.9 (morbidly obese) and laceration to right foot. Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated Resident #7 was understood and had the ability to understand others. The MDS indicated Resident #7 had adequate hearing, clear speech, and severely impaired vision. The MDS indicated Resident #7 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #7 had functional limitation in range of motion to her upper and lower extremities on one side. The MDS indicated Resident #7 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, dressing, personal hygiene, roll left and right and dependent for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The MDS indicated Resident #7 was always incontinent for urine and bowel. Record review of Resident #7's care plan dated 06/26/22, edited on 02/14/24 indicated Resident #7 has potential for injury related to falls due to unsteady gait, history of previous falls, visual deficits, attempt to stand unassisted, and loses balance easily. Interventions included staff to assist x2 with bed mobility, transfer, and incontinent care. Record review of Resident #7's care plan dated 06/10/22, edited 02/14/24 indicated Resident #7 had an ADL self-care performance deficit and limited physical mobility. Intervention included bathing and bed mobility required extensive assistance. Record review of Resident #7's care plan dated 08/02/22, edited 02/14/24 indicated Resident #7 had impaired visual functioning and was at risk for decrease in ADL's and injuries. Intervention included alert resident for changes in environment, announce self by name, and call resident by name. Record review of Resident #7's event report dated 02/08/24 at 7:57 a.m., completed by LVN C, indicated .aide [CNA A] was giving personal care to resident when she turned the resident to clean her back side up the resident and the mattress slid halfway to the floor with the resident. The event details, pain observation, body observation, neurological check, mental status, possible contributing factors, and interventions were not documented. Record review of Resident #7's event report dated 02/09/24 at 5:39 p.m., completed by LVN C, indicated .fall .resident room .laying in bed fixing to get a bed bath stated reached for a rail that is not there and rolled herself out of the bed .fall not witnessed .resident complain of right hip pain .moderate pain .right toes the three middle toes have lacerations to the bottom of the toes, complain of pain to right hip .laceration .alert wakefulness (perceives the environment clearly and responds appropriately to stimuli .clear speech . Record review of Resident #7's hospital record dated 02/09/24 indicated .patient [Resident #7] with fairly extensive laceration across the plantar aspect (sole) of the right foot directly where the toes join the foot .full-thickness (wounds that extend past the two layers of skin (dermis and epidermis) and extend into the subcutaneous tissue (fat and muscle)) and relatively deep .x-ray foot right 3 view .final result .probable fracture of the fifth proximal phalanx distal diaphysis(pinky toe) .x-ray hip left 2 view .no acute findings . operating room washout and closure of laceration . During an interview and observation in a local hospital, on 02/14/24 at 10:35 a.m., Resident #7 was sitting up in the hospital bed with her left arm contracted. She said CNA B was giving her a bed bath by herself and turned her on her side and left. She said the next thing she knew she was on the floor. She said she was trying to reach for the side rails, but CNA B said there were no side rails. During an interview on 02/14/24 at 3:18 p.m., LVN C said she had recently started at the facility. She said she worked the 6am-6pm shift. She said she was the nurse who worked the two days Resident #7 had falls. She said on Thursday morning (02/08/24), CNA A was providing incontinence care for Resident #7 by herself. She said 2 people are needed for Resident #7's care. She said when she arrived after the fall that involved CNA A, on 02/08/24, Resident #7 was on the right side of the bed with the bed mattress partially underneath her. She said CNA A must have moved Resident #7's bed from against the wall to provide care. She said Resident #7's fall mat was on the left side of the bed but thankfully when Resident #7 fell , the mattress partially slid with her. She said Resident #7 slid out of her wheelchair sometime after lunch on the same day. She said on Friday (02/09/24), she was told by CNA B, that her and another staff from laundry put the resident back to bed because Resident #7 was about to get a bed bath. She said CNA B said Resident #7 reached for the rail, which she did not have on her bed, and fell out of the bed. She said Resident #7 was blind and had learned Resident #7 had a history of falling. She said when she arrived after the fall, the mechanical lift pad was on the bed and Resident #7 was on the left side of the bed. She said Resident #7's was bleeding, and they could not figure out what caused the foot to bleed. During an interview on 02/14/24 at 3:45 p.m., CNA A said she had been working at the facility since 18th of last month (January 2024). She said she worked the 6am-2pm shift. She said she had provided incontinent care to Resident #7 alone. She said she thought Resident #7 required 2 people for incontinent care. She said Resident #7 was blind and needed to be directed where things were. She said Resident #7's right side of the bed was normally on the wall. She said she was turning Resident #7 towards her right side to change her, and she reached out for the rail and fell . She said Resident #7's body when she fell made the mattress partially fall with her. She said Resident #7's right side of the bed was away from the wall. She said after the incident Resident #7 complained of shoulder pain but refused to go the emergency room . She said Resident #7 just wanted her pain medication. She said turning Resident #7 to the right side was hard but her left side was easier. She said she thought the care plans told staff what assistance the resident needed for ADLs. She said she had not seen Resident #7's care plan to know the amount of assistance she required. She said she had not been shown how to access the care plans on the facility's electronic charting system. She said when she started working at the facility, she was not told the amount of assistance Resident #7 required. She said having the right number of staff members for ADL care prevented falls. She said falls risked the resident passing away, hitting their head, bleeding, or hurting something. During an interview on 02/14/24 at 4:07 p.m., LVN G said she had worked at the facility for [AGE] years. She said Resident #7 required 2 people for turning and changing. She said she observed staff to ensure the correct amount of assistance was provided to residents. She said if 2 CNAs were not available to assist, she offered to help. She said not having the correct amount of assistance for ADL care could cause injuries and kill them. During an interview on 02/14/24 at 4:14 p.m., CNA E said she had worked at the facility for 5 years on the 2pm-10pm shift. She said Resident #7 required 2 people to put her back to bed but 1 person for changing. She said sometimes Resident #7 could help on one side. She said she did not know what Resident #7's care plan said her assistance was for ADLs. She said she had access to Resident #7's care plan on the electronic charting system. She said not having enough assistance for ADL care could cause falls. She said falls could result in injuries. During an interview on 02/14/24 at 4:35 p.m., LVN H said she had been working at the facility since May 2023. She said Resident #7 required 1 person for turning or changing on a good day. She said if Resident #7 had behaviors, she required 2 people. She said she believed Resident #7's care plan said she required 2 people. She said care plans were accessed on the electronic charting system. She said she made observations of CNAs to ensure they used the required number of staff for ADLs. She said if staff did not use the required number of staff for ADLs, falls could happen. She said the falls could result in injuries. During an interview on 02/14/24 at 4:14 p.m., CNA B said she had been employed at the facility for a year. She said she normally worked the 2pm-10pm shift. She said she was the CNA involved in Resident #7's fall on Friday (02/09/24). She said she and MR D transferred Resident #7 to her bed. She said MR D left the room to put the mechanical lift away and was coming back. She said she was getting supplies ready for Resident #7's bed bath. She said she turned her back on Resident #7 to put water in a basin. She said while she was putting water in the basin, she told Resident #7, do not roll over. She said suddenly Resident #7 was on the floor on the left side of her bed. She said she asked Resident #7 what happened, and Resident #7 said I was reaching for the rail. She said Resident #7 required 2 people for ADL care. She said not having the required staff placed residents at risk for falls and hurting themselves. During an interview on 02/15/24 at 10:30 a.m., CNA J said she had been working for the facility since June 2022 but had previously worked at the facility for 4 years. She said she worked all shifts at the facility. She said she worked the middle hall (Rooms 201-216) and sometimes the B long hall (room [ROOM NUMBER]-228). She said Resident #7 required 2 people assistance with cares. She said not having the required staff placed residents at risk to hurt themselves. During an interview on 02/15/24 at 10:47 a.m., LVN K said she had been working at the facility since 2021. She said she was prn and had worked all the halls. She said Resident #7 required 2 people for cares. She said her left arm was contracted and flaccid. She said Resident #7 was completely blind and staff had to tell her where things were placed and push her in the wheelchair. She said the required number of staff needed for ADLs was in the care plan. She said all staff had access to resident's care plans. She said without the required number of staff, there was a risk of residents falling or rolling out of the bed. She said residents could develop brain bleeds or fractures from falls or rolling out of the bed. She said nurses, ADON, and DON should monitor the CNAs to ensure they used the required number of staff. During an interview on 02/15/24 at 10:57 a.m., MA L said she had worked at the facility for a year and half. She said she worked the 6am-2pm shift on all the halls. She said MR D was not a CNA and normally only passed out food trays. She said she did not think she should be using the mechanical lift. During an interview on 02/15/24 at 11:00 a.m., Resident #7's family member #3 said when Resident #7 mentioned rails, she was referring to the bed frame. Family member #3 said Resident #7 had been blind since her stroke [AGE] years ago. Family member #3 said Resident #7 grabbed the bed frame when she was turned. During an interview on 02/15/24 at 11:35 a.m., MR D said she worked in medical records and was not a CNA. She said she helped CNA B put Resident #7 back to bed last Friday (02/09/24). She said she had not been trained to operate the mechanical lift. She said she pushed the buttons on the mechanical