Every finding on record at Avir at Fort Worth

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one of three residents (Resident #1) reviewed for accidents. The facility failed when on 08/09/2026, LVN A and CNA B did not utilize a gait belt when transferring Resident #1; instead, they lifted Resident #1 from under her armpits. This failure could place residents at risk for accidents/injuries, including dislocation of joints and/or falls.Findings included: Record review of Resident #1's Face Sheet, dated 08/10/26, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including malignant neoplasm of unspecified part of right bronchus or lung (right-sided lung cancer), chronic pain (ongoing or recurring pain that lasts or returns for more than three months), and edema (swelling caused by too much fluid trapped in your body's tissues). Record review of Resident #1's MDS Assessment, dated 07/28/26, reflected she had a BIMS of 6, indicating severe cognitive impairment. The MDS Assessment reflected Resident #1 was dependent upon staff for transfers. Record review of Resident #1's Care Plan, dated 07/23/26, reflected she was at a high risk for falls due to confusion and gait/balance problems. Resident #1's Care Plan reflected she was dependent upon two staff members for transfer assistance. Observation of Resident #1 on 08/09/26 at 8:20PM revealed she was sitting in her wheelchair, by her bed. LVN A and CNA B were both observed to stand on either side of Resident #1, and both placed their own arm under Resident #1's armpits. LVN A and CNA B then lifted Resident #1 from a sitting position into a standing position, shifted her to a position in which she was facing away from her bed, and then assisted her into a lying position on her bed. Neither LVN A nor CNA B utilized a gait belt during this transfer. During an interview with LVN A on 08/09/26 at 8:25PM, he stated Resident #1 was totally dependent and could not assist in her own transfers. He stated she required the assistance of two staff members for transfers. LVN A stated the manner in which he and CNA B transferred Resident #1 (by not utilizing a gait belt but instead lifting Resident #1 from under her arms) was appropriate because she did not require a mechanical lift for transfers. During an interview with CNA B on 08/09/26 at 8:28PM, she stated prior to this instance, she had never transferred Resident #1. However, she knew Resident #1 required the assistance of two staff members for transfers. CNA B stated the facility did not require the use of gait belts, and she said that the manner in which she and LVN A transferred Resident #1 (by not utilizing a gait belt but instead lifting Resident #1 from under her arms) was appropriate. During an interview with the Director of Nursing on 08/10/26 at 1:05PM, she stated the expectation was for facility staff to utilize a gait belt any time they were assisting a resident with a transfer (excluding residents who required a mechanical lift for transfers). She stated the risk of staff members not utilizing a gait belt included injury to the residents. Record review of the facility's Safe Lifting and Movement of Residents Policy, dated 2001, reflected, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. and Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation and food storage. 1) The facility failed to ensure food items were properly labeled with the product's name and expiration dates. 2) The facility failed to ensure food items were properly sealed and dated when not in use. These failures could place the residents at risk for food-borne illness and food contamination. Findings included: An observation on 06/07/2026 at 9:25 AM revealed on the table one sheet cake uncovered on the counter. An observation on 06/07/2026 at 9:29 AM revealed in the walk-in refrigerator one bag of mild cheddar cheese, opened, unwrapped and undated. In an interview on 06/07/2026 at 9:35 AM, CK D stated when she opened an item that she knew would not be completely used, she automatically wrote the opened date on the package prior to use and resealed it with saran wrap, placed it in a zip lock bag, or a storage container. CK D stated when she placed leftover food into a storage container or bag, she wrote the name of the item and dated it. CK D stated all kitchen staff were expected to do the same. CK D stated the opened bag of mild cheddar cheese could remain in the original packaging, but it must be securely wrapped with saran wrap, placed in a zip lock bag or plastic container with an opened date written on it. CK D stated the mild cheddar cheese could become stale or air could have seeped in causing it to become hard and develop mold. CK D stated she baked the sheet cake this morning and after it cooled off, she should have covered the cake, labeled it and dated it. CK D stated the worse that could have happened was that the cheese could have been spoiled and the uncovered sheet cake could have been affected with airborne contaminants and caused the residents to become ill. In an interview on 06/07/2026 at 9:55 AM, DA F stated she was trained by the DM to always label items and write the received and/or opened date prior to storing anything. DA F stated the opened mild cheddar cheese should have been securely wrapped with saran wrap, placed in a zip lock bag or a covered storage container prior to being placed back in the refrigerator. DA F stated CK D baked the sheet cake this morning (6/7/26) and placed it on the counter to cool off. DA F stated the sheet cake should have been covered and dated once it cooled off. DA F stated in the future, they should set a timer as a reminder. DA F stated the sheet cake could have become contaminated with airborne particles. DA F stated the mild cheddar cheese could have become stale and molded due to not having an open date or being stored properly. DA F stated not being mindful of these minor details could cause the residents to become sick and develop food poisoning. An observation on 06/08/2026 at 12:05 PM revealed in the walk-in refrigerator the same bag of mild cheddar cheese now wrapped with saran wrap and dated. In an interview on 06/08/2026 at 12:15 PM, the DM stated kitchen staff must make sure everything was properly labeled and dated prior to storage. The DM stated all items regardless of whether they were perishable or not must be unpacked, dated and stored immediately. The DM stated the mild cheddar cheese was delivered to the facility last week on Thursday (6/3/26) and it was opened over the weekend. The DM stated she was unsure who opened the cheese, but it should have been dated and properly stored. The DM stated once the sheet cake had cooled off, it should have been covered, labeled and dated. The DM stated staff may have become busy and failed to cover the sheet cake. The DM stated the mild cheddar cheese could become spoiled due to being a dairy product. The DM stated the cheese could become softened or molded if it was left out or undated. The DM stated she tried not to buy dairy products in bulk due to it not having a long shelf life. The DM stated she would ensure staff were re-educated on dates and proper storage of all products. In an interview on 06/08/2026 at 12:46 PM, CK E stated she made sure she recorded a date on all packages. CK E stated once an item was opened, she added an open date. CK E stated if she must transfer the remaining product to a storage container or zip lock bag, she would write the name of the item on the outside and date it. CK E stated that even open beverages being served to residents must be covered and labeled with a date written on it. CK E stated leftover food should be wrapped with saran wrap, placed in a zip lock bag, or placed in a storage container and dated. CK E stated once the sheet cake had cooled off, it should have been covered and dated to prevent airborne particles from coming into contact. CK E stated the cheese could have become stale, molded or air could have seeped into the opened bag due to not being properly stored. In an interview on 06/08/2026 at 1:10 PM, DA G stated he expected his co-workers to follow procedures to ensure they were keeping all food items safe to prevent spoilage. DA G stated opened cheese could become contaminated and hardened if not stored properly and dated. DA G stated you could use saran wrap, place it in a zip lock bag or storage container with the opened date written on the outside. DA G stated any food products on the counter should be covered, labeled and dated even if the item was being used for the next meal. DA G stated residents could become ill from contamination when proper storage guidelines were not followed. In an interview on 06/09/2026 at 2:12 PM, DA H stated if you open something, you must securely wrap up any remaining product in saran wrap, place it in a secure zip lock bag or storage container and write an opened date on it. DA H said that without an open date written on the mild cheddar cheese, it could be kept in the refrigerator too long and become spoiled due to not knowing when it was opened. DA H said all baked goods must be covered once cooled off to prevent contamination. DA H said the DM completed an in-service today (6/9/26) on if you take something out and open it, make sure you wrap it up securely and date it before you store it. DA H said she did not learn anything new as she already knew the expectations and what needed to be done. In an interview on 06/09/2026 at 2:32 PM, CK I stated the mild cheddar cheese should not have been placed in the refrigerator without an open date nor properly stored. CK I stated leftovers food was stored in storage container and dated. CK I stated they could only leave cooked items in the walk-in refrigerator for 3 days and then it must be discarded. CK I stated this was the residents' home and they wanted them to remain safe. CK I stated the mild cheddar cheese should have been wrapped securely with saran wrap, placed in a zip lock back or storage container with an opened date written on it. CK I stated the sheet cake should have been covered due to the open air and to prevent any airborne particles. CK I said the worse that could have happened was the cheese could have turned bad and caused the residents to become sick. CK I stated the DM in-serviced her today on not leaving items uncovered and ensure you write an open date. CK I stated the DM preached this to them every day and it was no reason for the mild cheddar cheese nor sheet cake to be observed that way by anyone. In an interview on 06/09/2026 at 2:50 PM, the DON stated kitchen staff should have labeled and dated the mild cheddar cheese and sheet cake to know when it should be thrown out. The DON stated the worst thing that could happen was open and undated food could become spoiled and cause the residents to become ill. The DON stated they would definitely be completing in-services and teachings with the entire staff. In an interview on 06/09/2026 at 3:05 PM, the ADM stated the DM ordered all the food items and had her staff label and date everything. The ADM stated the DM was responsible for going behind staff to ensure food items were stocked, labeled and dated. The ADM stated without a doubt, staff should have covered and dated the mild cheddar cheese and the sheet cake. The ADM stated his expectation was for all kitchen staff to adhere to protocol for handling food safely and to follow policies the facility had in place. The ADM said the worst thing that could happen was it could become a habit that perpetuated into something that could make the residents sick. The ADM stated with open and undated food, the residents could become sick or experience an altered digestive tract. Record review of the facility's Food Receiving and Storage Policy with a revised date of November 2022 states: Policy Statement: Foods 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). 3. Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers. 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on observation, interview and record review, the facility failed to ensure Drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 resident (Resident#3) medication on 2 medication carts (hall 100 nurses cart and 400/500/600 medication aides cart) reviewed for pharmacy Services.The facility failed to ensure Zofran 4mg (prescription medication for nausea and vomiting) was labeled with patients label before storing in the medication cart. The facility failed to ensure Nystatin powder 100,000 powder units (a prescription-only antifungal medication used to treat fungal and yeast infections), was properly labeled with patients label before storing in the medication cart. The facility failed to ensure nystatin cream 100,000 powder units was properly labeled with patients label before storing in the medication cart. The facility failed to ensure Nitrofurantoin 100MG (a prescription antibiotic used exclusively to treat and prevent urinary tract infections) was properly labeled with patients label before storing in the medication cart. The facility failed to ensure proper storage of opened Acidophilus (meant to keep or improve the healthy bacteria in the body) which required refrigeration per manufacturer's guidelines was observed stored unrefrigerated in the medication cart. The facility failed to properly dispose Resident#3's expired nitroglycerin 0.4MG (medication to treat or prevent acute chest pain). These failures could place residents at risk for compromised unsafe administration, and increased harm to residents. Findings included: Resident#3Record review of Resident #3's Quarterly MDS Assessment, dated 05/13/26, reflected she was a [AGE] year-old female. She was admitted on [DATE] and had a BIMS score of 06, which indicated she had severe cognitive impairment. She had a diagnosis of heart failure (a serious chronic condition where the heart muscle cannot pump enough oxygen-rich blood to meet the body's needs).Record review of Resident #3's Care plan active as of 6/07/2026 revealed the care plan did not include focus, goals, and interventions of the medication.Review of Resident #3's active Physician's Orders, dated 6/07/2026, reflected Nitroglycerin Sublingual Tablet Sublingual (Nitroglycerin) Give 0.4 mg sublingually every 8 hours as needed for Chest pain Active 12/22/2025.Observation on 06/07/2026 at 9:03 AM with LVN A on the 100 hall nurses cart revealed: Seven pills of Zofran 4mg with no prescription labels, Nitrofurantoin 100mg with no prescription label, three bottles of Nystatin powder 100,000 powder units with not prescription labels, one tube of nystatin cream 100,00 units with nor prescription label, and Resident#3's Nitroglycerin 0.4MG which expired on 3/11/2026.During an interview on 06/07/2026 at 9:16 AM with LVN A revealed the nurses were responsible for ensuring all medication was properly labeled before storing in the medication cart. She stated that all expired medication was to be removed immediately from the cart so that it was not available for administration. She stated the risk was medication error. She stated that if a medication did not have label, it was to be removed from the cart and disposed of or she would contact pharmacy for further instructions.Observation on 06/08/2026 at 10:13 AM with MA C on the 400/500/600 hall medication cart revealed Acidophilus that was unrefrigerated.During an interview on 06/08/2026 at 10:16 AM with MA C revealed she was unaware that the acidophilus was supposed to be refrigerated. She stated that medication that required refrigeration and was not refrigerated was no longer effective and was not good for the residents because it would not be effective to treat the residents' symptoms. She stated she had been in serviced on medication storage. During an interview on 06/09/2026 at 1:04 PM, the ADON stated nurses were responsible for ensuring medication carts were clean and medication was properly labelled and stored. She stated that she audited the medication carts weekly, then the pharmacy consultant audited the medication room, and the medication cart every month. She stated that she had not had the time to audit the carts in the last few weeks because she had been working on the floor as a charge Nurse. She stated the risk if medication did not have the proper patients label was that the nurses would not know who the medication belonged to and would administer to the wrong patient. She stated medication that required refrigeration and was not refrigerated would lose its strength and not be effective to treat the residents' symptoms. She stated that expired medication should not have been available in medication cart and anytime because if administered to a resident it could have negative side effects that could make the resident sick. She stated her expectation was that the nurses did the medication rights and check to make sure the medication were properly labeled before administration. She stated the nurses and medication aides had been in serviced on medication storage and labeling. During an interview on 06/09/2026 at 1:04 PM, the DON stated nurses were responsible for ensuring medication carts were clean and medication was labelled and stored properly. She stated that the ADON audited the medication carts weekly, then the pharmacy consultant checks the medication room, and the medication cart every month. She stated the risk of not having proper labels on medication was that the nurses would not know who the medication belonged to and could administer to the wrong patient. She stated medication that required refrigeration could lose its potency and not be effective to treat the residents' symptoms. She stated expired medication could make the resident sicker and not treat the symptoms it was intended to treat. She stated her expectation was that the nurses did the medication rights and check to make sure the medication was properly labeled before administering. She stated the nurse had been in serviced on medication storage and labeling.Review of the facility's policy titled Medication Labeling and Storage Revised 02/2023 reflected the following:Policy headingThe facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys.6.Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.Medication Labeling1.Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.2.The medication label includes, at a minimum:a.medication name (generic and/or brand);b.prescribed dose;c.strength;d.expiration date, when applicable;e.resident's name;f.route of administration; andg.appropriate instructions and precautions.8.If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 4 Residents (Resident# 78, Resident# 62, Resident# 14, and Resident# 20) of 10 Residents reviewed for pharmacy services.The facility failed to ensure proper disposal of Resident #78's Lorazepam (controlled medication) which expired on [DATE]. The facility failed to ensure proper disposal of Resident #62's Tylenol# 3 (controlled medication) which expired on [DATE]. The facility failed to ensure proper disposal of Resident #14's Tramadol HCL tab 50mg- (controlled medication) which expired on [DATE]. The facility failed to ensure proper storage and disposal of Resident #20's Butalbital/acetaminophen - (controlled medication) by taping a narcotic medication and storing it in the medication cart. These failures could place residents at risk of drug diversion, medication error, and risk of pills contamination due to broken seals.Findings included:Resident#78Review of Resident #78's Quarterly MDS Assessment, dated [DATE], reflected a [AGE] year-old male admitted on [DATE]. He had a BIMs score of 10 which indicated moderate cognitive impairment. The resident had diagnoses which included Cirrhosis (the advanced, permanent scarring of liver tissue caused by long-term liver disease or injury). Review of Resident #78's Comprehensive Care Plan, initiated [DATE], reflected: I am at risk for pain presence. Interventions included: Administer pain medications as ordered by physician and assess effectiveness.Review of Resident #78's active physician orders Dated:[DATE] reflected Lorazepam (calming the central nervous system and is primarily used for the short-term relief of anxiety disorders) Give Lorazepam Oral Tablet 0.5MG (Lorazepam) Give 1 tablet by mouth at bedtime for anxiety Active [DATE].Resident# 62Review of Resident #62's Quarterly MDS Assessment, dated [DATE], reflected a [AGE] year-old male admitted on [DATE], with reentry on [DATE]. He had a BIMs score of 06 which indicated severe cognitive impairment. Section J - Health Conditions reflected Resident#62 Received scheduled pain medication. Review of Resident #62's Comprehensive Care Plan, initiated [DATE], reflected: I am at risk for alteration in comfort, at risk for pain presence. Interventions included: Administer pain medications as ordered by physician and assess effectiveness.Review of Resident #62's active physician orders Dated:[DATE] reflected ACETAMINOPHEN-COD #3 TABLET Give 1 tablet orally every 6 hours as needed for PAIN (HOLD FOR SEDATION) related to PAIN Do not exceed 3000mg of acetaminophen in 24 hours Verbal Active [DATE].Resident# 14Review of Resident #14's Quarterly MDS Assessment, dated [DATE], reflected an [AGE] year-old male admitted on [DATE], with reentry [DATE]. He had a BIMs score of 10 which indicated moderate cognitive impairment. His diagnosis included chronic pain. Review of Resident #14's Comprehensive Care Plan, initiated [DATE], reflected: [Resident#14] has chronic pain r/t cancer. Interventions Administer medication per MD orders, offer and give 1/2 hour before treatments or care that are known to be uncomfortable for me. After medication is administered, return and observe for the effectiveness of the medication. If the pain is not relieved by the medication, notify the nurse and/or MD.Review of Resident #14's active physician orders Dated:[DATE] did not reflect orders for tramadol 50mg (prescription medication used to treat moderate to moderate severe pain).Review of Resident #14's active physician orders Dated:[DATE] reflected Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1tablet by mouth every 8 hours as needed for Anxiety for 14 Days start date [DATE].Resident#20Review of Resident #20's Quarterly MDS Assessment, dated [DATE], reflected a [AGE] year-old female admitted on [DATE].She had a BIMs score of 14 which indicated no cognitive impairment. Her diagnosis included chronic pain. Review of Resident #20's Comprehensive Care Plan, initiated [DATE], reflected: [Resident#20] is at risk for chronic pain arthritis. Interventions included: Administer pain medications per order if non-medication interventions are ineffective. Review of Resident #20's active physician orders Dated:[DATE] reflected no active orders for Butalbital/acetaminophen (a prescription medication used to treat tension headaches). Observation on [DATE] at 9:03 AM with LVN A on the 100 hall nurses cart revealed:Resident #78's (Lorazepam I mg) with expiration date of [DATE] and the medication was last administered on [DATE].Resident #62's (Tylenol#3) with expiration date of [DATE] - last administered on [DATE].Resident #14's (Tramadol HCL tab 50mg) tramadol with expiration date of [DATE], the medication was last administered on [DATE].Resident#20's, (Butalbital/acetaminophen) had broken blisters and was secured with tap last administered [DATE].Resident#14's (Lorazepam 1 mg) had broken blisters and was secured with tap. During an interview on [DATE] at 9:16 AM with LVN A stated she was unaware that Resident #78's (Lorazepam), Resident #62's (Tylenol#3), Resident #14's(Tramadol HCL tab 50mg) were expired , and Resident#20's, (Butalbital/acetaminophen) Resident#84's (Lorazepam 1 mg) had broken blisters and were secured with tap. She stated the nurses were responsible for ensuring expired medication was removed from the medications carts and given to the DON for proper destruction. She stated that when blisters bubbles were damaged the pill should be disposed of by two nurses. She stated that the risk to the residents was administration of expired medication which would not being effective to treat the residents' symptoms or could make the residents sicker. She stated that the risk of taping narcotics was that the nurse would not know if the pill that was tapped was the right pill. She stated she had been in serviced on medication administration, and storage. During an interview on [DATE] at 10:24 AM, LVN B stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics at change of shift. She stated all expired narcotics should be removed from the medication cart and given to the DON for proper destruction. She stated that the risk of a damaged blister would be potential for drug diversion and contamination of the medication and expired medication could have bad side effects if administered. She stated she had been in serviced on medication storage.During an interview on [DATE] at 12:04 PM, the ADON stated nurses were responsible for ensuring medication carts were clean and all narcotic medication was properly secured and not expired. She stated that she audited the medication carts weekly, then the pharmacy consultant audits the medication room, and the medication cart every month. She stated she had not had time to audit the carts in the last few weeks because she has been assisting working on the floor. During an interview on [DATE] at 1:04 PM, the DON stated nurses were responsible for ensuring medication carts were clean and all narcotic medication was properly secured and not expired. She stated that the ADON audited the medication carts weekly, then the pharmacy consultant checks the medication room, and the medication cart every month. She stated the risk was that the nurses would not know if the taped pill was the correct medication. She stated that her expectation was that the nurses did the medication rights of administration and checked to make sure the medication was not expired before administration. She stated the nurses and medication aide had been in serviced on medication administration and narcotic count to include not taping medication but wasting the medication witnessed by another nurse. Review of the facility's policy titled Medication Labeling and Storage Revised 02/2023 reflected the following: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.3.If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interviews and record reviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 2 of 4 residents (Resident #10 and Resident #65) reviewed for assessments.1)Resident #10's PASRR Level I was negative for mental illness despite having a diagnosis of anxiety disorder (ongoing uncontrollable, and excessive worry, fear, or dread that significantly interferes with daily life), bipolar disorder (extreme, recurring mood swings), depression (feelings of severe sadness and inability to initiate activity), and PTSD (triggered by witnessing or experiencing a terrifying or life-threatening event).). 2) Resident #65's PASRR Level I screening form did not reflect mental illness, and the resident did not have a PASRR Level II evaluation.These failures could place residents at risk of not receiving necessary specialized services to meet their individual needs. Findings included: Record review of Resident #10's MDS assessment dated [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE], with a BIMS score of 15 which indicated she was cognitively intact. Her diagnoses included: Anxiety Disorder Bipolar Disorder Depression and Post-Traumatic Stress Disorder. Record review of Resident #10's undated Care Plan, reflected she received psychotropic medication to treat symptoms of bipolar disorder, antianxiety to treat anxiety, and antidepressant medications to treat depression. Record review of Resident #10's PASRR Level 1 Screening dated 08/21/2025 after admission, under Section C – PASRR reflected the resident did not have evidence of a mental illness. Record Review of Resident #65's MDS assessment dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. The residents' BIMS score was 10, indicating the residents' cognition was moderately impaired. Resident #65 diagnoses included Depression , Manic (mood, energy or activity level becomes much higher than usual) Multiple Sclerosis (a disease that causes breakdown of the protective covering of nerves), and Vascular Dementia (type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues). Record review of Resident #65's Care Plan dated 12/11/2025, reflected psych consultation and follow up as indicated. Record review of Resident #65's PASRR Level 1 Screening dated 10/04/2023, under Section C – PASRR reflected the resident did not have evidence of a mental illness. During an interview on 06/09/2026 at 1:42 PM, the MDS Coordinator stated she oversaw PASRR screenings for the facility. The MDS Coordinator stated upon admission to the facility, if the resident came from a health-setting or facility the PASRR would already be completed. The MDS Coordinator stated the only time the facility would re-evaluate a resident was if something occurred with their behavior or medications that prompted them to complete a new PASRR screening. The MDS Coordinator looked in the system and confirmed that Resident #65's PASRR screening reflected negative. The MDS Coordinator said Resident #65 was admitted to the facility with depression. The MDS Coordinator stated based on Resident #65's diagnoses she could be re-evaluated to see if she qualified for additional services. The MDS Coordinator stated she would forward information over to MHMR to come out to see Resident #65 and depending on the services she fell under she would be evaluated. The MDS Coordinator stated if a resident was deemed negative incorrectly, the resident could be affected by not receiving services that they may have qualified for to help them cope. During an interview on 06/09/2026 at 2:50 PM, the DON stated a Resident could be affected when they were deemed negative incorrectly on their PASRR screening by not receiving what was afforded to them. The DON stated the MDS Coordinator could see from the resident's MDS when she went over their form and had PASSR come out and re-evaluate them. The DON stated they went over PASRRs during their morning meetings and IDT meetings and if something was missing the MDS Coordinator would handle it. During an interview on 06/09/2026 at 3:05 PM, the ADM stated they received a complete PASRR screening prior to anyone admitting from the hospital. The ADM stated once the new resident arrives, they should be assessed because all the information may not be 100% accurate. The ADM stated it was outside of his scope as he was not medical. The ADM stated they discussed any changes in behaviors during daily and quarterly meetings. The ADM stated the worse that could happen with a resident's inaccurate PASRR screening was that the resident would not receive qualified services to assist with meeting their needs. Record Review of the facility's PASRR Policy dated 01/20/2026 reflected in part the following: Purpose: The aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. 2. When it is determined that a PL1 was filled out incorrectly, the MDS Coordinator, Social Worker or designee will reach out to the hospital/responsible case worker and ask them to correct the form. a. If the referring case worker is unwilling/unable to correct the PL1 that contains a potential error, the social worker or designee will complete and submit a form 1012 (MI) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings (MI).