lift controller and CNA B guided Resident #7's body during the transfer. She said after she helped place Resident #7 in the bed, she left the room with no intention to return to help with the bed bath. She said immediately after helping CNA B transfer Resident #7, she clocked out to go home for a family emergency. She said as she clocked out, she heard a splat then heard CNA B scream out Resident #7 fell out the bed. She said she heard CNA B say, I told you not to move! During an interview on 02/15/24 at 1:20 p.m., the DON said Resident #7 required 2 persons assistance with cares per her care plan. She said all staff had access to resident's care plan on the electronic charting system. She said new employees were taught in training and during orientation on how to access resident's care plans. She said she ensured care plans were followed by having care plan meetings and educating staff on how to access them. She said residents could get hurt when the care plan was not followed. She said she did not know all the details related to Resident #7's falls on 02/08/24. She said a note was written about the incident on 02/08/24 but not an incident report. She said she needed to contact LVN C about the report. She said she also did not know all the details about Resident #7's fall on 02/09/24. She said family member #1 saw her in the hallway and told her about it. She said from what she gathered, CNA B was about to give Resident #7 a bed bath and was getting stuff ready for it. She said she was told CNA B told Resident #7 not to turn but she did anyway. She said she was told Resident #7 was grabbing a rail. She said Resident #7's left side was weak, but she had witnessed her turning herself left to right without assistance. She said Resident #7 possibly could have been turned on her left side before she fell . She said she would have rather not had CNA B step away from Resident #7, if she was on her side, when she was alone in the room. She said the risk of 2 people not being in the room with Resident #7 was a fall and deep laceration in her foot. She said MR D was not trained to use the mechanical lift nor was she a CNA. She said she did not know if both people operating the mechanical lift had to be trained. She said she would have rather both people operating the mechanical lift on 02/09/24 were trained. She said staff members operating the mechanical lift without training could hurt someone. She said CNAs and nurses knew only trained staff should us the mechanical lift for transfers. During an interview on 02/15/24 at 2:09 p.m., the ADM he did not know the details about Resident #7's falls, he was just notified she went to the hospital. He said he expected care plan intervention to be followed such as 2 people for cares. He said when interventions were not followed it placed residents at risk for negative outcomes. He said charge nurses should make observations and when staff made rounds to ensure care plan interventions were followed. He said only direct care staff such as nurses and CNAs should operate the mechanical lift. He said staff were trained or checked off during annual competencies and returned demonstration. He said if MR D was not a CNA, then she should not have been using the mechanical lift. He said if untrained staff used the mechanical lift, negative outcomes could happen. He said the CNAs should be observed and monitored to ensure only trained staff operated the mechanical lift. A policy on mechanical lift was requested and received. A policy on accident, hazards, and supervision was requested but not received prior to or after exit. During an interview on 02/15/24 at 2:20 p.m., the DON said she just spoke to therapy and Resident #7 did not require two people for bed mobility. During an interview on 02/15/24 at 2:39 p.m., COTA N said Resident #7 was on occupational therapy services 01/31/24-02/09/24. She said Resident #7's OT plan of care worked on grooming, self-feeding, sit/balance time, and upper body strength. She said she could not definitely say what type of ADL assistance such as bed mobility, Resident #7 needed because PT worked on that not OT. She said Resident #7 could maintain her balance on her side, in the center of the bed, but she would not be able to self-correct if something happened during cares. Record review of Resident #7's Occupational Therapy Discharge Summary dated 02/09/24 indicated .start date 01/31/23 .discharge date [DATE] .balance/coordination .prior status .poor .maximal assist to maintain position standing balance in order to complete ADLS while .current .the patient will demonstrate balance in order to while .Strength .prior status .fair bilateral upper extremities strength in order the complete ADLs .current . fair bilateral upper extremities strength in order the complete ADLs .self-care .personal hygiene .significant functional progress gains due to improved strength . The discharge summary did not indicate mobility or rolling left, and right being worked on during therapy sessions. Record review of a facility's Mechanical lift policy dated 12/2017 did not reveal who could or could not operate a mechanical lift. Record review of a facility's Falls-Evaluation and Prevention policy dated 12/2017 indicated .it is the policy of this home to evaluate residents for their fall risk and develop intervention for prevention .the goal is to prevent falls if possible and avoid any injury related to falls .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of five residents (Resident #38) reviewed for accidents and hazards in that: 1. The facility failed to ensure Resident #38 did not elope after he was identified to be of high risk for elopement. Resident #38 eloped on 06/09/23 through his window. 2. The facility failed to put alarms on all unit windows after the elopement as indicated in the PIR. 3 windows were missing alarms. 2 of 3 windows had screws to keep them permanently closed. 3. The facility failed to establish a system to monitor alarms. 4. The facility failed to have sufficient staff to safely monitor residents on the secured unit. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 07/10/23 at 03:59 PM. While the IJ was removed on 07/11/23 at 2:59 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for harm, serious injury, or death. Findings included: Record review of Resident #38's undated face sheet indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. He had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #38's admission MDS, dated [DATE], indicated he had a BIMS score of 05, which indicated severe cognitive impairment. Resident #38 was independent in bed mobility and transfers. He required supervision assistance for walking and locomotion on unit, dressing, toileting, eating, and personal hygiene. He received antipsychotics, antidepressants, and anticoagulants 7 of 7 days of the assessment window. Record review of Resident #38's physician's orders, dated 07/11/23, indicated he had this order: *Admit to secured unit related to wandering / elopement risk. The start date was 05/15/23. Record review of Resident #38's care plan, with a review date of 06/09/23, indicated a focus of elopement risk as evidenced by elopement on 06/09/23. The interventions included staff will monitor resident's location frequently and to monitor and record behavior when it occurs. Record review of Resident #38's progress notes, dated 06/09/23 through 06/30/23, indicated Resident #38 eloped on 06/09/23, and was later found 25-30 minutes later down the street. The progress notes further indicated that on 06/17/23 the alarm in Resident #38's room had been removed from the window and was reapplied by facility staff. Record review of Resident #38's elopement/wandering observation, dated 05/16/23, indicated he was a high risk for wandering. The assessment further indicated that Resident #38 had a history of elopement, exhibited wandering behavior, has shown exit seeking behavior, is likely to follow someone through a facility exit, and resident was physically able to exit on foot or by wheelchair. Record review of Resident #38's elopement/wandering observation, dated 06/09/23, indicated he was a high risk for wandering. The assessment further indicated that Resident #38 had a history of elopement, exhibited wandering behavior, had shown exit seeking behavior, is likely to follow someone through a facility exit, had verbalized the need and/or desire to go home or to another location and had the ability to act on that verbalization, and resident was physically able to exit on foot or by wheelchair. Record review of Resident #38's elopement incident report, dated 06/09/23, indicated he was found at 10:05 AM on 06/09/23. Record review of the Provider Investigation Report, dated 06/15/23, indicated Resident #38 was noted missing from the facility on 06/09/23 at approximately 9:30 AM. Facility staff searched the facility and were unable to locate him internally. The facility expanded their search outside and Resident #38 was found at an EZ Mart gas station down the street. The report indicated that the facility staff estimated Resident #38 was out of the facility for an estimated 20-25 minutes. The PIR indicated the facility had taken action by placing alarms on all occupied resident room windows. Record review of Resident #38's vital signs after his elopement indicated his vital signs were taken on 06/09/23 at 10:24AM and his blood pressure was 125/81 and his pulse was 99 beats per minute. No temperature reading was found. No respiration reading was found. During an observation and interview on 07/10/23 at 10:57 AM, Resident #38 was observed walking out of his room [ROOM NUMBER] in the secured unit. He was independently able to open and close his bedroom door and ambulate throughout the unit. He said he remembered leaving the unit and said he was trying to go visit his mom and dad. During an observation on 07/10/23 at 10:59 AM, room [ROOM NUMBER], at the end of the unit, was observed with the door open. Residents wandering in the unit had open access to this room. The window alarm for the window in this room was not attached to the window and was laying in the windowsill. This surveyor was able to open the window fully and the alarm did not make any noise. During an observation and interview on 07/10/23 at 11:06 AM, CNA E said she was not working the day Resident #38 eloped. She said she was familiar with him and she monitors him if he started fidgeting or exit seeking. She said she tries to keep him occupied. She took this surveyor into Resident #38's room ( room [ROOM NUMBER]) and the window had a screw in the frame so it could not be opened. It did not have an alarm attached. During an interview on 07/10/23 at 11:14 AM, RN F said she was taking care of Resident #38 that day. She said she was not working the day he eloped. She said when he starts exit seeking, she attempts to distract him by talking to him or having him call his daughter. During an interview on 07/10/23 at 11:18 AM, the Social Worker said she was in her office on the day Resident #38 eloped when she noticed staff were looking for him so she went outside to help. She said she was unable to find him in the facility so she jumped into her car to assist looking for him. She had looked around the neighborhood and they had already found him when she came back to