Based on observation , interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 residents (Resident #68 and Resident#6) reviewed for comprehensive care plans. The facility failed to ensure Resident #68's comprehensive care plan identified bed rail use as an intervention for mobility assistance.The facility failed to ensure Resident #6's comprehensive care plan identified the resident had a Colostomy (a surgical procedure that brings a portion of the large intestine (colon) to the outside of the abdominal wall to create an opening called a stoma. This allows stool to bypass the lower digestive tract and collects in an external pouch). This failure could place residents at risk for not receiving proper care and services due to inaccurate care plans.Findings included:Resident#68Record review of Resident #68's MDS assessment dated [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE] and re-entry 03/21/2026. Her BIMS score was 14 which indicated intact cognitive function. Her diagnoses included: SPONDYLOPATHY (disease of the spine). Record review of Resident #68's Physician Orders dated 06/08/2026, revealed an active order with a start date of 03/26/2025 May use assist bars to bed bil for bed mobility, positioning and transfers.Record Review of Resident #68's comprehensive care plan initiated on 04/21/2026, revealed the care plan did not address the use of side rails as a mobility intervention.Observation on 06/07/2026 at 10:16 AM revealed Resident #68 had half side rails on both sides of her bed.During an interview on 06/07/2026 at 10:17 AM with Resident #68, she reported she used the side rails on her bed every day. She reported she used them mostly to help her reposition herself because of her weight. She reported the side rails were very helpful and denied the rails prevented her ability to get out of bed.Resident#6Record review of Resident #6's MDS assessment dated [DATE], reflected a [AGE] year-old male, originally admitted to the facility on [DATE]. His BIMS score was 13 which indicated moderate cognitive impairment. Resident#6 was coded to have a colostomy. Record review of Resident #6's Physician Orders dated 06/08/2026, revealed an active order with a start date of 01/17/2026 Every shift check skin around stoma site for redness, irritation, excessive bleeding, swelling every shift for Colostomy.Record Review of Resident #6's comprehensive care plan active as of 06/08/2026, revealed the care plan did not address the use of colostomy.During and observation on 06/08/2026 at 9:06 AM revealed Resident #6 had colostomy. During an interview on 06/08/2026 at 9:07 AM with Resident #6, he reported that he had a colostomy and the staff assist with emptying the colostomy. During an interview on 06/08/2026 at 12:00 PM with MDSC she reported the Inter Disciplinary Team was responsible for updating residents care plan. She stated Resident#68's side rail and Resident#6's colostomy should have been added to the resident's care plan. She stated the nursing department was responsible for updating Resident#68's side rails on the care plan and Resident#6's colostomy on his care plan. MDSC reported the risk to residents who did not have accurate care plans was that staff would not know the care needs of the residents. During an interview on 06/09/2026 at 11:45 AM with the ADON, she reported she was responsible for completing the Baseline and Comprehensive Care Plans. She stated that therapy was responsible to assess residents for bed rails, then therapy gave the assessments to the nursing department (ADON and DON) to update the care plans. She stated the risk to residents who did not have accurate care plans was the staff would not know the focus issue that the interventions may not be followed. An attempt to interview therapy director was unsuccessful left voice mail with call back number. During an interview on 06/09/2026 at 11:55 AM with the DON, she reported she was responsible for completing the Baseline and Comprehensive Care Plans. She stated that therapy did the assessment on bed rails then she was responsible for updating the care plans. She stated it was an oversight on her part. She stated the risk to residents who did not have accurate care plans was that interventions may not be followed and residents were at risk of not receiving the care needed. Record Review of the Facility Care Plans, Comprehensive Person-Centered dated March 2022, reflected in part: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.7.The comprehensive, person-centered care plan:a.includes measurable objectives and timeframes.b.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:(1)services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;(2)any specialized services to be provided as a result of PASARR recommendations; and(3)which professional services are responsible for each element of care;c.includes the resident's stated goals upon admission and desired outcomes;d.builds on the resident's strengths; ande.reflects currently recognized standards of practice for problem areas and conditions. It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. The comprehensive care plan will describe at minimum the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care that meet the professional standards of quality of care for one (Resident #2) of four residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of Resident #2's admission to the facility. This failure could place the residents at risk of not receiving effective, person-centered care and experiencing adverse events that are most likely to occur right after admission. Findings included: Record review of Resident #2's initial MDS, dated [DATE], revealed she was a [AGE] year-old admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (a type of stroke caused by a blockage in a blood vessel). Resident #2's BIMS score was 13, indicating her cognition was intact. Resident #2 had a Foley catheter (a thin tube inserted through the urethra into the bladder to provide continuous drainage of urine) and was incontinent of bowel. Record review of Resident #2's baseline care plan revealed it was not completed, with only one entry that revealed the following: Focus: Resident is at risk for falls r/t gait/balance problems and fearful of falling Goals: The resident will not sustain serious injury through the review date Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach of the resident to use it for assistance as needed. Pt evaluate and treat as ordered or PRN. Use gait belt with transfers. During an interview with the Social Worker on 03/11/2026 at 1:13pm, the Social Worker was shown the care plan section for Resident #2 in PCC (an electronic health record software platform used to manage resident data) and confirmed the baseline care plan was not completed. The Social Worker was asked whose responsibility it was to make sure the care plan was complete and she stated it was the responsibility of every discipline of the IDT to make sure their section was complete. The Social Worker stated they must have missed that one. The Social Worker identified the risk for the resident was the staff did know what care they needed to provide if it's not there. During an interview with the DON on 03/11/2026 at 3:43pm, the DON was shown Resident #2's record in PCC and was shown the baseline care plan was not there. The DON looked under the miscellaneous tab, stating sometimes they scanned it to the miscellaneous tab instead. The DON confirmed the baseline care plan was not in Resident #2's chart. The DON stated she usually went into PCC and checked the care plans, but she must have missed it. The DON was asked if there was a risk for the resident if the care plan was not completed and she stated of course, to be able to care for her, it's so they knew what to do, it's the staff's plan of care. A review of the facility's Care Planning-Interdisciplinary Team policy, dated March 2022, updated 12/2024, revealed the following: 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 S483.21.

Based on observation, record review and interviews, the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for resident rights. The facility failed to provide an alternative means of communication to the call light system for Resident #1. This failure could place residents at risk for delayed assistance and an inability to request help when needed. Findings included: Record review of Resident #1's MDS, dated [DATE], revealed Resident #1 was a [AGE] year-old admitted to the facility on [DATE] with severely impaired vision and had a BIMS score of 6, indicating severe impairment in cognition, thinking and memory. Resident # 1 was incontinent of bowel and bladder and had a primary diagnosis of hypertensive heart (structural and functional changes to the heart caused by long-term high blood pressure) and chronic kidney disease without heart failure. Record review of Resident #1's care plan, not dated, revealed the following: Focus: Sensory/Perception Alterations: Visual Goal: Resident to achieve maximum functional status within limits of visual impairments Intervention: Evaluate Resident's ability to function safely within limits of visual impairmentsRemove possible environmental barriers to ensure safety Further review of Resident #1's care plan did not reveal an entry reflecting the resident was known not to use the call light, nor was there an entry identifying an alternative means of communication to the call light system. During an observation on 03/11/2026 at 12:07pm, Resident #1 was observed standing in the middle of her room, motionless and silent. Resident #1 was observed in this position for approximately one minute and was asked from the hallway if she needed help. The resident responded she needed the bathroom. Upon entering Resident #1's room, the smell of BM was observed. Resident #1 was asked if she needed help and she said yes. Resident #1 was asked if she had pressed the call light to request help and she stated she did not know what that was. Resident #1 was asked if she knew how to press the call light to get a nurse and she stated she did not know how to do that. The call light was observed to be inaccessible with the cord wrapped up and against the wall, behind the privacy curtain. The surveyor requested assistance from staff down the hall. During an interview with LVN A on 03/11/2026 at 12:40pm, LVN A was asked if Resident #1 used her call light. LVN A stated she was fully blind, and she could not press the call light. She further stated if they put the call light within reach, Resident #1 would not press the call light, even if they clipped it to her shirt. LVN A was asked how Resident #1 communicated that she needed help, and LVN A stated she was able to verbalize what she needed, she would shout if she did need help and her door was always left open. LVN A stated she kept an eye on Resident #1, and mostly everyone knew to do that for her because she was one of two blind patients on that hall. LVN A was asked if an alternative method to the call light had been designated for Resident #1 and she stated she was not aware of one. LVN A was asked if there was a risk for the resident not using the call light, and she stated she did not think there was because she could tell them or shout out what she needed, when she was agitated, she was very vocal. During an interview with CNA B on 3/11/2026 at 2:16pm, CNA B was asked if she knew Resident #1 used the call light. CNA B stated she had only worked at the facility for three days, but she knew Resident #1 was blind and did not think she used the call light. CNA B further stated she knew Resident #1 needed assistance, and she could eat on her own. CNA B stated she would poke her head in and check on her; she was constantly rounding on the hall. CNA B was asked if she was aware of an alternative method to the call light for Resident #1 and she stated she was not aware of one. During an interview with the DON on 03/11/2026 at 3:43pm, the DON was asked if it was known that Resident #1 did not use her call light, and she stated she has used it in the past, but maybe she had days she did not recognize what it was. The DON stated they kept her door open, and she was close to the nurse's station so that they could see her when they went by. The DON was asked if Resident #1 did not use her call light, had an alternative communication method been identified and documented, and the DON stated it had not. The DON was asked if there was a risk for the resident not having a way to communicate she needed help and the DON stated her safety, and she could have skin breakdown if she wore a soiled brief for too long. A review of the facility's Call System, Residents Policy, dated September 2022 and updated January 2025 revealed the following: 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. 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 maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Residents #1 and Resident #2) reviewed for infection control practices 1. CNA A and CNA B failed to perform hand hygiene prior to and after providing Resident #2 with incontinence care.2. CNA A and CNA B failed to wear a gown when providing incontinence care to Resident #2, who was on EBP due to having a feeding tube. 3. CNA A failed to perform hand hygiene and glove changes while providing Resident #1 and Resident #2 with incontinence care.These failures could place residents at risk of cross-contamination and infections. Findings included: Record review of Resident #2's Face Sheet, dated 01/20/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's Quarterly MDS, dated [DATE], reflected the resident's diagnoses included: cerebral palsy (neurological condition affecting movement, posture, and muscle coordination); urinary tract infection (bacterial infection in any part of the urinary system); seizure disorder (condition characterized by recurring, unprovoked seizures); chronic pain; and muscle weakness. The MDS also reflected Resident #2's cognitive skills were severely impaired, indicating she was unable to make decisions. In addition, the MDS reflected that the resident was dependent on staff for all care, incontinent of bowel and bladder, and had a feeding tube for nutrition. Record review of Resident #2's Care Plan, revised 01/09/26, reflected the resident required tube feeding, had a urinary tract infection in December, had impaired communication due to intellectual disability (limitations with thinking and learning), had an ADL self-care performance deficit with interventions for staff to reposition every 2 hours and revealed she was dependent on staff for showering, eating, hygiene, incontinent care, and transfers. Record review of Resident #2's active physician orders, dated 01/20/26, reflected the following: Enhanced-Barrier Precautions every shift for infection prevention.Observation on 01/20/26 at 9:46 AM revealed CNA A and CNA B entered Resident #2's room, did not wash/sanitize their hands, and did not put on PPE (gown and gloves) prior to entering the room. Resident #2 was observed lying in bed. CNA A and CNA B applied clean gloves, closed the door, and pulled the privacy curtain. CNA A prepared supplies on a clean barrier, unlatched Resident #2's brief, and began to clean the resident's perineal area. CNA A then assisted Resident #2 to turn onto her side, used new wipes and cleaned the buttocks. CNA A rolled the soiled brief within itself and discarded it in the trash. Without performing hand hygiene or changing gloves, CNA A obtained a clean brief and placed it under Resident #2's buttocks, turned the resident onto her back, and secured the brief. CNA A and CNA B then repositioned Resident #2. Both CNAs removed their gloves and exited the room. No hand hygiene was observed upon exit, and both CNAs proceeded down the hallway. CNA A and CNA B did not apply PPE for EBP and did not perform hand hygiene prior to or after providing incontinent care. CNA A also did not change gloves or perform hand hygiene prior to applying a clean brief during incontinent care. Observation at 01/20/26 at 12:21 PM revealed the enhanced barrier precautions sign next to Resident #2's name plate. The sign reflected the following: Enhanced Barrier precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene. Observation also revealed PPE was available right inside the room door and hand sanitizer noted right outside the door. Record review of Resident #1's Face Sheet, dated 01/20/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #1's Annual MDS, dated [DATE], reflected the resident had diagnoses of Hemiplegia following Cerebral Infarction affecting right dominant side (Right side paralysis following a stroke), Aphasia (disorder that affects how you communicate), Seizure Disorder (Condition characterized by recurring, unprovoked seizures), and Anxiety. The MDS also reflected Resident #1's cognitive skills were severely impaired, indicating she was unable to make decisions. In addition, the MDS reflected that Resident #1 was dependent on staff for toileting, showering, dressing, and was incontinent of bowel and bladder. Record review of Resident #1's Care Plan, reflected the resident had impaired physical mobility with interventions for staff to assist resident in performing movements/tasks, had memory loss, and had an ADL self-care performance deficit with interventions that resident was dependent on staff assistance for transfers, incontinent care, personal hygiene, showering, and bed mobility. Observation on 01/20/26 at 1:43 PM revealed CNA A and CNA B entered Resident #1's room and performed hand hygiene. The door was shut, and the privacy curtain was pulled. CNA A gathered supplies on a clean barrier, and both CNAs applied clean gloves. The brief was unlatched, and CNA A cleansed the perineal area, using a new wipe with each swipe. CNA B assisted Resident #1 to turn onto her side and CNA A wiped her buttocks. CNA A folded the soiled brief inward and discarded it into the trash. Without performing hand hygiene or changing gloves, CNA A obtained and applied a clean brief. Resident #1 was rolled back onto her back, and the brief was secured. Resident #1 was scooted up and repositioned by CNA A and CNA B. Both CNAs removed their gloves. CNA B performed hand hygiene. CNA A did not perform hand hygiene and exited the room, proceeding down the hallway. CNA A did not change gloves or perform hand hygiene prior to applying a clean brief and did not perform hand hygiene after incontinent care was completed.Interview on 01/20/26 at 2:55 PM with CNA A revealed she had been working at the facility for 2 months. CNA A stated hand hygiene should be performed anytime she enters or exits a resident's room. CNA A stated she washed her hands in the utility room when getting the supplies for Resident #2 but did not perform hand hygiene after entering or exiting the room. CNA A stated she must have forgotten. CNA A stated she washed her hands before incontinent care on Resident #1 but must have forgotten to do so afterward. CNA A stated she was not taught to change gloves during incontinent care. She stated she usually uses the same gloves for incontinent care but changes them before putting new sheets on the bed. CNA A stated the risk of not performing appropriate hand hygiene or glove changes, was it could spread infections. CNA A stated she did not have many residents in her hallway on EBP. She stated that PPE should be applied before entering the room. CNA A stated she was not aware that Resident #2 was on EBP and missed seeing the sign. CNA A stated she was not trained to use a gown for any of Resident #2's care. CNA A stated she was trained on incontinent care and infection control upon hire; however, she did not recall being taught this. CNA A stated not wearing PPE was an infection problem and could cause cross contamination. Interview on 01/20/26 at 3:15 PM with CNA B revealed hand hygiene should be performed before and after any care. CNA B stated she did not perform hand hygiene before or after incontinent care on Resident #2. CNA B stated she normally washes her hands but had not been feeling good and forgot. ten. She stated if hand hygiene were not performed properly, it could spread infection from one room to the other. CNA B stated she was familiar with EBP. She stated a gown, and gloves should be worn before entering the room. CNA B stated she was aware of the sign and saw the PPE in Resident #2's room but thought it was only used if the resident was sick. She stated she was not aware that the feeding tube meant she needed to wear a gown. CNA B stated the risk of not wearing PPE was spreading infections. Interview on 01/20/26 at 4:12 PM with ADON C revealed she expected her staff to perform hand hygiene when entering or leaving a resident room. She stated with any incontinent care, hand hygiene should be performed between glove changes. ADON C stated glove changes should be completed between removing the soiled brief and applying a clean brief. ADON C stated if the CNAs were not performing hand hygiene or glove changes appropriately, it could cause a risk of spreading infections or UTIs. ADON C stated if staff are not performing hand hygiene in-between residents, they could take infections from patient to patient or even to themselves. ADON C stated if a resident was on EBP, staff should be using the PPE provided to them. She stated the staff were aware of residents on EBP by reading the sign. ADON C Stated there was a sign by the name plate and if it was A bed, it was above the plate and if it was B bed, it was below the name plate. She stated the bins were also right outside or right inside the room and contained the PPE needed. ADON C stated the CNAs should be wearing PPE for any resident care. ADON C stated if the staff were not wearing PPE, it puts them at risk of spreading infection. Interview on 01/20/26 at 4:19 PM with the DON revealed her expectation with hand hygiene was that staff perform it when entering or leaving any rooms. She stated with incontinent care, hand hygiene should be performed when going from dirty to clean. The DON stated if they were not performing hand hygiene or changing gloves appropriately, the risk was infection. She stated it was an infection control issue. The DON stated she expected her staff to wear a gown and gloves before entering a resident room on EBP. She stated the staff were aware of residents on EBP because of the sign on the wall and the PPE present. The DON stated that CNAs were trained upon hire and as needed on infection control and incontinent care. The DON stated she was the infection preventionist and was unable to recall the last in-service completed on infection control. The DON stated if the staff were not using PPE, it was also an infection control issue. The DON stated her and the ADONs were responsible and monitored the staff during their daily rounds. The DON stated she was going to start in-services and training for infection control.Interview on 01/20/26 at 4:50 PM with The Administrator revealed he expected his staff to wash their hands before and after care, before wearing gloves and with any glove changes. He stated if staff were not properly performing hand hygiene, it could transfer infections.Record review of the facility's Enhanced Barrier Precautions Policy, revised March 2024, reflected the following: Policy Statement: Enhanced barrier precautions (EBP) are utilized to reduce the transmission of multi-drug-resistant organisms to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions for not otherwise apply. A. Gloves and gown are applied prior to performing the high contact resident care activity. 3. Examples of high contact resident care activities requiring the use of gowns and gloves for EBPs include A. dressing; b. Bathing/showering; c, transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting.Record review of the facility's Handwashing/Hand Hygiene policy, revised January 2025, reflected the following: .1. Hand hygiene is indicated: a. Immediately before touching a resident.d. after touching a resident; e. after touching a resident's environment; f. before moving from work on a soiled body site on the same resident; g. immediately after glove removal. Record review of the facility's Perineal Care Policy, revised February 2018, reflected the following: .4. Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens/adult brief b. If gloved, remove and discard gloves following center guidelines at the appropriate time to avoid environmental contamination. Sanitize hands.Record review of the CDC guidelines, Clinical Safety: Hand Hygiene for Healthcare Workers, updated on 02/27/24, reflected the following: Know when to clean your hands: Immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal.When to change gloves and clean hands: If gloves become damaged, if gloves become soiled with blood or body fluids after a task. If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. If moving from care on one patient to another patient. If they look dirty or have blood or body fluids on them after completing a task. Before exiting a patient room.