the facility. She said the staff gave him water and assessed him. She said it was warm outside, and he had a sweater on. She said he looked tired and hot. She said she did not talk to him directly. She said the Marketing, business office, and medical records staff found Resident #38 and brought him back. During an interview on 07/10/23 at 11:30AM, CNA G said she was the CNA that noticed Resident #38 was not in his room. She said she was not assigned to the unit that day. She said she was weighing residents around the facility that day. She said she was trying to go get Resident #38 to weigh him and was unable to locate him in his room. She said she told the nurse Resident #38 was not in his room or in the unit. She said she then left the unit to weigh another resident. After this she came back to the unit to assist the nurse in finding Resident #38. She said her and the nurse looked around the unit and then notified the DON. Then the facility staff searched the facility for Resident #38 and were unable to locate him. She said they eventually found him near a busy roadway at a gas station about 0.8 miles away from the facility. She said he was gone from the facility about an hour. She said when he returned he was wearing a sweater and he was hot and sweaty. She said he eloped from the unit through the window in his room. She said this was the first time that she recalls Resident #38 eloping from the facility. She said there was only typically one staff member assigned to the unit. She said there was only a nurse assigned to the unit on the day Resident #38 eloped. She said the Marketing Director brought Resident #38 back to the facility. She said the facility put window alarms in place to keep the unit residents from eloping and Resident #38 likes to take the alarms off the windows. During an observation on 07/10/23 at 11:47AM, the Super Bingo and the EZ Mart were both located off of N [NAME] Road, approximately 0.6 to 0.8 miles from the facility. The speed limit was 35 miles per hour. It was a busy 4 lane street. The EZ mart was on the opposite side of the street and Resident #38 would have crossed the street to reach the EZ mart. During an interview on 07/10/23 at 12:05PM, LVN D said she was assigned to the unit the day Resident #38 eloped. She said she was in the middle of medication pass. She said she was giving the resident next door to Resident #38 and noticed Resident #38 had walked down the hallway and entered his room. She said a CNA came to get Resident #38's weight and said he was not in his room. She said she immediately stopped medication pass and searched for Resident #38. She said she could not find him in the dining area and the MDS coordinator came to help. She said had not heard any alarms. She said her and the MDS coordinator searched all over the unit. She said she noticed the screen in Resident #38's room window appeared to be bent. She said she was unable to open the window. She then notified the DON and they searched all over the facility. She said eventually other facility staff found Resident #38 offsite. She assessed him and he was hot and sweaty. She said he was found first at the EZ Mart and then they finally picked him up at the Super Bingo hall. She said she obtained his vitals and he had a sweat shirt on and long pants. She said they got him some ice water because he was tired and sweaty. She said it was hot outside. She said Resident #38 had no bruises or injuries. She said Resident #38 told the staff he wanted to go walking. She said He has not eloped at this facility but he has eloped before at another facility before he came to this one. She said they put alarms on the windows to ensure the residents do not escape through the windows. She said she checks the windows at least once a shift, but she was not told by administration how often she should check them. She said she works back in the unit by herself most of the time. She said she has only had another staff member assigned with her about 5-6 times since she started working there in February of 2023. She said she does her nursing duties as well as the CNA duties when she was the only staff assigned to the unit. She said she performed incontinent care when she was back there alone. She said she tries to do as many baths as possible and will notify the next shift when she was not able to complete all the baths. She said there were typically around 9 residents back in the unit. She said she saw Resident #38 about 10 mins before anyone noticed he was missing. During an interview on 07/10/23 at 12:21PM, the Marketing Director said she went out front to help the Social Worker look for Resident #38. After they searched the facility she and the Business Office Manager jumped into her car to look for Resident #38. She said they found him at a bingo hall near a busy roadway. She said Resident #38 was leaning against the telephone pole. He was hot and sweaty and was wearing a sweater. They got him into the car and brought him back to the building and got him some water. They handed him back to the nurse assigned to the unit that day. During an interview on 07/10/23 at 12:25PM, the Business Office Manager said the DON asked her if she saw Resident #38. She said the staff looked all over the facility for the resident. She said she and the Marketing Director went out the side door to make sure he was not out in the patio. She said they hopped in the Marketing Director's vehicle to look for Resident #38. She said they travelled down a busy roadway and found him near the bingo hall. She said she got out of the vehicle and talked to Resident #38 and he said he was walking. They got him back in the vehicle to take him back to the facility. She said he was wearing a sweater, hat and long pants. She said he was hot and sweaty. They got him back to the facility and used cool rags to cool him off. She said she notified Resident #38's daughter. She said she left him with the nursing staff. She said it was warm outside that day. During an interview on 07/10/23 at 12:30PM, the Maintenance Supervisor said after Resident #38 eloped they put a screw in Resident #38's room window and the window next door to his room to make the window stay closed. He said he put alarms on all windows in the unit and made sure the alarms on the unit doors were functioning properly. He said he tries to check the window alarms in the unit at least 3 times a week. He said he will also go check on them if he was notified by the CNAs in the unit. He said he did not keep any log or documentation of him checking the alarms. During an interview on 07/10/23 at 12:36PM, CNA E said she checks the alarms as often as possible. She said she was not told by administration how often to check the alarms. She said she did not keep a log of when she has checked the alarms. During an interview on 07/10/23 at 12:37PM, RN F said she does not routinely check the alarms. She said she did not keep a log of when they were checked. She said she thought the maintenance director was responsible for checking the alarms routinely. During an observation on 07/10/23 at 2:15PM, the middle window in the secured unit dining room had no alarm attached to the window. There were residents in the room and they had free access to it. There was a screw in the frame of the window that was supposed to keep it from opening. During an observation on 07/10/23 at 2:20PM, Resident #38's room [ROOM NUMBER] had no alarm attached to the window. The screw was still in place on the window frame. During an observation on 07/10/23 at 2:30PM, room [ROOM NUMBER] alarm was still in the windowsill, not attached to the window. This surveyor was able to lift the window open and then close it back. During an interview on 07/11/23 at 9:45AM, the DON said the facility does not have a policy that addresses supervision of residents. She said they do not have a policy that addresses alarms or monitoring of alarms. During an interview on 07/11/23 at 02:50PM, Resident #38's Responsible Party said she was not surprised when the facility notified her that Resident #38 had eloped. She said he had eloped before he came to this facility. During an interview on 07/12/23 at 1:12PM, the ADON said she did not work in this facility when Resident #38 eloped. She said she started working in this facility on 06/20/23. The incident occurred on 06/09/23. She said she was not aware of anyone being assigned to check the alarms routinely before surveyor intervention this week. She said before surveyor intervention this week, they tried to have two staff members assigned to the unit during the day, and only one staff nurse assigned from 10pm-6am. She said she does not think one staff member assigned in the unit was enough staff to properly monitor all the unit residents and keep them from eloping. She said the one staff member would not be able to get their work done, or even leave the unit to go to the bathroom. During an interview on 07/12/23 at 02:01PM, the DON said after Resident #38 eloped they installed window alarms on occupied rooms and the room next to him. She said they did not put a procedure in place to monitor the alarms. She said the staff would report the alarms missing whenever they saw it. She said they did in-services about the alarms. there were 1 -2 staff members assigned to the unit at times, there was not a specific set schedule of how many people should have been back there at a time. She said she did not have enough staff to assign more staff to the unit. She said there was an average of eight residents back in the unit at a time. She said they did not increase staff immediately after the elopement. She said on 07/05/23 they increased staffing to 2 staff assigned to the unit all the time except for 10PM to 6AM. she said they finally had enough staff then to be able to permanently assign more staff back in the unit. She said she did not feel like one nurse would be able to adequately monitor the residents in the unit while passing medications. She said the nurse that was assigned to the unit was primarily responsible for ensuring the residents did not elope. She said it was ultimately all staff's responsibility to prevent residents from eloping. She said there was risk to all residents if they eloped for serious injury, serious harm, or death. During an interview on 07/12/23 at 2:20PM, the ADON said if a resident eloped like Resident #38 did there was a potential for serious injury, serious harm, or death. During an observation on 07/12/23 at 2:44PM, the Administrator said after Resident #38 eloped, they put window alarms on all occupied rooms in the unit. He said they increased rounding and supervision of Resident #38. He said they reported the elopement to the state, notified his family and the doctor. He said the MD director was notified. He said the nurse took an assessment of Resident #38 and they gave him water and made sure he did not suffer heat exhaustion. He said the Administrator, Maintenance and all other staff were responsible for ensuring that the alarms were in place. He said that the Administrator and the other management were constantly replacing window alarms in the unit. He said they did not document that they were checking alarms. He said he was in the unit daily along with maintenance and other staff assigned to the unit, and they were checking the alarms. He said there was no documentation that logged the staff checking the alarms. He did not know without checking the schedule if there was only one staff assigned to the unit at a time before 07/05/23. He said on 7/05/23 they changed the staffing to ensure that 2 staff members were assigned to the unit all the time except for 10pm to 6am. He said after surveyor intervention on 07/10/23 the staffing was changed to ensure 2 staff were assigned to the unit at all times. He said he expected one nurse to be able to take care of 8 residents in the unit while passing meds. He said he expected the nurse to be able to keep the 8 residents from eloping. He said that all staff were responsible for ensuring that the residents do not elope, but the nurse was assigned to take care of the residents in the unit that day. He said a resident that eloped like Resident #38 was at risk for heat stroke, heat exhaustion, a possible vehicle accident, fall, serious harm, serious injury, or death. The Administrator was notified of an IJ on 07/10/23 at 3:59PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 07/11/23 at 9:45AM and included the following: 7/11/2023 Plan of Removal - F 689 Immediate Action Taken Resident Specific * Resident #38 was located by Business Office Manager and Marketer on 6/9/2023 at 10:02am and returned to the facility. * Resident #38 assessed by licensed nurse on 6/9/2023 at 10:15am. Findings documented in Matrix. No injuries or adverse effect noted. * Elopement Risk Assessment for Resident #38 completed on 6/9/2023 at 11:13am by RN. * Elopement Risk Careplan for Resident #38 updated on 6/9/2023 at 11:30am by RN. * NP notified of elopement on 6/9/2023 at 10:15am by LVN. No new orders received. * Responsible party notified of elopement on 6/9/2023 at 10:15am by LVN. No concerns voiced. * MD notified of the IJ on 7/10/2023 at 4:45pm by Director of Nursing, no new orders received. * Resident #38 remains in the Secured Unit and has had no further elopement attempts. System Changes * Elopement Risk Assessments completed for all residents in the facility on 6/9/2023 at 1:40pm by DON and RN. * Window alarms placed on windows of all occupied rooms on 6/9/2023 at 12:30pm. * Window alarms placed on all secured unit windows on 7/10/23 at 4:45pm. * Staff increased in Secured Unit to 1 Licensed Nurse and 1 Nurse Aide, from 6am to 10pm on 7/5/23. * Staff increased in Secured Unit to 1 Licensed Nurse and 1 Nurse Aide, 24 hours a day on 7/10/2023. * Secured Unit rounds established on 7/10/2023 at 6:00pm. This is to monitor that all windows have alarms, alarms are functioning properly, and all residents are in place. * All windows in the Secured Unit secured and raise a minimum of 4 inches, as of 7/11/23 at 6:30am. * Elopement policy reviewed on 6/9/23 at 11:30am by Administrator, Regional Nurse, and Director of Nursing. No changes made to policy at this time. Education * Director of Nursing provided education to all staff regarding the Elopement Policy. All staff present in the facility were educated on 7/10/2023, at 5pm. Staff not present for the education will receive the education prior to their next shift. * Director of Nursing provided education to nursing staff regarding the Secured Unit Rounds to ensure residents are in place, alarms are on windows, and alarms are functioning properly. All nursing staff present in the facility were educated on 7/10/2023, at 5pm. Staff not present for the education will receive the education prior to their next shift. * Director of Nursing provided education to nursing staff regarding the Secured Unit staffing pattern - 2 staff members on all shifts. All nursing staff present in the facility were educated on 7/11/2023, at 8:30am. Staff not present for the education will receive the education prior to their next shift. Monitoring * Administrator/designee to review Secured Unit rounds 5x/week to ensure compliance. The surveyor verification of the Plan of Removal from 07/11/23 was as follows: During an observation on 07/11/23 at 7:56AM room [ROOM NUMBER] has an alarm on the window and the screw was removed. Resident #38's room [ROOM NUMBER] had an alarm on the window and the screw was removed. During an observation on 07/11/23 at 7:59AM, all three unit dining room windows had alarms and the screw in the middle window was removed. During an observation on 07/11/23 at 08:05AM, two staff members were assigned and working in the unit. During an observation on 07/11/23 at 10:54AM, it was observed that all windows in the unit had alarms installed and they were turned on. During interviews conducted from 07/11/23 11:52AM through 3:20PM, 21 of 38 staff (15 from day shift, and 6 from night shift and including CNAs, LVNs, and RNs) were interviewed. All staff said they received education on elopement, rounding on the unit and checking alarms every two hours, and that there will be two staff assigned to the unit at all times. Record review of in-service training, dated 06/09/23, after the elopement, indicated training related to window alarms in the secured unit was provided to facility staff. The training stated: .Residents on the unit will have window alarms on their windows, please ensure the alarm is on and functioning, if you find one that does not work, please contact Admin/DON/maintenance director. If you hear any alarms going off, you are to respond immediately. The Weather Underground website, accessed on 07/13/23 at 10:59AM, indicated that the temperature in the city of Texarkana was 82 degrees Fahrenheit on 06/09/23 at 9:53AM. The wind speed was 5 miles per hour with 0 miles per hour wind gusts. There was 0.0 inches of precipitation and the condition was fair. The humidity was 67%. Record review of facility's policy titled Elopement, effective December 2017, stated: It is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or home grounds. Procedure The following steps are to be followed when a resident is noted absent and is not found on initial search of the home. This also includes when a resident leaves the home grounds without staff notification. Home staff will: *Search the home and grounds *Send staff member(s) out to locate the resident *Notify Administrator or on-call person immediately *If resident is not located within 30 minutes, call the local police Charge Nurse will: *Notify responsible party (this may be done when the search is initiated) *Notify the resident's physician *Assess the resident on return to the home *Document the time resident absence is noted, time of return, assessment of resident, and notification of physician and responsible party *Complete and incident report in the clinical software *Follow-up charting for 24 hours if no injuries . .Administrative / supervisory staff will: *Determine if elopement is reportable to state regulatory agency *Interview staff and obtain written statements . *Establish a monitoring system for resident until flight risk is resolved *Determine what measures can be taken to prevent it from happening again On 07/11/23 at 02:59PM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accident hazards (Resident #1). The facility transporter did not ensure Resident #1's safety lap belt was fastened during transport to a doctor's appointment on 9/29/22. On 9/29/22 Resident #1 fell out of her wheelchair during transport and sustained a sprain to her left ankle. (A sprain is defined as an injury that occurs when the ankle rolls, twists, or turns in an awkward way causing stretching or tearing to the tough bands of tissue (ligaments) that help hold the ankle bones together. A sprained ankle causes swelling, pain, and limited range of motion.) This failure could place dependent residents at risk for injury, pain, and hospitalization . Findings included: Record review of the Resident #1's face sheet indicated she was [AGE] years old readmitted to the facility on [DATE] with diagnoses including history of pain in the thoracic spine (runs from the base of the neck to the base of the rib cage), disease of spinal cord, [CONDITION(S)] (an [CONDITION(S)] and [CONDITION(S)] disease, in which your immune system attacks healthy cells in your body by mistake, causing inflammation /painful swelling in the affected parts of the body), [CONDITION(S)] (when the protective cartilage that cushions the ends of the bones wears down over time), muscle wasting and atrophy (Loss of muscle leading to its shrinking and weakening), muscle weakness , muscle spasm (sudden involuntary contraction of a muscle or group of muscles), history of falling, high blood pressure and type II diabetes. Record review of the MDS dated [DATE] indicated Resident #1 usually made herself understood and usually understood others. The MDS indicated she had no cognitive impairment (BIMS of 15) and no behavior of rejecting care. The MDS indicated Resident #1 was totally dependent on staff for bed mobility, transfers, locomotion in her wheelchair, eating, bathing, and personal hygiene. The MDS indicated she normally used a wheelchair (manual or electric). The MDS indicated Resident #1 was always incontinent of bowel and bladder. The care plan revised on 9/30/22 indicated Resident #1 had an injury to her left ankle related to a fall on 9/29/22. The care plan interventions included administer pain, and anti-[CONDITION(S)] medications as ordered; handle resident gently when moving or positioning; keep splint on affected area, apply ice and elevate as directed by MD. The care plan indicated Resident #1 was at risk for falls, with an actual fall on 9/29/22. The care plan interventions were updated on 9/29/22 with the intervention, Resident #1 was to be transported to appointments in a standard wheelchair. The care plan interventions prior to 9/29/22 included place Resident #1's bed in the lowest position while she was in the bed; place call light in reach; and place frequently used items within reach. There were no care plan interventions prior to 9/29/22 that addressed how Resident #1 was to be transported to doctor appointments. Record review of the facility investigation report dated 10/4/22 indicated on 9/29/22 while being transported to a doctor's appointment Resident #1 slid out of her reclined Broda chair (Broda is a brand of wheelchair that traditionally offers tilt-in space positioning and comfort tension seating). The report indicated the van driver immediately contacted the administrator. The administrator, DON, treatment nurse and maintenance supervisor immediately responded to the van's location. The DON and treatment nurse performed an assessment of Resident #1 with no abnormalities noted and Resident #1 had no complaints of pain at the time. Resident #1 was returned to her chair and proceeded to her doctor's appointment. While at the appointment, Resident #1 indicated she was starting to have pain to her left ankle. The report indicated a doctor's order for a mobile x-ray was received and performed. The results of the mobile x-ray showed diffused [CONDITION(S)] and a sclerotic (induration or hardening) line in the talus (ankle bone). The MD was notified of the results and ordered Resident #1 to be transferred to the hospital for better imaging and treatment. The provider investigation indicated the hospital records reported Resident #1 had not sustained a fracture. The provider investigation report indicated the maintenance supervisor