Based on observation, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 15 of 18 rooms (Rooms 102, 202, 203, 401, 402, 403, 411, 503, 508, 601, 603, 607, 608, 612, and 806) reviewed for physical environment. The facility failed to ensure residents had functioning toilets, sinks, and electrical outlets in Rooms 102, 202, 203, 401, 402, 403, 411, 503, 508, 601, 603, 607, 608, 612, and 806. This failure could place residents at an increased risk of infection or poor sanitation. Findings included:Interview on 10/13/25 at 11:00 AM with Resident #1's Family Member revealed Resident #1 when the resident admitted to the facility on [DATE], the resident was put in a room with a toilet that would not flush. The resident was then moved to a different room, but there was no call light cord in the room, and the air conditioner was not working. Resident #1's Family Member stated the air conditioner plug and the cord had black scorch marks on them. She stated the nurse told them not to plug it in because it was a fire hazard. The resident was then moved to a third room where they noticed the toilet had no seat. They opted to stay in that room because the resident would most likely not use the toilet. She stated their observations were mentioned to staff, and they seemed unfazed. She stated they moved the resident to another facility within 24 hours. Observations on 10/14/25 of the following resident rooms revealed the following: 9:20 AM - room [ROOM NUMBER] (Unoccupied)The toilet would not flush.9:23 AM - room [ROOM NUMBER] (Unoccupied)The toilet did not have a toilet seat, and the plug for the air conditioner unit was loose in the wall. 9:30 AM - room [ROOM NUMBER] (Unoccupied)The hot water did not turn on at the bathroom sink. 9:32 AM - room [ROOM NUMBER] (Unoccupied)The lighting in the bathroom was dim. 9:34 AM - room [ROOM NUMBER] (Unoccupied)The toilet tank leaked water on the floor when flushed. 9:37 AM - room [ROOM NUMBER] (Unoccupied)The cold water did not turn on at the bathroom sink. 9:40 AM - room [ROOM NUMBER] The light in the bathroom was burnt out. The resident stated he has a urinary catheter and does not use the bathroom.9:42 AM - room [ROOM NUMBER] The hot water did not turn on at the bathroom sink. The resident stated he uses hand sanitizer instead of washing his hands. 9:48 AM - room [ROOM NUMBER] (Unoccupied)There was no hot water at the bathroom sink.9:50 AM - room [ROOM NUMBER] There was no outlet cover for the air conditioner plug. The resident did not notice the condition of the cover. 9:52 AM - room [ROOM NUMBER] The electrical outlet cover was broken. The resident did not notice the condition of the cover. 9:55 AM - room [ROOM NUMBER] There was no outlet cover for the air conditioner plug. The resident did not notice the condition of the cover. 10:00 AM - room [ROOM NUMBER] The toilet would not flush, and the flush handle spun around on the tank. The resident stated he only uses the bathroom to brush his teeth.10:03 AM - room [ROOM NUMBER]The toilet would not flush, and there was no water in the toilet tank. The resident was bedridden. 10:05 AM - room [ROOM NUMBER] The outlet cover for the air conditioner was broken. The resident did not notice the condition of the cover. Interview on 10/14/254 at 10:15 AM, the Administrator stated at the beginning of October 2025 the facility had converted from paper maintenance request forms to a digital system (TELS). He stated all staff received training on how to use the new system for submitting maintenance requests. He stated the new system allowed himself, the DON, and others at the corporate level to see what issues were being reported to the Maintenance Director.Record review of paper maintenance requests from August and September 2025 reflected none of the environmental issues observed on 10/14/25 had been reported to the Maintenance Director. Record review of the electronic log from TELS for the month of October 2025 reflected none of the environmental issues observed on 10/14/25 had been reported to the Maintenance Director. Interview on 10/14/25 at 10:25 AM, RN A stated maintenance requests were submitted on a paper request form that was then placed in the Maintenance Request binder for maintenance to address. She was not aware of any of the issues found on Halls 500, 600, and 800. She stated the residents needed working toilets and hot water for basic sanitation. Interview on 10/14/25 at 10:40 AM, CNA B stated maintenance requests were submitted on a paper form that was put in the binder for the Maintenance Director to work on. She was not aware of any of the issues on Hall 500. She stated it was important for the residents to have a toilet and hot water to prevent infections and for sanitation. Interview on 10/14/25 at 10:44 AM, RN C stated work orders were placed in the maintenance binder to be fixed. She was not aware of the issues on Halls 100, 200, 300, or 400. She stated the residents needed working toilets, hot water, and safe electrical outlets for safety and infection prevention. Interview on 10/14/25 at 10:48 AM, CNA D stated requests for repairs were placed in the binder for maintenance. She was not aware of the issues on Halls 100 and 300. She stated it was important for residents to have working toilets, hot water, and safe electrical plugs for their safety, comfort, and to prevent infections. Interview on 10/14/25 at 11:00 AM, CNA E stated she did not know how to request for something to be repaired by maintenance. She stated she usually just told the nurse, or the Maintenance Director if she saw him. She stated it was important for the residents to have hot water and flushing toilets for their comfort. Interview on 10/14/25 at 11:13 AM, CNA F stated requests for maintenance were put in their binder at the nurse's station. She was not aware of the issues on Halls 200 and 400. She stated residents needed working toilets and hot water for sanitation and infection reasons. Interview on 10/14/25 at 11:55 AM, Resident #2 stated there were always maintenance issues in the building. He stated when staff were notified about the issues, it took quite a while for things to get fixed. He stated there was never any feedback about whether maintenance knew about the issues, or if there was a wait for parts to be ordered.Interview on 10/14/25 at 12:03 PM, Resident #3 stated there had been no hot water in his bathroom for a while. He stated it made washing his hands uncomfortable. He stated he told the Maintenance Director about the lack of hot water, but he did not know what the status on it was. Interview on 10/14/25 at 12:15 PM, Resident #4 stated his hot water in the bathroom sink ran wide open, and the Maintenance Director had turned it off at the valve under the sink. Resident #4 stated he knew how to turn the valve on when he wanted hot water. Interview on 10/14/25 at 1:00 PM, the Maintenance Director stated he was aware of the sinks that had no water. He stated he had new faucets ordered on 10/06/25, and he was waiting for their delivery. He was not aware of the other issues with the toilets and the electric outlets. He stated staff had been trained on the new TELS system, but the majority still filled out paper forms and put them in the binder. He stated he still checked the binders every morning, and then again before he left for the day. He stated he could not fix things that were not reported to him. He stated he tried to do basic checks weekly on resident rooms but could not always get to them. The Maintenance Director stated it was important for the residents to have safe and functional rooms for their comfort as it was their home. Interview on 10/14/25 at 3:00 PM, the DON stated she was not aware of the issues found. She stated staff knew how to use the TELS system. She stated it was supposed to be linked to their electronic record system, but Information Technology was having a hard time making that work. There was a link the staff could click and then sign in to place work orders, but she felt since it was so inconvenient staff were just not reporting anything. She stated it was important to have functioning toilets and hot water for infection control issues as well as basic comfort. Interview on 10/14/25 at 3:12 PM, the Administrator stated staff had been trained on the TELS system before it went live at the beginning of the month, so there was no reason for them not to report anything needing repairs. He stated he would have the DON in-service staff again. The Administrator stated it was important for the residents to have a functional and safe environment for their comfort and for basic sanitation reasons. The Administrator was unable to provide a policy that addressed a safe, comfortable, homelike environment.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse and neglect, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility for 1 of 3 residents reviewed for abuse and neglect. CNA F and CNA G failed to report to the Administrator when they overheard CNA A threaten to [NAME] Resident #1 during a verbal altercation the morning of 11/16/25. Four hours later, the resident entered into a verbal altercation with CNA A, which escalated to CNA A spraying [NAME] at the resident. The noncompliance was identified as past noncompliance. The noncompliance began on 11/16/25 and ended on 11/18/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of incidents of abuse or neglect not being reported timely and thoroughly investigated.Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included bipolar disorder (a chronic mental health condition characterized by extreme mood swings, energy level shifts, and difficulty with activity levels, ranging from manic episodes to depressive episodes), schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a distorted perception of reality), and spinal stenosis (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves, causing symptoms like back and leg pain, numbness, tingling, and weakness). The residents' cognition was intact with a BIMS score of 15. The resident had other behavioral symptoms not directed towards others at least 4 to 6 days during the assessment review period but less than daily. Those behavioral symptoms included but were not limited to physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds and had the potential to interfere with the resident's participation in activities or social interactions. These behavioral symptoms had the potential to put others at significant risk of physical injury and/or significantly intrude on the privacy or activity of others. The MDS also showed that Resident #1 used a wheelchair due to impairment on both sides to his lower extremities. Record review of Resident #1's care plan revised on 11/12/25 reflected he had a mood problem related to the disease process of bipolar disorder. Interventions included administering medications as ordered, consulting behavioral health, and monitor/record/report to MD mood patterns, signs/symptoms of depression, anxiety, sad mood, impulsiveness or euphoria as per facility behavior monitoring protocols. Record review of the Provider Investigation Report dated 11/21/25 reflected the following: [Resident #1] was around the Activity room arguing with [CNA A]. [CNA A] sprayed resident with pepper spray to the back side of head Record review of Resident #1's progress notes dated 11/16/25 documented by RN B reflected she was at the nurses' station when she heard people yelling/fighting and hear Resident #1 say CNA A had sprayed pepper spray to the back of his head. Other residents and staff in the area were coughing. RN B documented CNA C, who was providing 1:1 supervision told her (RN B) that Resident #1 had gone to the activity room and then began to kick the activity room door when it closed and at that time CNA A came out of the activity room and told everyone around to step back as she sprayed pepper spray on the back of Resident #1's head. The notes also reflected that Resident #1 had called the police after the incident, and the resident had refused a head-to-toe assessment or have the pepper spray washed off his head until the police arrived at the facility. The notes reflected RN B observed multiple small clear liquid scattered on Resident #1's head and once the 2 police men left, the resident allowed RN B to assess/wash his head and she did not notice any redness, bruises, or a rash to Resident #1's head nor did he complain of burning or irritation to his eyes and his speech was clear. Record review of Resident #1's hospital records dated 11/16/25 reflected the resident was seen for toxic effect of lacrimogenic gas (tear gas), assault, initial encounter. Further review of the hospital records reflected there were no injuries documented and no further orders. Observation and interview on 11/18/25 at 10:31 AM revealed Resident #1 was sitting in a wheelchair outside in the courtyard patio socializing with a female resident. CNA C sat near the residents monitoring them. Resident #1 was moved to another part of the patio for a private conversation. Resident #1 stated a staff member (CNA A) had sprayed him with [NAME]. He stated it happened out of nowhere, and he denied having an altercation with CNA A. The resident stated he was going down the hall and CNA A was staring at him, and then all a sudden he had to back out because the CNA was coming at him with the [NAME]. The resident said he was sprayed on the back of the head with [NAME], and some had gotten in his eyes. He stated that both areas began to burn. After CNA A sprayed him with the [NAME], he stated he called the police. He stated he later went to the hospital due to the burning sensation. Interview on 11/18/25 at 12:06 PM, RN B revealed Resident #1 had been placed on one-to-one supervision a few days prior to the incident on 11/16/25 due to an unrelated incident. RN B said the morning of 11/16/25, Resident #1 started having verbal behaviors towards CNA C, who was providing one-to-one supervision. RN B stated Resident #1 began to yell, curse, and call the staff around him names including RN B. RN B stated as Resident #1 began to go down another hall, she instructed CNA C to follow behind the resident at a distance in case Resident #1 became physically aggressive. As the resident and CNA C got further down the hall, RN B said she heard people raising their voices. RN B stated she heard Resident #1 yell and curse again. She stated there were multiple staff present including CNA A. RN B said as Resident #1 continued to yell and curse, she heard CNA A call 911 due to the resident's behaviors. RN B stated CNA A claimed Resident #1 had swung at another staff member at that time (Housekeeper D). RN B said the police came to the facility and spoke with Resident #1 and CNA A. The police left the facility, and the resident remained calm for the next few hours. RN B said sometime after lunch, she heard people screaming. She stated she went down the hall, and she noticed