inspected the wheelchair lift and seat belt equipment to ensure they were in working order. The report indicated the van driver was suspended during the investigation. Record review of the mobile x-ray to Resident #1'a left ankle dated 9/29/22 indicated Resident #1 had [CONDITION(S)] and noted a sclerotic (induration or hardening) line across the talus (ankle bone). The x-ray indicated the sclerotic line could be indicative of an acute impaction fracture. Record review of the x-ray of Resident #1's left tibia and fibula (leg bones) dated 9/29/22 at 3:28 p.m. (obtained at the hospital), indicated there was no acute fracture or malalignment. The image did note [CONDITION(S)] ([CONDITION(S)] joint disease condition when bone strength weakens and is susceptible to fracture) and mild soft tissue swelling. Record review of the x-ray of Resident# 1's left ankle dated 9/29/22 at 3:28 p.m. (obtained at hospital), noted osteoporotic bones but indicated there was no fracture or dislocation. Record review of the hospital discharge paperwork for Resident #1 dated 9/29/22 at 5:29 p.m., indicated she had a left ankle sprain. During an interview and observation on 12/5/22 at 2:00 p.m., Resident #1 said she could not remember if both the lap and shoulder belts were on when she was initially transported from the facility on 9/29/22. She said she was sitting in her chair just like this [reclined in a semi-fowler (head of the resident is laid back in a 15-45-degree angle and knees to ankles are in relatively same level) position in her BRODA chair] and we hit a bump in the road. Resident #1 said she just slid right out of the chair. Resident #1 said she went to the doctor and her ankle started to hurt. Resident #1 said her ankle hurt pretty bad. Resident #1 said when she got back to the facility, she received x-rays and then was sent to the hospital. Resident #1 said at the hospital, the emergency room doctor told her the ankle was not broken and it was just a bad sprain. Resident #1 said the facility applied ice, administered pain medication, and applied a splint. She said her ankle was better now. Resident #1 said she had been transported since the incident and there were no problems. During an interview on 12/6/22 at 9:35 a.m., the DON said when she arrived at the van on 9/29/22 Resident #1 was laying on the floor of the van. The DON said she and the treatment nurse performed a prompt assessment and found no obvious injuries. She said Resident #1 had no complaints of pain at the time of the assessment. The DON said she did not really pay attention/note the position of the wheelchair safety belts (whether or not they were latched or not) because she was focused on providing immediate care to Resident #1. The DON said the treatment nurse with her on 9/29/22 was no longer with the facility. During an interview on 12/6/22 at 9: 40 a.m., the van driver said the day he transported Resident #1 to her doctor's appointment she was in her Broda chair in a reclined position. The van driver said he secured the front and back securements to the wheelchair wheels. The van driver said he applied the shoulder safety belt. The van driver said he did not apply the lap belt to Resident #1 because it would not fit over the resident and the chair. The van driver said while driving, he hit a pothole and Resident #1 said I'm sliding out. The van driver said he turned around and Resident #1 was on the van floor. The van driver said he asked if she was hurt, and Resident #1 indicated she was ok. The van driver said he placed a pillow under her head and called the administrator. The van driver said he should have notified the administrator that the lap belt would not fit over the resident and the chair. The van driver said he should not have transported the resident without the lap belt secured because it was probably part of the reason, she slid out of the Broda chair. He said when the maintenance director arrived, he (the maintenance director) obtained the extender piece from the equipment box. The van driver said he did not obtain the extender piece from the equipment box before transport of Resident #1 because he did not know it was in there. The van driver clarified he knew the extender piece existed; he just did not know where it was. The van driver said he was in-serviced after the incident and understood the lap belt must be secured. During an interview on 12/6/22 at 10:00 a.m., the maintenance director said when he arrived to the van on 9/29/22 he helped to get Resident #1 back into her chair. The maintenance director said he checked all the equipment, and it was in good working order. The maintenance director said he obtained the lap belt extender from the equipment box (in the van) and secured Resident #1 with both the lap and shoulder belt. He said the lap belt would not go over Resident #1 and the chair without the extender. During an interview on 12/6/22 at 11:00 a.m., the business office manager said she rarely provided transport but did so occasionally when van driver was unavailable, and the third-party transport team was not being used. The business office manager said she had been in-serviced before the incident over basic transport guidelines and indicated staff received in-service after the incident over basic transport guidelines. She said it was very important to ensure both the lap and shoulder belts were secured during transport. The business office manager said in the event there was any issue that impeded the use of either lap or shoulder safety belts, she would not transport the resident and would notify the administrator. During an interview on 12/6/22 at 12:00 p.m., the administrator said the Broda chair had been okayed for transportation and indicated the 3rd party transport company, the facility used at times, did routinely transfer residents in Broda chairs. The administrator said the facility would no longer transfer Resident #1 in her Broda chair because in meetings with the corporate office after the facilities investigation of the incident, it was felt the Broda chair was causative factor in the incident. The administrator said he conducted a facility in-service with transportation personnel (the van driver and business office manager) and maintenance director after incident over transport safety/ discontinued use of Broda chairs during transport. He said the in-service required transportation personnel to demonstrate transport safety concepts where in staff had to use him as the resident in a wheelchair and perform all transportation elements. The administrator said he was not aware that the van driver had not fastened the lap belt across Resident #1 on 9/29/22. He said the lap belt not being secured was probably a causative factor in Resident #1 sliding out of the chair. The administrator indicated that ensuring both the lap and shoulder belt were part of in-service training the transportation personnel received. During an interview on 12/6/22 at 12:30 p.m., the 3rd party transport company employee said they did transfer Residents with Broda chairs frequently. The employee said all Broda chairs were safe to use during transport if safety precautions were taken. She said these safety precautions would include the securement of the lap belt. Record review of the employee file for the van driver indicated he had been working for the facility in the role of van driver since 12/1/2020. Record review of the van drivers Orientation of transportation Personnel Checklist dated 4/28/22 indicated the van driver had been educated and demonstrated he was able to apply lap/shoulder safety belts. Record review of the van drivers Orientation of transportation Personnel Checklist dated 9/29/22 indicated the van driver had been educated and demonstrated he was able to apply lap/shoulder safety belts. Record review of the facility policy and procedure titled Orientation - Transportation Personnel dated December 2018 stated POLICY: It is the policy of this home to ensure [Orientation Check] list is provided to transportation personnel. PROCEDURE; (1) Prior to providing transportation to any resident in community van/bus they will be completely trained on transportation requirements .(4) General areas covered: .(e.) Wheelchair and Occupant Securement System . Record review of the facility orientation of Transportation Personnel Check List dated 12/1/28 indicated personnel would have to check off on several elements of the Wheelchair and Occupant Securement System. These elements included Able to apply lap/shoulder belts.

Based on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 4 residents reviewed for pain management. (Resident #68) The facility did not assess Resident #68's pain level and did not provide pain management for Resident #68 when she reported pain. The facility did not monitor the effectiveness of pain medications and report her uncontrolled pain to the physician. Due to uncontrolled pain Resident #68 was unable to eat resulting in a weight loss, sleeplessness and an inability to participate in activities. This failure could place residents at risk for unnecessary pain and discomfort and decreased quality of life. Findings included: Consolidated physician orders [REDACTED].#68 was [AGE] years old, re-admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #68 made herself understood and was able to understand others. The MDS indicated Resident #68 required extensive assistance with bed mobility, transferring, dressing, toileting, and personal hygiene; limited assistance with eating; and was dependent on staff for bathing. The MDS indicated Resident #68 had received scheduled pain medication. An admission/readmission assessment dated [DATE] indicated Resident #68 had existing pain, rated a 7 out of 10 on a 0-10 pain scale (0 being no pain, and 10 being the worst pain ever experienced). The section regarding Resident #68's satisfaction with her pain control was blank. The care plan updated 2/28/19 indicated Resident #68 had intermittent episodes of mild pain with a history of pain and [MEDICAL CONDITION] (nerve damage) with interventions of: The resident would verbalize full relief of pain; nursing staff would evaluate Resident #68's pain daily and administer pain medication as ordered; and the resident would be monitored for worsened pain symptoms, and symptoms would be reported to the physician. A weight change history report dated 3/20/19 indicated the following weights for Resident #68: *on 12/1/18 - 99.3 pounds; *on 1/1/19 - 98.2 pounds; *on 2/1/19 - 94.8 pounds; and *on 3/1/19 - 94.2 pounds. A nursing note dated 2/1/19 at 1:51 a.m., indicated Resident #68 was awake and alert at 11:30 p.m., complained of non-specific discomfort, and requested and received pain medication. The nursing note did not indicate Resident #68 rated her pain level. A nursing note dated 2/2/19 at 1:48 a.m., indicated Resident #68 was awake and alert at 11:00 p.m., complained of general discomfort, and requested and received pain medication. The nursing note did not indicate Resident #68 rated her pain level. A nursing note dated 2/3/19 at 1:42 a.m., indicated Resident #68 was awake at 12:00 a.m., complained of general discomfort, and requested and received pain medication. The nursing note did not indicate Resident #68 rated her pain level. A nursing note dated 2/7/19 at 2:40 a.m., indicated