Resident #1 had some liquid dots on the back of his head. She stated staff around the resident were coughing. At that time both Resident #1 and CNA A were calling the police. RN B stated someone, whom she did not recall, stated that CNA A had sprayed Resident #1 with pepper spray. RN B said she tried to assess Resident #1, but he would not allow her to wash the back of his head until he spoke with the police. After the police completed their visit at the facility, RN B said Resident #1 allowed her to wash his head and face. She stated she did not notice any redness or swelling to his eye or the back of his head. RN B said after a while, Resident #1 stated he wanted to be sent to the emergency room because the back of his head, neck, and eyes were burning. The resident was sent to the hospital, and he returned from the hospital with no new orders. Interview on 11/18/25 at 12:46 PM, CNA C revealed she was asked to provide one-to-one supervision to Resident #1 related to previous behaviors. CNA C said the morning of 11/16/25 Resident #1 was upset and began to curse and insult her along with other staff. She stated RN B told her to keep her distance from the resident as she monitored him, in case he became physically aggressive. CNA C said a few hours later after lunch, Resident #1 was in the television room and requested to be pushed back to his room because it was too loud. CNA C stated as they passed the activity room, Resident #1 saw CNA A sitting in the room. As soon as Resident #1 saw CNA A, he went into the activity room. CNA C stated Resident #1 and CNA A began to argue. CNA C said she did not understand what was going on. She stated the only thing she understood or heard was CNA A tell Resident #1, Get your ass in here! CNA C said she stood back and watched as Resident #1 and CNA A argued. She then stated suddenly, the activity room door closed, and Resident #1 wheeled backwards. She stated Resident #1 began to kick the activity room door. At that time, the activity room door opened, and CNA A came out and yelled, Everybody move! Everybody move! CNA C stated CNA A then sprayed something in the direction of Resident #1. CNA C said whatever CNA A sprayed made them all cough. CNA C stated she heard someone say it was pepper spray. CNA C said she saw some liquid spots to the back of Resident #1's head, and he said it burned. She stated Resident #1 was taken to his room and assessed by RN B. CNA C said the verbal altercation went on for a while, but she did not know for how long. CNA C revealed she did not try to intervene because she was in shock, so she just stood back and watched. CNA C acknowledged if she had intervened, Resident #1 might not have been sprayed with [NAME] by CNA A. CNA C also revealed she did not inform the Administrator she had not attempted to intervene during the verbal altercation between Resident #1 and CNA A. CNA C stated she was just confused by it all, and she did not know what to do. Interview on 11/18/25 at 1:12 PM, CNA A revealed the morning of 11/16/25 Resident #1 had been in a rage, but she did not know what started it. CNA A said she heard Resident #1 yelling and cursing, so she asked Housekeeper D and Dietary Aide E to assist her. She stated they were male staff, and she thought Resident #1 would respond better to them. CNA A said Resident #1 was yelling, cursing, and calling her names. She stated Resident #1 said to her, Bitch, you are the one I don't like. CNA A said Houskeeper D tried to calm the resident down, but Resident #1 swung at Houskeeper D. CNA A stated the resident then rolled towards her in his wheelchair as he cursed at her. CNA A stated she called 911 because she felt threatened by the resident. CNA A said the police showed up at the facility and spoke to the resident. CNA A stated the police told her they could not do anything to the resident because he had only made verbal threats. CNA A stated the police told her she could call them back if Resident #1 touched her. She stated they advised her to keep her distance from the resident. Later that day after lunch, CNA A stated she was taking her lunch break in the activity room. She stated she saw CNA C pushing Resident #1 in his wheelchair. She stated as they were passing by the activity room, she heard Resident #1 say, Wait a minute. Is that who I think it is? She stated CNA C rolled Resident #1 back to the activity room, and the door to the room was slightly open. Resident #1 proceeded to open the door, and he rolled inside. She stated Resident #1 told her, Bitch, you can't hide from me! I'll kill you and beat you ass! CNA A said at that time she called the Activity Director to tell her she was in her office/room, and she was afraid for her safety because Resident #1 was threatening her and had been all day. CNA A said she kept yelling at Resident #1 to stay away and get out of the room, but the resident continued to yell and curse at her. CNA A stated the verbal exchange went on for several minutes, but she did not recall the exact amount of time. CNA A said she told Resident #1 if he did not leave her alone, she would [NAME] him. CNA A said Resident #1 then stood up out of his wheelchair. CNA A stated her purse was right in front of her, so she pulled out her [NAME]. CNA A stated Resident #1 sat back in his wheelchair and rolled backwards out of the room, and she closed the door. Resident #1 then began kicking the door, so she opened the door, came out of the room, and told everyone to get back as she sprayed Resident #1 with [NAME]. CNA A said she recalled Resident #1 turning his head as she sprayed him, and the [NAME] got the side and back of his head. CNA A stated she then went back into the activity room and closed the door again. CNA A said there were other people in the area, but she could not recall who. She stated soon after the incident, she was told she needed to clock out and go home and she had not returned to work. CNA A further stated CNA C, who was providing Resident #1 with one-to-one supervision, never intervened nor did CNA C remove Resident #1 from the area or call other staff for help. Interview on 11/19/25 at 8:49 AM with Housekeeper D revealed the morning of 11/16/25 he was cleaning the dining room when he heard CNA A yell for him. Resident #1 had rolled up on CNA A cursing at her and called her terrible names and CNA A wanted his help to try to calm down Resident #1. Housekeeper D said he attempted to calm the resident down by talking to him, but Resident #1 swung at him striking his arm, so Houskeeper D said he stepped away and let RN B take over. Housekeeper D said when Resident #1 hit him in the arm, CNA A told the resident she was going to call the police. Interview on 11/18/25 at 1:38 PM with the Social Worker revealed the morning of 11/16/25 around 9:00 AM, she saw the police at the facility, and it was her understanding CNA A had called 911 because Resident #1 has been verbally aggressive and threatening. The police told CNA A they could not do anything to Resident #1 unless he became physically aggressive. At about 1:00 PM the Social Worker said she was asked to go to the activity room, did not recall by who, and she saw several people gathered around the room coughing and someone said Resident #1 had been pepper sprayed by CNA A. The Social Woker said the only person she could recall being there was RN B and another CNA but did not recall who. She called the Administrator who told her to send CNA A home. The Social Worker further stated she did not see anything on Resident #1's face/head, nor did he complain of any discomfort other than a cough. Interview on 11/18/25 at 2:06 PM, the Administrator revealed he was called on 11/16/25 and told CNA A called the police early in the morning due to Resident #1's behavior and the police were called again after lunch that same day. The Administrator said after lunch, there appeared to be some verbal exchange between Resident #1 and CNA A and that Resident #1 had tried to kick CNA A, so the CNA told everyone to stand back, and she pulled out pepper spray and sprayed Resident #1. The Administrator said the resident had been sent to the hospital for further evaluation but there did not appear to be any harm. He further stated he was not aware CNA C did not intervene or that she had been a spectator during the verbal exchange between Resident #1 and CNA A. The Administrator stated CNA C did tell him both the resident and CNA A had exchanged words but was not able to understand what was being said. The Administrator said if CNA C did not try to intervene, then they should have in-serviced the staff about that too. Interview on 11/18/25 at 6:04 PM with CNA F revealed the morning of 11/16/25, Resident #1 was yelling and cursing at staff and had been harassing CNA A to the point that CNA A told Resident #1 that if he kept going up to her like that she would go to her car to get her pepper spray. CNA F said she did not tell anyone about the threat that CNA A made about the pepper spray because she claimed, everyone heard, but did not specify who. CNA F said sometime after lunch she heard commotion and loud profanity; Resident #1 was insulting CNA A and CNA A was yelling back at the resident to leave the room. CNA F said as she went down the hall, she saw Resident #1 kick at CNA A and then saw Resident #1 back up and then the activity room door slammed shut as the resident continued to kick the door. At that time, CNA A was seen coming out of activity room and said everyone step back as she sprayed Resident #1 with pepper spray and the people around including the resident, began to cough. CNA F said the whole commotion/verbal exchange lasted about 5 minutes. Interview on 11/19/25 at 9:55 AM with the Activity Director revealed on 11/16/25 around 1:00 PM she received a call from CNA A who stated she was in her office/activity room and fearful for her life because Resident #1 was in the same room with her threatening her. CNA A told the Activity Director that Resident #1 has been on a rampage since 9:00 AM and she did not understand why CNA C had wheeled him in her direction. The Activity Director said that while she was talking to CNA A on the phone, she heard Resident #1 say you can call whoever you want and cursed her and called her names. The Activity Director said during Resident #1 and CNA A's verbal exchange she heard CNA A say, you need to back up or I will spray you. The Activity Director said she was trying to help CNA A calm down and asked her what other staff were around, and CNA A said, I don't know but he needs to get out of my face. The Activity Director said she lived nearby and told CNA A she was on her way and when she got off the phone the Activity Director contacted the Social Worker, who was at the facility to let her know she needed to get to the activity room. The Activity Director looked at her phone and said the phone call with CNA A during her exchange with Resident #1 lasted 8 minutes. Interview on 11/19/25 at 10:38 AM, CNA G revealed the morning of 11/16/25 Resident #1 became upset because he asked CNA C personal questions and CNA C told him she did not wish to talk about her personal life because she was just there to take care of him. CNA G said Resident #1 became belligerent and began to curse at CNA C. Resident #1 went towards another hallway where he saw CNA A and the resident was trying to roll up on CNA A while Housekeeper D tried to calm Resident #1 down. Resident #1 began to curse and yell at CNA A and CNA A then said, if you run up on me again, I'm going to [NAME] you. CNA G said she did not report the threat CNA A made because she assumed other people around heard her. Later around 1:00 PM, CNA G said she was in another hall when she heard what appeared to be people fighting so when she followed the commotion, [NAME] had already been sprayed because people were coughing including Resident #1. Interview on 11/19/25 at 4:14 PM, the Administrator revealed he was not aware other staff overheard CNA A threaten Resident #1 with pepper spray. The Administrator said if he would have known about the threat made earlier in the day, he would have suspended CNA A and the whole incident could have been avoided. Interview on 11/19/25 at 4:41 PM, the ADON revealed she had gotten a phone call from CNA A the morning of 11/16/25 stating Resident #1 was attacking everyone so CNA A had called 911. The ADON said she spoke with RN B who said Resident #1 was not hitting everyone but had hit Housekeeper D when he tried to calm the resident down. The ADON said she got a phone call from RN B a few hours later and was told CNA A had maced Resident #1 and the police had been called again. The ADON said no one told her they had overheard CNA A threaten Resident #1 with [NAME] or she would have been told to go home at that time. Record review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 reflected the following: Policy Statement 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, verbal, mental, sexual, or physical abuse, and physical and chemical restraint not required to treat the resident's symptoms. Review of the facility's Abuse and Neglect education provided to the staff reflected the following: .Report suspected abuse immediately to the Abuse Coordinator (Administrator) if not available DON or supervisor when neither is available. This was determined to be a Past Non-Compliance Immediate Jeopardy on 11/18/25 at 5:56 PM. The Administrator was provided with the IJ template on 12/04/25 at 9:00 AM. The facility took the following actions to correct the non-compliance prior to the survey: Interview on 11/19/25 at 4:41 PM, the Administrator revealed CNA A remained suspended after she was told to go home after the incident with Resident #1. Record review of Record of Employee Counseling dated 11/18/25 reflected CNA C reflected the following: .Details of Situation: The incident involving resident [Resident #1], [CNA C] should have immediately removed resident from harm .Expectations/Outcome: To immediately remove any resident from situations that would put resident in harm's way. Record review of the in-services dated 11/16/25 reflected staff were educated/re-educated on Resident Rights, abuse and neglect. Review of the sign-in sheets also reflected CNA C had been provided with each of the inservices. The following staff from various shifts were interviewed on 11/19/25 from 9:55 AM to 4:41 PM. RN B, CNA C, Housekeeper D, Dietary Aide E, CNA F, Activity Director, CNA G, ADON, RN I, Housekeeper J, Transport, MA K, Receptionist, Housekeeper L, RN M, CNA N, [NAME] O, Dietary Aide P, MA Q, Dietary Aide R, CNA S, CNA T, CNA U, CNA V, CNA W. The staff were able to define abuse/neglect - verbalize the different type of abuse and who to report if they see abuse. The noncompliance was identified as past noncompliance. The noncompliance began on 11/16/25 and ended on 11/18/25. The facility had corrected the noncompliance before the investigation began.