Resident #68 was awake at 1:00 a.m., complained of general discomfort, and requested and received pain medication. The nursing note did not indicate Resident #68 rated her pain level. A nursing note dated 2/17/19 at 3:01 a.m., indicated Resident #68 had been awake off and on all night per her usual. The nursing note did not indicate Resident #68 complained of pain or requested pain medication. A nursing note dated 2/18/19 at 1:39 a.m. indicated Resident #68 was lying in bed awake. The note indicated Resident #68 had complained of generalized pain at 11:00 p.m. and received pain medication. A nursing note dated 2/20/19 at 2:25 a.m. indicated Resident #68 was awake at 11:30 p.m., requested and received pain medication for an unspecified type or location of discomfort. The note indicated Resident #68 complained of discomfort in multiple areas often. The nursing note did not indicate Resident #68 rated her pain level. A nursing note dated 2/21/19 at 2:31 a.m. indicated Resident #68 was awake at 11:30 p.m., complained of general discomfort, and requested pain medication. The note indicated Resident #68 was awake at 2:30 a.m. and requested pain medication again, and the nurse reminded her about the 6-hour time limit between pain medication doses. A nursing note dated 3/18/19 at 1:27 a.m. indicated Resident #68 was awake at 12:30 a.m., complained of general discomfort, and requested and received pain medication. The nursing note did not indicate Resident #68 rated her pain level. A nursing Medication Administration Record [REDACTED] *3/2/19 - pain level of 6 - Resident #68 did not receive as needed pain medication; *3/3/19 - pain level of 6 - Resident #68 did not receive as needed pain medication; *3/8/19 - pain level of 6 - Resident #68 did not receive as needed pain medication; *3/9/19 - pain level of 6 - Resident #68 did not receive as needed pain medication; *3/10/19 - pain level of 6 - Resident #68 did not receive as needed pain medication; *3/11/19 - pain level of 6 - Resident #68 did not receive as needed pain medication; *3/12/19 - pain level of 4 - Resident #68 did not receive as needed pain medication; *3/13/19 - pain level of 4 - Resident #68 did not receive as needed pain medication; *3/15/19 - pain level of 5 - Resident #68 did not receive as needed pain medication; *3/16/19 - pain level of 6 - Resident #68 did not receive as needed pain medication; *3/17/19 - pain level of 5 - Resident #68 did not receive as needed pain medication; and *3/20/19 - pain level of 5 - Resident #68 did not receive as needed pain medication. A nursing Medication Administration Record [REDACTED]. A MA administration record dated (MONTH) 2019 indicated Resident #68 received scheduled [MEDICATION NAME]/Tylenol 5/325 mg 1 tab by mouth at 9:00 a.m. and 5:00 p.m. daily. During an observation and interview on 3/17/19 at 3:33 p.m., Resident #68 was lying in bed and said she was hurting all over. She said she always hurt all over and could not sleep or eat because she hurt so badly. During an observation and interview on 3/18/19 at 11:50 a.m., Resident #68 was sitting in her wheelchair in her room and said she was hurting all over. Resident #68 said her legs, feet, and chest hurt the most, and she needed her pain medication dosage increased. Resident #68 said her pain was so bad it woke her up at night. She said she could not eat and had lost weight because she was in so much pain. Resident #68 said the staff knew her pain medication was not working because she always asked for her pain medication too soon. During an observation and interview on 3/18/19 at 12:55 p.m., Resident #68 was in the dining room, she had eaten approximately 25 percent of her lunch. She said she ate more than she usually did but could not eat because she was hurting. During an observation and interview on 3/19/19 at 10:05 a.m., Resident #68 was lying in bed and said her arms, chest, legs, and feet were hurting. She said she had told the nurse she was hurting but could not receive a pain pill because it was too soon. During on observation and interview on 3/20/19 at 9:05 a.m., Resident #68 was lying in bed and said she did not feel good at all. Resident #68 said she was hurting all over. She said the pain was so bad she could not eat or sleep. Resident #68 said she had received her routine pain medication that morning and it was not working. During an observation and interview on 3/20/19 at 9:45 a.m., the AD went to Resident #68's room and asked her if she wanted to come to the activity in the dining room. Resident #68 was lying in bed and said she did not want to go because she did not feel good at all. Resident #68 said she would get up after lunch. The AD said Resident #68 was alert and oriented and frequently complained of not feeling good. During an observation and interview on 3/20/19 at 2:24 p.m., Resident #68 was lying in bed, awake, and said she was hurting from head to toe. During an observation and interview on 3/20/19 at 2:59 p.m., Resident #68 was sitting in her wheelchair in her room. Resident #68 said she had told some CNA's and LVN R that she did not want to live because the pain was so bad sometimes. She said, but the good Lord will take me when he is ready, he must not be ready yet. During an interview on 3/20/19 at 9:08 a.m., LVN R said Resident #68 did not complain of pain that morning. LVN R said Resident #68 received a routine [MEDICATION NAME]/Tylenol 5/325 mg tablet at 9:00 a.m. for pain. LVN R said she had not administered as needed pain medication to Resident #68 during any of her day shifts because Resident #68 had not complained of pain. LVN R said there was not a place to document routine pain medication follow up assessment for effectiveness, and as needed pain medication follow up assessment was documented on the pain management flowsheet. A narcotic administration record for 3/1/19 through 3/20/19 indicated Resident #68 received as needed pain medication as follows: *Days - 3/18/19 at 1:30 p.m. *Evenings - no administration of as needed pain medications *Nights - 3/1/19 at 11:00 p.m.; 3/3/19 at 12:00 a.m. and 11:30 p.m.; 3/4/19 at 11:00 p.m.; 3/6/19 at 11:00 p.m.; 3/8/19 at 1:25 a.m. and 11:30 p.m.; 3/9/19 at 5:30 a.m. and 11:00 p.m.; 3/10/19 at 11:30 p.m.; 3/11/19 at 11:00 p.m.; 3/12/19 at 11:00 p.m.; 3/14/19 at 12:30 a.m. and 11:30 p.m.; 3/15/19 at 11:00 p.m.; 3/17/19 at 1:30 a.m.; 3/18/19 at 12:00 a.m.; 3/19/19 at 11:30 p.m.; *unspecified time - 3/1/19 A pain management flowsheet dated (MONTH) 2019 indicated there were 3 follow up assessments for the as needed pain medication Resident #68 received on 3/11/19, 3/12/19, and 3/18/19. During an observation on 3/20/19 at 9:55 a.m., LVN R entered Resident #68's room. Resident #68 complained of not feeling well and pain to her left arm, legs, and feet. During an interview on 3/20/19 at 10:03 a.m., LVN R said she did not recall if she was notified that Resident #68 had complained of pain. LVN R said she had just notified Resident #68's physician of her uncontrolled pain and the ineffectiveness of her routine pain medication. She said the physician ordered [MEDICATION NAME] (a nerve pain medication) by mouth at bedtime for Resident #68. During an interview on 3/20/19 at 10:07 a.m., LVN O said Resident #68's pain should be re-assessed approximately 45 minutes to 1 hour after pain medication was administered. LVN O said the re-assessment should be documented in the nurse's notes or on the pain management flowsheet. During an interview on 3/20/19 at 11:56 a.m., LVN J said Resident #68 complained of pain every morning when her routine pain medication was administered. She said Resident #68 usually complained of pain all over. She said when a resident complained of pain they should be assessed immediately. LVN J said she had not notified the DON or MD of Resident #68's lack of pain control. During an interview on 3/20/19 at 3:48 p.m., LVN V said Resident #68 complained of pain frequently after pain medication was administered and throughout the evening shift. LVN V said she had not notified the DON or MD of Resident #68's frequent complaints of pain. During an interview on 3/20/19 at 4:00 p.m., LVN W said she routinely worked the night shift. LVN W said Resident #68 complained of pain 2-3 times during the night shift and asked for pain medication. LVN W said approximately 30 minutes after pain medication was administered Resident #68 would complain of pain and ask for pain medication. LVN W said Resident #68 woke up at night and sometimes said, I'm dying, dying in pain, and asked for pain medication. LVN W said she had not notified the physician about Resident #68's complaints of frequent pain after pain medication was administered. During an interview on 3/20/19 at 10:05 a.m., MA L said Resident #68 complained of pain every morning. MA L said she notified the nurse every time Resident #68 complained of pain. During an interview on 3/20/19 at 10:00 a.m., CNA S said Resident #68 complained of pain to her chest, stomach, legs and feet every day, every time she was in her room on the day shift. CNA S said she was in Resident #68's room approximately every hour. CNA S said she notified the nurse every time Resident #68 complained of pain. CNA S said she was unaware if Resident #68 received pain medication as needed. During an interview on 3/20/19 at 2:29 p.m., CNA N said Resident #68 always complained of pain. CNA N said Resident #68 would call for a pain pill approximately 5-6 times per evening shift. CNA N said Resident #68 complained of pain to her stomach, left arm, and legs. She said she notified the nurse every time Resident #68 complained of pain. CNA N said she heard Resident #68 say she wanted to die on 3/18/19 because of the pain. CNA N said she reported the incident to LVN T. During an interview on 3/20/19 at 2:35 p.m., CNA H said Resident #68 always called for pain medication during the evening shift. CNA H said Resident #68 always complained of pain to her stomach, legs, and left arm. CNA H said she notified the nurse every time Resident #68 complained of pain. She said Resident #68 complained of pain directly after she received pain medication and throughout the evening shift. During an interview on 3/20/19 at 2:52 p.m., CNA U said Resident #68 complained of pain often, approximately 2-3 times during the evening shift. CNA U said she notified the nurse each time Resident #68 complained of pain. She said Resident #68 would complain of pain approximately 20-30 minutes after she received her routine evening pain medication. CNA U said Resident #68 did not get out of bed often and she thought it was because Resident #68 was hurting. During an interview on 3/20/19 at 2:56 p.m., the AD said she asked Resident #68 to come to activities every day and most of the time she refused because she did not feel good. During an interview on 3/20/19 at 4:10 p.m., Resident #68's physician said she had complained of pain and he increased her pain medication today to every 4 hours as needed. He said he had not heard anything from the facility regarding Resident #68 in the last few weeks, until today when he was notified of her increased complaints of pain. He said Resident #68 always complained of pain and had always been very difficult to treat. He said he had to be careful not to prescribe her too much pain medication. He said the [MEDICATION NAME] had