Based on observation, 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 of 3 residents (Resident #1) reviewed for abuse and neglect. CNA C, who was responsible for providing Resident #1 with one-to-one supervision, failed to protect the resident when the resident entered into a verbal altercation with CNA A, which escalated to CNA A spraying [NAME] at the resident on 11/16/25. The noncompliance was identified as past noncompliance. The noncompliance began on 11/16/25 and ended on 11/18/25. The facility had corrected the noncompliance before the investigation began. The failure placed residents at risk for serious physical and psychological harm. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included bipolar disorder (a chronic mental health condition characterized by extreme mood swings, energy level shifts, and difficulty with activity levels, ranging from manic episodes to depressive episodes), schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a distorted perception of reality), and spinal stenosis (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves, causing symptoms like back and leg pain, numbness, tingling, and weakness). The residents' cognition was intact with a BIMS score of 15. The resident had other behavioral symptoms not directed towards others at least 4 to 6 days during the assessment review period but less than daily. Those behavioral symptoms included but were not limited to physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds and had the potential to interfere with the resident's participation in activities or social interactions. These behavioral symptoms had the potential to put others at significant risk of physical injury and/or significantly intrude on the privacy or activity of others. The MDS also showed that Resident #1 used a wheelchair due to impairment on both sides to his lower extremities. Record review of Resident #1's care plan revised on 11/12/25 reflected he had a mood problem related to the disease process of bipolar disorder. Interventions included administering medications as ordered, consulting behavioral health, and monitor/record/report to MD mood patterns, signs/symptoms of depression, anxiety, sad mood, impulsiveness or euphoria as per facility behavior monitoring protocols. Record review of the Provider Investigation Report dated 11/21/25 reflected the following: [Resident #1] was around the Activity room arguing with [CNA A]. [CNA A] sprayed resident with pepper spray to the back side of head Record review of Resident #1's progress notes dated 11/16/25 documented by RN B reflected she was at the nurses' station when she heard people yelling/fighting and hear Resident #1 say CNA A had sprayed pepper spray to the back of his head. Other residents and staff in the area were coughing. RN B documented CNA C, who was providing 1:1 supervision told her (RN B) that Resident #1 had gone to the activity room and then began to kick the activity room door when it closed and at that time CNA A came out of the activity room and told everyone around to step back as she sprayed pepper spray on the back of Resident #1's head. The notes also reflected that Resident #1 had called the police after the incident, and the resident had refused a head-to-toe assessment or have the pepper spray washed off his head until the police arrived at the facility. The notes reflected RN B observed multiple small clear liquid scattered on Resident #1's head and once the 2 police men left, the resident allowed RN B to assess/wash his head and she did not notice any redness, bruises, or a rash to Resident #1's head nor did he complain of burning or irritation to his eyes and his speech was clear. Record review of Resident #1's hospital records dated 11/16/25 reflected the resident was seen for toxic effect of lacrimogenic gas (tear gas), assault, initial encounter. Further review of the hospital records reflected there were no injuries documented and no further orders. Observation and interview on 11/18/25 at 10:31 AM revealed Resident #1 was sitting in a wheelchair outside in the courtyard patio socializing with a female resident. CNA C sat near the residents monitoring them. Resident #1 was moved to another part of the patio for a private conversation. Resident #1 stated a staff member (CNA A) had sprayed him with [NAME]. He stated it happened out of nowhere, and he denied having an altercation with CNA A. The resident stated he was going down the hall and CNA A was staring at him, and then all a sudden he had to back out because the CNA was coming at him with the [NAME]. The resident said he was sprayed on the back of the head with [NAME], and some had gotten in his eyes. He stated that both areas began to burn. After CNA A sprayed him with the [NAME], he stated he called the police. He stated he later went to the hospital due to the burning sensation. Interview on 11/18/25 at 12:06 PM, RN B revealed Resident #1 had been placed on one-to-one supervision a few days prior to the incident on 11/16/25 due to an unrelated incident. RN B said the morning of 11/16/25, Resident #1 started having verbal behaviors towards CNA C, who was providing one-to-one supervision. RN B stated Resident #1 began to yell, curse, and call the staff around him names including RN B. RN B stated as Resident #1 began to go down another hall, she instructed CNA C to follow behind the resident at a distance in case Resident #1 became physically aggressive. As the resident and CNA C got further down the hall, RN B said she heard people raising their voices. RN B stated she heard Resident #1 yell and curse again. She stated there were multiple staff present including CNA A. RN B said as Resident #1 continued to yell and curse, she heard CNA A call 911 due to the resident's behaviors. RN B stated CNA A claimed Resident #1 had swung at another staff member at that time (Housekeeper D). RN B said the police came to the facility and spoke with Resident #1 and CNA A. The police left the facility, and the resident remained calm for the next few hours. RN B said sometime after lunch, she heard people screaming. She stated she went down the hall, and she noticed Resident #1 had some liquid dots on the back of his head. She stated staff around the resident were coughing. At that time both Resident #1 and CNA A were calling the police. RN B stated someone, whom she did not recall, stated that CNA A had sprayed Resident #1 with pepper spray. RN B said she tried to assess Resident #1, but he would not allow her to wash the back of his head until he spoke with the police. After the police completed their visit at the facility, RN B said Resident #1 allowed her to wash his head and face. She stated she did not notice any redness or swelling to his eye or the back of his head. RN B said after a while, Resident #1 stated he wanted to be sent to the emergency room because the back of his head, neck, and eyes were burning. The resident was sent to the hospital, and he returned from the hospital with no new orders. Interview on 11/18/25 at 12:46 PM, CNA C revealed she was asked to provide one-to-one supervision to Resident #1 related to previous behaviors. CNA C said the morning of 11/16/25 Resident #1 was upset and began to curse and insult her along with other staff. She stated RN B told her to keep her distance from the resident as she monitored him, in case he became physically aggressive. CNA C said a few hours later after lunch, Resident #1 was in the television room and requested to be pushed back to his room because it was too loud. CNA C stated as they passed the activity room, Resident #1 saw CNA A sitting in the room. As soon as Resident #1 saw CNA A, he went into the activity room. CNA C stated Resident #1 and CNA A began to argue. CNA C said she did not understand what was going on. She stated the only thing she understood or heard was CNA A tell Resident #1, Get your ass in here! CNA C said she stood back and watched as Resident #1 and CNA A argued. She then stated suddenly, the activity room door closed, and Resident #1 wheeled backwards. She stated Resident #1 began to kick the activity room door. At that time, the activity room door opened, and CNA A came out and yelled, Everybody move! Everybody move! CNA C stated CNA A then sprayed something in the direction of Resident #1. CNA C said whatever CNA A sprayed made them all cough. CNA C stated she heard someone say it was pepper spray. CNA C said she saw some liquid spots to the back of Resident #1's head, and he said it burned. She stated Resident #1 was taken to his room and assessed by RN B. CNA C said the verbal altercation went on for a while, but she did not know for how long. CNA C revealed she did not try to intervene because she was in shock, so she just stood back and watched. CNA C acknowledged if she had intervened, Resident #1 might not have been sprayed with [NAME] by CNA A. CNA C also revealed she did not inform the Administrator she had not attempted to intervene during the verbal altercation between Resident #1 and CNA A. CNA C stated she was just confused by it all, and she did not know what to do. Interview on 11/18/25 at 1:12 PM, CNA A revealed the morning of 11/16/25 Resident #1 had been in a rage, but she did not know what started it. CNA A said she heard Resident #1 yelling and cursing, so she asked Housekeeper D and Dietary Aide E to assist her. She stated they were male staff, and she thought Resident #1 would respond better to them. CNA A said Resident #1 was yelling, cursing, and calling her names. She stated Resident #1 said to her, Bitch, you are the one I don't like. CNA A said Houskeeper D tried to calm the resident down, but Resident #1 swung at Houskeeper D. CNA A stated the resident then rolled towards her in his wheelchair as he cursed at her. CNA A stated she called 911 because she felt threatened by the resident. CNA A said the police showed up at the facility and spoke to the resident. CNA A stated the police told her they could not do anything to the resident because he had only made verbal threats. CNA A stated the police told her she could call them back if Resident #1 touched her. She stated they advised her to keep her distance from the resident. Later that day after lunch, CNA A stated she was taking her lunch break in the activity room. She stated she saw CNA C pushing Resident #1 in his wheelchair. She stated as they were passing by the activity room, she heard Resident #1 say, Wait a minute. Is that who I think it is? She stated CNA C rolled Resident #1 back to the activity room, and the door to the room was slightly open. Resident #1 proceeded to open the door, and he rolled inside. She stated Resident #1 told her, Bitch, you can't hide from me! I'll kill you and beat you ass! CNA A said at that time she called the Activity Director to tell her she was in her office/room, and she was afraid for her safety because Resident #1 was threatening her and had been all day. CNA A said she kept yelling at Resident #1 to stay away and get out of the room, but the resident continued to yell and curse at her. CNA A stated the verbal exchange went on for several minutes, but she did not recall the exact amount of time. CNA A said she told Resident #1 if he did not leave her alone, she would [NAME] him. CNA A said Resident #1 then stood up out of his wheelchair. CNA A stated her purse was right in front of her, so she pulled out her [NAME]. CNA A stated Resident #1 sat back in his wheelchair and rolled backwards out of the room, and she closed the door. Resident #1 then began kicking the door, so she opened the door, came out of the room, and told everyone to get back as she sprayed Resident #1 with [NAME]. CNA A said she recalled Resident #1 turning his head as she sprayed him, and the [NAME] got the side and back of his head. CNA A stated she then went back into the activity room and closed the door again. CNA A said there were other people in the area, but she could not recall who. She stated soon after the incident, she was told she needed to clock out and go home and she had not returned to work. CNA A further stated CNA C, who was providing Resident #1 with one-to-one supervision, never intervened nor did CNA C remove Resident #1 from the area or call other staff for help. Interview on 11/19/25 at 8:49 AM with Housekeeper D revealed the morning of 11/16/25 he was cleaning the dining room when he heard CNA A yell for him. Resident #1 had rolled up on CNA A cursing at her and called her terrible names and CNA A wanted his help to try to calm down Resident #1. Housekeeper D said he attempted to calm the resident down by talking to him, but Resident #1 swung at him striking his arm, so Houskeeper D said he stepped away and let RN B take over. Housekeeper D said when Resident #1 hit him in the arm, CNA A told the resident she was going to call the police. Interview on 11/18/25 at 1:38 PM with the Social Worker revealed the morning of 11/16/25 around 9:00 AM, she saw the police at the facility, and it was her understanding CNA A had called 911 because Resident #1 has been verbally aggressive and threatening. The police told CNA A they could not do anything to Resident #1 unless he became physically aggressive. At about 1:00 PM the Social Worker said she was asked to go to the activity room, did not recall by who, and she saw several people gathered around the room coughing and someone said Resident #1 had been pepper sprayed by CNA A. The Social Woker said the only person she could recall being there was RN B and another CNA but did not recall who. She called the Administrator who told her to send CNA A home. The Social Worker further stated she did not see anything on Resident #1's face/head, nor did he complain of any discomfort other than a cough. Interview on 11/18/25 at 2:06 PM, the Administrator revealed he was called on 11/16/25 and told CNA A called the police early in the morning due to Resident #1's behavior and the police were called again after lunch that same day. The Administrator said after lunch, there appeared to be some verbal exchange between Resident #1 and CNA A and that Resident #1 had tried to kick CNA A, so the CNA told everyone to stand back, and she pulled out pepper spray and sprayed Resident #1. The Administrator said the resident had been sent to the hospital for further evaluation but there did not appear to be any harm. He further stated he was not aware CNA C did not intervene or that she had been a spectator during the verbal exchange between Resident #1 and CNA A. The Administrator stated CNA C did tell him both the resident and CNA A had exchanged words but was not able to understand what was being said. The Administrator said if CNA C did not try to intervene, then they should have in-serviced the staff about that too. Interview on 11/18/25 at 6:04 PM with CNA F revealed the morning of 11/16/25, Resident #1 was yelling and cursing at staff and had been harassing CNA A to the point that CNA A told Resident #1 that if he kept going up to her like that she would go to her car to get her pepper spray. CNA F said she did not tell anyone about the threat that CNA A made about the pepper spray because she claimed, everyone heard, but did not specify who. CNA F said sometime after lunch she heard commotion and loud profanity; Resident #1 was insulting CNA A and CNA A was yelling back at the resident to leave the room. CNA F said as she went down the hall, she saw Resident #1 kick at CNA A and then saw Resident #1 back up and then the activity room door slammed shut as the resident continued to kick the door. At that time, CNA A was seen coming out of activity room and said everyone step back as she sprayed Resident #1 with pepper spray and the people around including the resident, began to cough. CNA F said the whole commotion/verbal exchange lasted about 5 minutes. Interview on 11/19/25 at 9:55 AM with the Activity Director revealed on 11/16/25 around 1:00 PM she received a call from CNA A who stated she was in her office/activity room and fearful for her life because Resident #1 was in the same room with her threatening her. CNA A told the Activity Director that Resident #1 has been on a rampage since 9:00 AM and she did not understand why CNA C had wheeled him in her direction. The Activity Director said that while she was talking to CNA A on the phone, she heard Resident #1 say you can call whoever you want and cursed her and called her names. The Activity Director said during Resident #1 and CNA A's verbal exchange she heard CNA A say, you need to back up or I will spray you. The Activity Director said she was trying to help CNA A calm down and asked her what other staff were around, and CNA A said, I don't know but he needs to get out of my face. The Activity Director said she lived nearby and told CNA A she was on her way and when she got off the phone the Activity Director contacted the Social Worker, who was at the facility to let her know she needed to get to the activity room. The Activity Director looked at her phone and said the phone call with CNA A during her exchange with Resident #1 lasted 8 minutes. Interview