helped her in the past with pain control, so he restarted it today. During an interview on 3/20/19 at 10:13 a.m., the DON said she expected staff to notify the nurse if a resident complained of pain, and she expected the nurses to assess a resident's pain when notified. The DON said if a pain medication was administered to a resident, she expected the resident to be re-assessed for pain approximately 1 hour after the pain medication was administered. She said a resident with chronic pain or frequent complaints of pain should be assessed for pain every couple of hours. She said all pain assessments and re-assessments should be documented in the nurse's notes. During an interview on 3/20/19 at 10:18 a.m., the administrator said she expected residents pain to be addressed immediately. She said a resident that received routine pain medication should be assessed for pain and the effectiveness of the pain medication every few hours. A Pain Assessment and Management Policy revised on (MONTH) (YEAR) indicated .the purposes of this procedure are to help the staff identify pain in the resident .pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident .assessing the potential for pain .monitoring for the effectiveness of interventions .modifying approaches as necessary .assess the resident's pain and consequences of pain at least each shift .recognizing pain .possible behavior sign of pain .behaviors such as resisting care, irritability, depression, decreased participation in usual activities, limitations in his or her level of activity due to the presence of pain .difficulty eating or loss of appetite, [MEDICAL CONDITION], and evidence of depression, anxiety, fear or hopelessness .ask the resident if he/she is experiencing pain .re-assess the resident's pain .monitor .to determine if the resident's pain is being adequately controlled .report the following information to the physician .prolonged, unrelieved pain despite care plan interventions.

Based on observation, interview, and record review, the facility failed to consult with the physician for 1 of 2 residents with [MEDICAL CONDITIONS] who was on contact isolation precautions for 2 ½ months (Resident #5). The facility did not consult with Resident #5's physician when she was asymptomatic for [MEDICAL CONDITION] from March 24, 2015 until surveyor intervention on 6/8/2015. There was no documentation that resident #5 had any signs and symptoms of [MEDICAL CONDITION] infection such as diarrhea, fever, nausea or foul smelling stool requiring medication and confinement to her room to prevent the spread of infection for 2 ½ months. Findings Included: A Consolidated physician's orders [REDACTED].#5 was [AGE] years old. Her [DIAGNOSES REDACTED]. She was readmitted to the facility 1/20/15. A lab result dated 3/3/2015 indicated Resident #5 tested negative for [MEDICAL CONDITION]. A Physician order [REDACTED]. On 3/28/15 a lab result indicated Resident # 5 was positive for [MEDICAL CONDITION]. A Physicians Order dated 3/30/15 indicated Resident #5 was placed on Contact Isolation precautions and confined to her room. An MDS dated [DATE] indicated Resident #5 could make herself understood and understood others. She was independent per wheelchair mobility and required minimal assist of one staff. She was incontinent of bowel and bladder. The resident received an antidepressant A care plan dated 1/24/15 indicated Resident #5 was on antibiotic and Contact Isolation for [MEDICAL CONDITION]. Approaches were to medicate as ordered, reculture after medication regimen is completed. Notify MD if recurrent problem or if further treatment is needed. A care plan dated 4/11/15 indicated Resident #5 had a history of [REDACTED]. and was on medication for both conditions. During an interview on 6/8/15 at 2:30 p.m. the nurse practitioner said she did not know Resident #5 had been on Contact Isolation for the past 2 ½ months. During a telephone interview on 6/8/15 at 4:20 p.m., the physician said he did not know Resident #5 had been on contact isolation so long. He said, Being in isolation that long would depress anyone. He said he would call the DON and find out more information immediately. During an interview on 6/10/15 at 8:40 a.m. the physician said if a person does not have diarrhea, or is asymptomatic, they do not have [MEDICAL CONDITION] and do not need to be isolated. He said he was not informed Resident #5 was asymptomatic until the evening of 6/9/15. His treatment was based on Resident #5 having diarrhea and a watery stool. He said he will consult with the [MEDICATION NAME] before and after Resident #5's visit today, but he thinks the [MEDICAL CONDITION] bacteria may be colonized and giving a false/positive lab result. During an observation on 6/8/15 at 9:10 a.m. Resident #5 was well groomed and friendly and sitting at the threshold of her door looking up and down the hall. A sign on her door instructed to, See nurse before entering, and an isolation cabinet containing gloves, gowns and masks was in the hall beside her door. Resident #5 became tearful and said she wanted to come out of her room because she had been in isolation for a long time. During an interview on 6/8/15 at 9:14 a.m. LVN A said Resident #5 had been on Contact Isolation and confined to her room for about 6 months. LVN A said Resident #5 had [MEDICAL CONDITION] and had been on a lot of antibiotics, and tested at least four times. LVN A said the DON decided whether or not Resident #5 needed to remain on contact isolation. LVN A said she did not think Resident #5 needed contact isolation; but she just does what she is told. During an interview on 6/8/15 at 12:25 p.m. CNA C said she was very close to Resident #5 and visited with her often. CNA C said Resident #5 cried and asked to come out of her room about once a day. She said Resident #5 was very depressed. During an interview on 6/8/15 at 1:40 p.m. LVN B performed a skin assessment on Resident #5. Resident #5 had no wound or excoriation to her buttocks or perineum. LVN B said the resident had excoriation in the past, but has not had a runny stool in several months. LVN B said Resident #5 was depressed and needed to come out of her room because she has been confined to her room too long. LVN B said Resident # 5 was receiving [MEDICATION NAME] 125 mg (milligrams) by mouth every other day. LVN B said this is the second time Resident #5 had received [MEDICATION NAME] to treat [MEDICAL CONDITION]. During an interview on 6/8/15 at 1:54 p.m. the DON said the nurses and CNAs told her Resident #5 still had a watery, runny stool. The DON said she made the decision whether or not to keep a resident on contact isolation. She said that the last lab results indicated Resident #5 was positive for the [MEDICAL CONDITION] infection and as long as she was positive she would stay in isolation no matter how long it had been. She said Resident #5 did not wash her hands and had been known to get feces all over her room and that was part of the reason Resident #5 needed to be in her room. The DON said Resident #5 had poor hygiene prior to acquiring [MEDICAL CONDITION] in January. During an interview on 6/9/15 at 7:56 a.m. Resident #5 cried as she asked LVN A if she could come out of her room. LVN A told resident #5 she could not come out of her room and the results of the lab test would determine if she could come out. During an interview on 6/9/15 at 8:37 a.m. following surveyor intervention, the DON said she spoke with the physician and he ordered lab and a consult with a [MEDICATION NAME]. The DON said she did not know a [MEDICATION NAME] consult was recommended 4/23/15. She did not know why it was not done. The DON said Resident #5 soiled her hands with feces and touched things, and this required her to be in isolation. During an interview on 6/9/15 at 8:40 a.m. the administrator said she was not aware if Resident #5 continued to have loose, watery stool, but her behaviors with her feces was a factor in her remaining on Contact Isolation. The administrator said she agreed confining Resident #5 to her room was necessary. During a telephone interview on 6/9/15 at 10:15 a.m. a nurse with The Centers for Disease Control, said their guidelines for [MEDICAL CONDITION] included, when a resident is asymptomatic; meaning no diarrhea for 24 hours or more; diarrhea being defined as 3 or more watery stools in a 24 hour period; after 24-48 hours of no symptoms, the resident did not need to be on contact isolation, even if they tested positive for [MEDICAL CONDITION]. During a telephone interview on 6/9/15 at 11:00 a.m. CNA C said Resident #5 had not had a watery stool in at least 2-3 weeks. CNA C said on 6/3/15 the stool was soft and had no odor. On 6/4/15 the stool was formed and had no odor, and the resident's stool had been formed ever since. She said she told the nurses Resident #5 did not have a loose stool. During an interview on 6/9/15 at 11:15 a.m., LVN C said she told Resident #5 she could come out of her room because the doctor had removed the contact isolation precautions. LVN C said the physician called 4 times concerning Resident #5. Following surveyor intervention, the physician gave an order to discontinue the contact isolation due to Resident #5 being asymptomatic. LVN C said Resident #5 cried when she told her she could leave her room. During an interview on 6/9/2015 at 12:13 p.m. CNA D said she did not know how long Resident #5 had been on Contact Isolation, but it had been too long. CNA D said the nurses were aware Resident #5 did not have diarrhea. During an interview on 6/9/15 at 2:10 p.m. CNA E said Resident #5 cried three or four times a week about wanting to come out of her room. Resident #5 told her, I will do better. CNA E said Resident #5 got feces on her hands when she cleaned herself. She would then get it on the wall and furniture without knowing. CNA E said Resident #5 was very social. She loved to visit and help the other residents. CNA E said Resident #5 based her entire day around activities. During an interview on 6/9/15 at 3:35 p.m. the Activity director said Resident #5 was one of the most active residents in the facility. In May, Resident #5 planned to attend an outing to the casino and was not allowed to attend due to the Contact Isolation Precautions. The AD said Resident #5 became very depressed and cried because she could not attend the outing, as that was her favorite activity. During an interview on 6/9/15 at 3:50 p.m. LVN B said Resident #5 had a formed stool without a foul odor for at least two weeks. LVN B said before that, the stool was soft, not loose, and the resident had not had diarrhea for at least a month. During an interview on 6/9/15 at 4:00 p.m. the DON said she had not reviewed the ADL log or the nurses' notes regarding Resident #5. The DON said she was not aware of what the consistency of Resident #5's stool had been. The ADL log dated from January 1, 2015 through June 8, 2015 indicated Resident #5 had not had a loose stool or diarrhea since March 24, 2015. A Care Plan Conference summary dated 4/23/15 indicated the PA recommended a GI consult due to the resident had [MEDICAL CONDITION], was on contact isolation and had a weight loss. The undated policy entitled, [MEDICAL CONDITION] (C. Diff) indicates Residents with diarrhea known or suspected to be infected with [MEDICAL CONDITION] should be placed on Contact isolation. Asymptomatic colonization may occur more commonly that the clinical disease. Stool samples for persons may test positive for the organism. Antibiotic therapy is not recommended, once primary colonization is established: the risk for CDAD is decreased once colonization occurs. Symptoms include: watery diarrhea, fever, loss of appetite, nausea, and abdominal tenderness/pain. The undated policy, Isolation Initiation and Discontinuation states, To provide guidance to licensed nurses regarding the initiation and discontinuation of isolation precautions that follow CDC recommendations. The undated policy, In-House Developed Infections Process: 1) Residents should be observed for signs and symptoms of infection. 2) Signs and symptoms of infection should be reported to the attending physician and noted in the medical record. During an interview on 6/8/15 at 1:54 p.m. the DON said there were 2 residents with [MEDICAL CONDITION].

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 2 residents reviewed with [MEDICAL CONDITIONS] infection requiring contact isolation. (Resident #5) The facility did not assess Resident #5 for an improvement in her condition and did not alter their plan of care. Resident #5 had one loose stool documented since 3/24/15. There was no documentation of diarrhea, fever, nausea or foul smelling stool, but Resident #5 was kept isolated in her room for 2 1/2 months until surveyor intervention on 6/8/2015. This failure caused Resident #5 emotional distress and a diminished quality of life and placed 1 other resident with [MEDICAL CONDITION] at risk of psychosocial stress. Findings Included: A Consolidated physician's orders [REDACTED].#5 was [AGE] years old. Her [DIAGNOSES REDACTED]. She was readmitted to the facility 1/20/15. A lab result dated 3/3/2015 indicated Resident #5 tested negative for [MEDICAL CONDITION]. A Physician order [REDACTED]. On 3/28/15 a lab result indicated Resident # 5 was positive for [MEDICAL CONDITION]. A Physicians Order dated 3/30/15 indicated Resident #5 was placed on Contact Isolation precautions and confined to her room. An MDS dated [DATE] indicated Resident #5 could make herself understood and understood others. She was independent per wheelchair mobility and required minimal assist of one staff. She was incontinent of bowel and bladder. The resident received an antidepressant A care plan dated 1/24/15 indicated Resident #5 was on antibiotic and Contact Isolation for [MEDICAL CONDITION]. Approaches were to medicate as ordered, reculture after medication regimen is completed. Notify MD if recurrent problem or if further treatment is needed. A care plan dated 4/11/15 indicated Resident #5 had a history of [REDACTED]. and was on medication for both conditions. During an interview on 6/8/15 at 2:30 p.m. the nurse practitioner said she did not know Resident #5 had been on Contact Isolation for the past 2 ½ months. During a telephone interview on 6/8/15 at 4:20 p.m., the physician said he did not know Resident #5 had been on contact isolation so long. He said, Being in isolation that long would depress anyone. He said he would call the DON and find out more information immediately. During an interview on 6/10/15 at 8:40 a.m. the physician said if a person does not have diarrhea, or is asymptomatic, they do not have [MEDICAL CONDITION] and do not need to be isolated. He said he was not informed Resident #5 was asymptomatic until the evening of 6/9/15. His treatment was based on Resident #5 having diarrhea and a watery stool. He said he will consult with the [MEDICATION NAME] before and after Resident #5's visit today, but he thinks the [MEDICAL CONDITION] bacteria may be colonized and giving a false/positive lab result. During an observation on 6/8/15 at 9:10 a.m. Resident #5 was well groomed and friendly and sitting at the threshold of her door looking up and down the hall. A sign on her door instructed to, See nurse before entering, and an isolation cabinet containing gloves, gowns and masks was in the hall beside her door. Resident #5 became tearful and said she wanted to come out of her room because she had been in isolation for a long time. During an interview on 6/8/15 at 9:14 a.m. LVN A said Resident #5 had been on Contact Isolation and confined to her room for about 6 months. LVN A said Resident #5 had [MEDICAL CONDITION] and had been on a lot of antibiotics, and tested at least four times. LVN A said the DON decided whether or not Resident #5 needed to remain on contact isolation. LVN A said she did not think Resident #5 needed contact isolation; but she just does what she is told. During an interview on 6/8/15 at 12:25 p.m. CNA C said she was very close to Resident #5 and visited with her often. CNA C said Resident #5 cried and asked to come out of her room about once a day. She said Resident #5 was very depressed. During an interview on 6/8/15 at 1:40 p.m. LVN B performed a skin assessment on Resident #5. Resident #5 had no wound or excoriation to her buttocks or perineum. LVN B said the resident had excoriation in the past, but has not had a runny stool in several months. LVN B said Resident #5 was depressed and needed to come out of her room because she has been confined to her room too long. LVN B said Resident # 5 was receiving [MEDICATION NAME] 125 mg (milligrams) by mouth every other day. LVN B said this is the second time Resident #5 had received [MEDICATION NAME] to treat [MEDICAL CONDITION]. During an interview on 6/8/15 at 1:54 p.m. the DON said the nurses and CNAs told her Resident #5 still had a watery, runny stool. The DON said she made the decision whether or not to keep a resident on contact isolation. She said that the last lab results indicated Resident #5 was positive for the [MEDICAL CONDITION] infection and as long as she was positive she would stay in isolation no matter how long it had been. She said Resident #5 did not wash her hands and had been known to get feces all over her room and that was part of the reason Resident #5 needed to be in her room. The DON said Resident #5 had poor hygiene prior to acquiring [MEDICAL CONDITION] in January. During an interview on 6/9/15 at 7:56 a.m. Resident #5 cried as she asked LVN A if she could come out of her room. LVN A told resident #5 she could not come out of her room and the results of the lab test would determine if she could come out. During an interview on 6/9/15 at 8:37 a.m. following surveyor intervention, the DON said she spoke with the physician and he ordered lab and a consult with a [MEDICATION NAME]. The DON said she did not know a [MEDICATION NAME] consult was recommended 4/23/15. She did not know why it was not done. The DON said Resident #5 soiled her hands with feces and touched things, and this required her to be in isolation. During an interview on 6/9/15 at 8:40 a.m. the administrator said she was not aware if Resident #5 continued to have loose, watery stool, but her behaviors with her feces was a factor in her remaining on Contact Isolation. The administrator said she agreed confining Resident #5 to her room was necessary. During a telephone interview on 6/9/15 at 10:15 a.m. a nurse with The Centers for Disease Control, said their guidelines for [MEDICAL CONDITION] included, when a resident is asymptomatic; meaning no diarrhea for 24 hours or more; diarrhea being defined as 3 or more watery stools in a 24 hour period; after 24-48 hours of no symptoms, the resident did not need to be on contact isolation, even if they tested positive for [MEDICAL CONDITION]. During a telephone interview on 6/9/15 at 11:00 a.m. CNA C said Resident #5 had not had a watery stool in at least 2-3 weeks. CNA C said on 6/3/15 the stool was soft and had no odor. On 6/4/15 the stool was formed and had no odor, and the resident's stool had been formed ever since. She said she told the nurses Resident #5 did not have a loose stool. During an interview on 6/9/15 at 11:15 a.m., LVN C said she told Resident #5 she could come out of her room because the doctor had removed the contact isolation precautions. LVN C said the physician called 4 times concerning Resident #5. Following surveyor intervention, the physician gave an order to discontinue the contact isolation due to Resident #5 being asymptomatic. LVN C said Resident #5 cried when she told her she could leave her room. During an interview on 6/9/2015 at 12:13 p.m. CNA D said she did not know how long Resident #5 had been on Contact Isolation, but it had been too long. CNA D said the nurses were aware Resident #5 did not have diarrhea. During an interview on 6/9/15 at 2:10 p.m. CNA E said Resident #5 cried three or four times a week about wanting to come out of her room. Resident #5 told her, I will do better. CNA E said Resident #5 got feces on her hands when she cleaned herself. She would then get it on the wall and furniture without knowing. CNA E said Resident #5 was very social. She loved to visit and help the other residents. CNA E said Resident #5 based her entire day around activities. During an interview on 6/9/15 at 3:35 p.m. the Activity director said Resident #5 was one of the most active residents in the facility. In May, Resident #5 planned to attend an outing to the casino and was not allowed to attend due to the Contact Isolation Precautions. The AD said Resident #5 became very depressed and cried because she could not attend the outing, as that was her favorite activity. During an interview on 6/9/15 at 3:50 p.m. LVN B said Resident #5 had a formed stool without a foul odor for at least two weeks. LVN B said before that, the stool was soft, not loose, and the resident had not had diarrhea for at least a month. During an interview on 6/9/15 at 4:00 p.m. the DON said she had not reviewed the ADL log or the nurses' notes regarding Resident #5. The DON said she was not aware of what the consistency of Resident #5's stool had been. The ADL log dated from January 1, 2015 through June 8, 2015 indicated Resident #5 had not had a loose stool or diarrhea since March 24, 2015. A Care Plan Conference summary dated 4/23/15 indicated the PA recommended a GI consult due to the resident had [MEDICAL CONDITION], was on contact isolation and had a weight loss. The undated policy entitled, [MEDICAL CONDITION] (C. Diff) indicates Residents with diarrhea known or suspected to be infected with [MEDICAL CONDITION] should be placed on Contact isolation. Asymptomatic colonization may occur more commonly that the clinical disease. Stool samples for persons may test positive for the organism. Antibiotic therapy is not recommended, once primary colonization is established: the risk for CDAD is decreased once colonization occurs. Symptoms include: watery diarrhea, fever, loss of appetite, nausea, and abdominal tenderness/pain. The undated policy, Isolation Initiation and Discontinuation states, To provide guidance to licensed nurses regarding the initiation and discontinuation of isolation precautions that follow CDC recommendations. The undated policy, In-House Developed Infections Process: 1) Residents should be observed for signs and symptoms of infection. 2) Signs and symptoms of infection should be reported to the attending physician and noted in the medical record. During an interview on 6/8/15 at 1:54 p.m. the DON said there were 2 residents with [MEDICAL CONDITION].