on 11/19/25 at 10:38 AM, CNA G revealed the morning of 11/16/25 Resident #1 became upset because he asked CNA C personal questions and CNA C told him she did not wish to talk about her personal life because she was just there to take care of him. CNA G said Resident #1 became belligerent and began to curse at CNA C. Resident #1 went towards another hallway where he saw CNA A and the resident was trying to roll up on CNA A while Housekeeper D tried to calm Resident #1 down. Resident #1 began to curse and yell at CNA A and CNA A then said, if you run up on me again, I'm going to [NAME] you. CNA G said she did not report the threat CNA A made because she assumed other people around heard her. Later around 1:00 PM, CNA G said she was in another hall when she heard what appeared to be people fighting so when she followed the commotion, [NAME] had already been sprayed because people were coughing including Resident #1. Interview on 11/19/25 at 4:14 PM, the Administrator revealed he was not aware other staff overheard CNA A threaten Resident #1 with pepper spray. The Administrator said if he would have known about the threat made earlier in the day, he would have suspended CNA A and the whole incident could have been avoided. Interview on 11/19/25 at 4:41 PM, the ADON revealed she had gotten a phone call from CNA A the morning of 11/16/25 stating Resident #1 was attacking everyone so CNA A had called 911. The ADON said she spoke with RN B who said Resident #1 was not hitting everyone but had hit Housekeeper D when he tried to calm the resident down. The ADON said she got a phone call from RN B a few hours later and was told CNA A had maced Resident #1 and the police had been called again. The ADON said no one told her they had overheard CNA A threaten Resident #1 with [NAME] or she would have been told to go home at that time. Record review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 reflected the following: Policy Statement 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, verbal, mental, sexual, or physical abuse, and physical and chemical restraint not required to treat the resident's symptoms.1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff. This was determined to be a Past Non-Compliance Immediate Jeopardy on 11/18/25 at 5:20 PM. The Administrator, DON, Regional VP of Operations, Regional Nurse Consultant, and the Director of Regulatory Relations were notified. The Administrator was provided with the IJ template on 11/18/25 at 5:56 PM. The facility took the following actions to correct the non-compliance prior to the survey: Observation on 11/18/25 at 7:55 PM of Resident #1 revealed he remained on one-to-one supervision, and the CNA was assisting the resident in the shower room. Interview on 11/19/25 at 4:41 PM, the Administrator revealed CNA A remained suspended after she was told to go home after the incident with Resident #1. Record review of Record of Employee Counseling dated 11/18/25 reflected CNA C reflected the following: .Details of Situation: The incident involving resident [Resident #1], [CNA C] should have immediately removed resident from harm .Expectations/Outcome: To immediately remove any resident from situations that would put resident in harm's way. Record review of the in-services dated 11/16/25 reflected staff were educated/re-educated on Resident Rights, Burnout, Staff not able to carry defense paraphernalia to include pepper spray and other weapons, abuse neglect, and crisis intervention and de-escalation. Review of the sign-in sheets also reflected CNA C had been provided with each of the inservices. The following staff from various shifts were interviewed on 11/19/25 from 9:55 AM to 4:41 PM. RN B, CNA C, Housekeeper D, Dietary Aide E, CNA F, Activity Director, CNA G, ADON, RN I, Housekeeper J, Transport, MA K, Receptionist, Housekeeper L, RN M, CNA N, [NAME] O, Dietary Aide P, MA Q, Dietary Aide R, CNA S, CNA T, CNA U, CNA V, CNA W. The staff were able to define and recognize signs/symptoms of burnout, Resident Rights to include the residents had the right to be free from abuse, Abuse/neglect - verbalize the different type of abuse and who to report if they see abuse, staff were able to verbalize they are not allowed to carry weapons in resident rooms to include pepper spray and [NAME], Crisis Intervention/de-escalation of behaviors. Recognizing agitation in residents, techniques to calm them down, staff are not to engage with agitated residents and remove the resident from any dangers or altercation and if the resident is not able to be moved, remove the staff member, if a staff member is involved. The noncompliance was identified as past noncompliance. The noncompliance began on 11/16/25 and ended on 11/18/25. The facility had corrected the noncompliance before the investigation began.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #1) of three residents, reviewed for infection control. 1. The facility failed to ensure CNA A and CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Review of Resident #1's Quarterly MDS Assessment, dated 04/14/25, reflected he had had a BIMs score of 15 and was cognitively intact The MDS reflected that Resident #1 had the following diagnoses diabetes mellitus, heart failure, anemia, anxiety disorder, malnutrition, chronic obstructive pulmonary disease (COPD) (a progressive lung disease characterized by difficulty breathing due to persistent airflow obstruction). The resident was occasionally incontinent of bowel and bladder. The functional abilities of the resident were documented as dependent for toileting. Review of Resident #1's Comprehensive Care Plan, edited dated 02/026/25, reflected the resident had an activities of daily living selfcare deficit requires assistance setup/supervision, resident ability fluctuates related to shortness of breath. Facility interventions included: provide necessary equipment and adequate time for self-performance or participate with daily care. An observation on 05/31/25 at 11:21am revealed Resident #1 was in electric wheelchair. He was awake, alert, and oriented. CNA A and CNA B transferred resident to bed and prepared to perform incontinence care for the resident. Resident#1 had a bowel movement and brief was wet. CNA A performed peri-care and cleaned the front including his penis. CNA B performed peri-care and cleaned the buttocks. CNA A and CNA B did not change gloves or perform hand hygiene. CNA A and CNA B put a clean brief on the resident and covered him with the linens. CNA B put dirty diaper in plastic trach bag and removed gloves CNA A moved residents table arranged his personal belongings on his bedside table to include his water pitcher then removed gloves. An interview on 05/31/25 at 12:36pm revealed CNA B knew that she was supposed to change gloves and perform hand hygiene but did not want to because she was moving fast and the surveyor was watching her she got nervous. An interview on 05/30/25 at 1:41pm revealed CNA A knew that she was supposed to change gloves and perform hand hygiene but did not want to because she only cleaned the front if she cleaned the buttocks she would have changed her gloves before applying the clean brief. An interview on 05/31/25 at 1:03pm with the Infection Preventionist revealed staff were supposed to clean a resident, change gloves, perform hand hygiene, and then put a clean brief on the resident. The Infection Preventionist said failure to change gloves and perform hand hygiene could cause issues with infection control. An interview with the DON on 05/31/25 at 3:34 PM revealed staff were supposed to change their gloves and perform hand hygiene after cleaning a resident. The DON said failure to do so could cause infection. Review of facility policy titled Handwashing/Hand Hygiene last updated 01/2025 reflected the following: This facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections. Policy Interpretation and Implementation Administrative Practices to Promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol -based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value for 1 of 1 kitchen reviewed for food and nutrition services. Cook E failed to prepare the pureed lunch meal in a manner to conserve nutrition, flavor, and palatability on 04/23/25 when she added water to the pureed scalloped potatoes and cornbread and did not follow the recipes. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss. Findings included: Record review of the lunch menu ticket for 04/23/2025 reflected the menu for the lunch service was Cheesy Sausage w/Sauteed onions, Scalloped Potatoes, Southern Style Turnip Greens, Cornbread and Fresh Baked Cookies. Record review of the facility's recipe for Pureed Scalloped Potatoes from the Dining RD 2025 Menu reflected the following: Ingredients: Scalloped Potatoes - Add milk if product needs thinning . 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Record review of the facility's recipe for Cornbread/Margarine from the Dining RD 2025 Menu reflected the following: Ingredients: Corn Bread, Milk, 2%, this is an estimate based on industry standards and adjustments in added liquid may be 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Observation on 04/23/25 at 11:35 AM revealed [NAME] E making pureed lunch. [NAME] E put scalloped potatoes in the blender and blended. [NAME] E added water without measuring, added breadcrumbs and blended the mixture. The pureed scalloped potatoes appeared to have a mashed potato consistency. [NAME] E then was observed to put cornbread in the blender and blended. [NAME] E added water without measuring it. She then added breadcrumbs and blended the mixture. Interview on 04/23/25 at 1:18 PM with [NAME] E revealed she had been employed at the facility for about a year and half. She stated prior to preparing a meal she reviewed the recipe. She stated she was aware the pureed food needed to have a smooth, mashed potatoes consistency. She stated when blending the food, she should add broth and breadcrumbs to obtain the consistency needed. She stated she added water to the scalloped potatoes and cornbread because she needed it to be soft and smooth. She stated she was not aware the recipe specified not to add water. She stated she had not been told not to add water to pureed food. She stated there was no risk to the resident if water was added to the food. Interview on 04/23/25 at 1:28 PM with the Dietary Manager revealed she and the [NAME] were responsible for reviewing the recipe prior to preparing the meal. The Dietary Manager stated when staff prepared pureed food, they should use the juice/broth of the food. She stated water could not be added to the pureed foods because it took the flavor out. Record review of the facility's Pureed policy, dated 2022, reflected the following: The Puree Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency. . Drain liquid from portions needed for pureed preparation. Reserve liquid in case additional liquid is needed when pureeing to the correct consistency. NEVER USE WATER AS THE LIQUID ADDED TO A PUREED ITEM .the following liquids would be acceptable to use when pureeing foods: prepared broth, gravy, sauce, milk, juice and melted margarine/butter.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs. The facility failed to prepare and serve pureed scalloped potatoes as a pudding consistency for residents who required pureed diets during the lunch meal on 04/23/25. This deficient practice could affect residents and place them at risk of not receiving meals that meet their needs. Findings included: Record review of the lunch menu ticket for 04/23/2025 revealed the menu for the lunch service was Cheesy Sausage w/Sauteed onions, Scalloped Potatoes, Southern Style Turnip Greens, Cornbread and Fresh Baked Cookies. Observation on 04/23/25 at 11:35 AM revealed [NAME] E pureed scalloped potatoes with a blender. After blending the scalloped potatoes, neither [NAME] E nor the Dietary Manager checked the consistency to ensure the scalloped potatoes were all blended to a pudding smooth consistency. Observation of the test tray on 04/23/25 beginning at 1:03 PM with the Dietary Manager revealed the test tray included the regular textured menu items and the pureed menu items. The pureed scalloped potatoes did not have a smooth, pudding consistency. The scalloped potatoes had chunks of potato not fully pureed. The Dietary Manager stated the pureed scalloped potatoes were not the correct consistency. Interview on 04/23/25 at 1:18 PM with [NAME] E revealed pureed food needed to have a smooth, mashed potatoes consistency. She stated when she blended the scalloped potatoes it appeared smooth. She stated she did not ensure it was all blended. She stated the potential harm to residents was the possibility choking. Interview on 04/23/25 at 1:28 PM with the Dietary Manager revealed the pureed food should had a smooth, pudding consistency. She stated the scalloped potatoes on the test tray were not the correct consistency because there were chunks of potatoes. She stated she and the [NAME] were responsible for ensuring the consistency was correct. She stated residents were at risk of choking if everything was not completely pureed. Record review of the facility's recipe for Pureed Scalloped Potatoes from the Dining RD 2025 Menu reflected the following: .2. If the product needs thickening, gradually add a commercial or natural food thickener to achieve a smooth, pudding or soft mashed potato consistency. Record review of the facility's Pureed policy, dated 2022, reflected the following: The Puree Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency.

Based on observations and interviews, the facility failed to ensure only permitted and authorized personnel had access to the keys for 1 of 8 medication carts (Hall 400/500/600 cart) reviewed for drug storage. RN A failed to secure the keys for the medication cart for Halls 400/500/600 after shift change. This failure could place residents at risk of accessing medications not intended for them. Findings included: Observation on 04/24/25 at 9:45 AM of the medication cart for Halls 400/500/600 revealed it was locked, but the keys were in the medication count binder. The binder was closed and on top of the cart, the keys were not visible until the binder was opened. The surveyor was able to open the cart with the keys from the binder. Interview on 04/24/25 at 9:50 AM with RN A revealed the keys should not have been left in the binder. He stated he or the medication aide should have been in possession of the keys. He stated the normal process for shift change at 6:00 AM was for the night shift nurse to count the cart with the on-coming medication aide or the nurse if the medication aide was not available. He stated that obviously did not happen this morning since the keys were left in the binder. RN A stated he would have to take the keys and the cart to the medication aide and count with her. Interview on 04/24/25 at 10:00 AM with MA B revealed she was the only medication aide for the facility on the 6:00 AM-2:00 PM shift. She stated she was running late because of the weather, so she did not arrive for the 6:00 AM shift change. She stated it was normal for her to find the keys for the Hall 400/500/600 medication cart in the count binder because she started on the Hall 100/200/300 medication cart. She stated the night nurse did not count with her, so she counted with the day nurse. She stated after she finished the first set of halls, she went to the other halls. She stated she counted with the day nurse and then took possession of the keys which were almost always in the binder. Interview on 04/24/25 at 10:15 AM with the DON revealed the acceptable practice was for the night nurse to count with the day medication aide, or the day nurse, and hand the keys over. The keys should always be in the physical possession of the nurse or the med aide. The DON stated it was not acceptable for the keys to be left in the count binder because anyone could access the cart with the keys and gain access to medications not intended for them. Phone interview attempt on 04/24/25 at 1:04 PM with LVN C was unsuccessful due to the voice mailbox being full. A text message was sent; however, there was no response to either. Phone interview on 04/25/25 at 9:40 AM with MA D revealed when she went off shift at 10:00 PM on 04/24/25, she counted her medication cart with LVN C and handed the keys over to her. MA D stated she had never left the keys in the count binder. Phone interview on 04/25/25 at 10:38 AM with LVN C revealed on 04/24/25 at 6:00 AM shift change she counted the nurse medication cart with RN A, but they did not count the medication aide cart. LVN C stated she placed the keys to the medication aide cart in the count binder because RN A had walked away before they could count the cart. Review of the facility's Medication Labeling and Storage policy, dated February 2023, reflected: The facility stores all medications and biologicals in locked compartments under proper temperatures, humidity, and light controls. Only authorized personnel have access to the keys.

Based on observation, interview, and record review, the facility failed to ensure the facility provided food that was palatable, for one of one observed meal reviewed for dietary services. The facility failed to serve food that had a palatable flavor during the lunch meal on 11/05/24. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Interview on 11/04/24 at 10:25 PM with Resident #52 revealed a lot of the times he did not eat the food provided by the facility because it did not taste good. He stated he would decline the meal tray and would ask staff to order take out or prepare food he had in his room. Interview on 11/04/24 at 10:54 AM with Resident #18 revealed the food was cold by the time she received her tray during mealtimes. Interview on 11/04/24 at 12:15 PM with Resident #33 revealed he did not care to eat the food provided by the facility. He stated the food in the facility did not have any flavor or taste, and he preferred not to eat it. Interview on 11/04/24 at 12:18 PM with Resident #9 revealed the food was not consistent with how it would taste. She stated sometimes the food would taste good and other times it would not. Interviews during the confidential resident group interview on 11/04/24 at 1:45 PM with seven alert and oriented residents revealed food was served cold when eating both on the halls and in the dining room. It was also mentioned that food was not tasty and did not have any flavor. Residents stated they had mentioned their concerns in prior resident council meetings; however, they had not seen a change. Interview on 11/04/24 at 2:12 PM with Resident #13 revealed a lot of the time she only ate foods from the alternate menu because she did not like the food provided by the facility. Record review of the facility's menu on 11/05/24 reflected the planned lunch consisted of chicken fried steak, cream gravy, mashed potatoes, squash medley, dinner roll, frosted cake, beverage of choice, and water. Observation and interview with [NAME] D on 11/05/24 at 12:48 PM revealed the test tray for the regular diets consisted of chicken fried steak with cream gravy, mashed potatoes, squash, and the test tray for the pureed diets consisted of chicken, squash and mashed potatoes. The food temperature of the test trays revealed the food was slightly warm. The squash and mashed potatoes on the regular tray was bland and lacked flavor. The chicken, mashed potatoes, and the squash on the pureed tray also was bland and lacked flavor. [NAME] D stated she agreed the food was bland and lacked flavor. She stated the reason was due to the facility not cooking with salt. [NAME] D stated she followed the menu by adding butter to mashed potatoes, but she stated she could not taste the butter. [NAME] D stated she was responsible for the taste and presentation of the food. [NAME] D stated if the food lacked flavor, it could cause people not to want to eat and cause weight loss. [NAME] D stated she had not had any complaints of food being bland and lacking flavor. Interview on 11/05/24 01:14 PM with the Registered Dietitian revealed she had not had a chance to evaluate the lunch trays today (11/05/24), but she had been informed by the Administrator there was concern with food items. She stated the [NAME] were responsible for ensuring the food provided to residents was enticing and flavorful. She stated [NAME] D followed the menu for the potatoes by using water, butter, and the instant potatoes. She stated she did see seasoning in the squash but could not say why the squash lacked flavor. She stated there were ways to add flavor to food items, such as broth and spices when not using salt. She stated they wanted all the residents to enjoy their meals, so they were getting nutrients they needed. Interview on 11/06/24 at 5:31 PM with the Administrator revealed he would like residents to enjoy the food and not have to use supplements. The Administrator stated the cooks and the Dietary Manager were responsible for following the menu, and not doing so would place residents at risk of weight loss, skin integrity, and their overall health. The Administrator stated he was not aware of the resident council meetings having complaints of the food, however he wanted everyone in the facility to enjoy the food. Record review of the August 2024 resident council meeting minutes reflected: Corporate rejects food and residents are not pleased with meals. Food that is on menu is not what is being prepared. Record review of the September 2024 resident council meeting minutes reflected: Temperature of food, leaves food cart waiting food gets cold. Record review of the October 2024 resident council meeting minutes reflected: will discuss in next resident council meeting. Record review of grievances from August 2024- October 2024 did not include mention food service or menu options. Record review of the facility's current, undated Food and Nutrition Services policy reflected: .Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs., taking into consideration the preferences of each resident. .7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for one of one lunch meals observed. The facility failed to ensure residents on mechanical soft diets were served soft chicken fried steak they were served soft chicken instead, residents on pureed diets were served pureed chicken instead of pureed chicken fried steak on 11/05/24 as specified by the menu for the lunch meal. This failure could place residents at risk of weight loss, altered nutritional status and diminished quality of life. Findings included: Record review of the August 2024 resident council meeting minutes reflected: .Food that is on menu is not what is being prepared. Record review of the facility's menu on 11/05/24 reflected the planned lunch consisted of chicken fried steak, cream gravy, mashed potatoes, squash medley, dinner roll, frosted cake, beverage of choice, water. Observation on 11/05/24 at 11:30 AM revealed [NAME] D taking temperatures of food items prior to serving, which included mechanical soft and pureed chicken. There was no mechanical soft or pureed chicken fried steak on the steamtable for the lunch service. Interview on 11/05/24 at 11:35 AM with [NAME] D revealed she prepared diced chicken for residents on mechanical soft and pureed diets. When asked why she prepared the chicken, she stated it was an alternate option. When asked where the chicken fried steak was that was going to be served to residents with mechanical soft and pureed diets, she stated she was going to serve them chicken. [NAME] D was asked to provide the survey team with sample trays for each regular, mechanical, and pureed diets. Observation and interview on 11/05/24 at 12:48 PM with [NAME] D revealed a test tray for regular texture diet to include chicken fried steak with cream gravy, mashed potatoes, squash and a pureed texture diet tray of chicken, squash, and mashed potatoes for three surveyors. [NAME] D was asked why the pureed textured tray included chicken and not chicken fried steak. [NAME] D stated she used the diced chicken because it gave a better texture than the chicken fried steak would when pureed. [NAME] D stated she could not give an account why she did not puree the chicken fried steak, other than it would be hard to puree because of the crust on the chicken fried steak. [NAME] D further stated she provided residents on mechanical soft diets with the same diced chicken instead of chicken fried steak because of the texture, she stated it was easier to break down the chicken because it did not have crust on it like the chicken fried stead did. Observation of the chicken fried steak revealed the breading was very thin and could be cut with a fork. [NAME] D stated she was responsible for ensuring all resident were fed based upon the menu. [NAME] D stated she did not see anything wrong with preparing the chicken because it would give them a smoother texture. Interview on 11/05/24 01:14 PM with the Registered Dietitian revealed she had not had a chance to test the lunch trays today (11/05/24); however, she was informed by the Administrator there was a concern with food items. She stated the cooks were responsible for ensuring the same meal was provided to all residents regardless of the textures. She stated the [NAME] followed the menu by making the chicken fried steak, potatoes, and the squash. She stated [NAME] D did not know chicken fried steak was not chicken, and [NAME] D thought they were the same meat. She stated [NAME] D thought the only difference between the two was that one was fried. The Registered Dietitian stated [NAME] D thought it would be difficult to puree chicken fried steak because it had crust on it. She stated [NAME] D placed residents at risk of not getting served the same food options. Interview on 11/05/24 at 1:34 PM with the Administrator revealed residents should receive what the menu reflected for that day. The Administrator said it was the residents' right to receive what was on the menu, and what they were expecting to eat. The Administrator stated it was the responsibility of the cooks and the Dietary Manager to ensure each resident was provided what was on the menu. Interview on 11/05/24 with the Dietary Manager was unsuccessful, she was on leave of duty due to surgery. Record review of the facility's current, undated Standardized Recipes policy reflected: Standardized recipes shall be developed and used in the preparation of foods. 1. Only tested , standardized recipes will be used to prepare foods. 2. Standardized recipes will be adjusted to the number of portions required for a meal. 3. The food services manager will maintain the recipe file and make it available to food services staff, as necessary. 4. Recipes are periodically reviewed for revisions and updating.

44937 Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services for 2 of 5 residents (Residents #14 and #54) reviewed for tube feeding management. 1. The facility failed to ensure Resident #14 received g-tube stoma site dressing changes and g-tube water flushes according to physician's orders. 2. LVN A and LVN B failed to ensure Resident #54's feeding tube infusion pump rate was correct. These failures could place residents at risk of dehydration, malnutrition, weight loss, and possible infections. Findings included: 1. Record review of Resident #14's face sheet, dated 11/06/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #14's quarterly MDS, dated [DATE], reflected she had a BIMS score of 12, which indicated her cognition was intact. She had active diagnoses which included Heart Failure (inability of heart to fill and pump blood), Hypertension (high blood pressure), Renal Insufficiency (kidney failure), Diabetes Mellitus (high blood sugar) Malnutrition (too few nutrients resulting in health problems) The MDS assessment Section GG Functional Abilities reflected Resident #14 required set up or clean up assistance. The MDS assessment Section K - Nutritional approaches reflected Resident #14 had parenteral/IV feeding, feeding tube and was also on a therapeutic diet. Record review of Resident #14's care plan, revised on 08/12/24, reflected Focus: [Resident #14] was dependent on tube feeding for hydration, with potential for complications, side effects. Goal: Will maintain adequate hydration status aeb weight stable, no signs, or symptoms of dehydration through review date. Interventions: Administer tube feeding and water flushes as ordered. See doctor orders for current feeding orders. Monitor weight per protocol or as ordered and record. Notify doctor of significant weight changes. Observe, document, report to doctor as needed aspiration (food entering the respiratory tract instead of the gastrointestinal tract (pathway food entered the body)) signs and symptoms, tube dislodged, infection at tube site, self-extubating, tube dysfunction or malfunction, abnormal lab values, abdominal pain, distention, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, and dehydration. Registered Dietician to evaluate quarterly and as needed. Monitor caloric intake, estimated needs. Make recommendations for changes to tube feeding as needed. Record review of Resident #14's physician's orders revealed: 07/07/23 - Elevate Head of Bed at least 30 degrees while administering formula/water/medications and for at least 30 minutes following administration. 07/11/23 - Clean g/tube site with normal saline, cover with gauze, and secure with tape every day at bedtime 06:00PM-06:00AM. 05/20/24 - Flush Gastrostomy Tube with 200 cc of water every 4 hours 08:00, 12:00, 4:00, 8:00, 12:00, 04:00. 10/30/24 - Diet: Low Calorie Sweetener (LCS), Regular texture, thin liquids continuous - as needed. Record review of Resident #14's MAR and TAR reflected Resident #14 was provided treatment and care to her g-tube site on 11/05/24. Record review of Resident #14's progress note dated 08/07/24 reflected: Tube Feeder Aug weight 186 (BMI 31.9, obese), stable without sig change and usual body weight 180's. Continues on a Regular LCS, thin diet with great app/po, 75% most meals, feeding self. Known to order outside food and snacks/soda which contributes to weight status but appears stable at this time. Diet remains appropriate related Blood Sugar levels and diagnosis of Diabetes, continues on insulin for Blood Sugar control. Fluid intake is encouraged to meet hydration needs, aid with bowels, history UTI and recurrent hypernatremia [high concentration of sodium in the blood]. Has PEG in place but for hydration only (no nutrition) with H2O flush 200ml Q4hr (1200ml fluid); PEG will not be removed as deemed necessary for hydration needs. Observation and interview on 11/04/24 at 11:52 AM revealed Resident #14 sitting in the dining area. Resident #14 stated she was doing well. Resident #14 stated she had a g-tube; however, she ate a regular tray at every meal. Resident #14 was observed to complete her full meal without complications. After her lunch, Resident #14 stated she still had the g-tube but did not use it for eating. Resident #14 pulled her up her shirt to expose her g-tube site. She stated she received water flushes only through the g-tube. When asked how often staff checked her g-tube site and when were the water flushes provided, Resident #14 responded, whenever they do it. Observation and interview with LVN C on 11/06/24 at 2:00 PM revealed Resident #14's g-tube stoma (an opening in the abdominal that connects the bowel to the outside of the body) had a dressing in place dated 11/04/24. LVN C was asked to observe the date on the bandage, and she stated it was dated 11/04/24. LVN C stated the stoma should have been cleaned and redressed on the night shift. LVN C stated the observation was her first-time flushing water with Resident #14 today (11/06/24). LVN C stated she was aware Resident #14 had several flushes during the day; however, Resident #14 would often refuse, so she had not attempted complete the flush. LVN C she stated she was not aware Resident #14's site had not been cleaned on 11/05/24 night shift. Further observation revealed LVN C she administered air to check for placement, next she stated she was not going to check for residual since Resident #14 did not receive feedings via the g-tube. LVN C did not check for residual. LVN C then administered 200 cc of water with the use of a syringe that she assisted by plunging. When asked if she was going to clean Resident #14's g-tube site, she shrugged her shoulders and left the room. According to LVN C, she was aware that g-tube sites were supposed to be cleaned daily by the nurses on night shift. She stated not checking and cleaning the g-tubes placed residents at risk of infection. LVN C stated not completing the required amount of water flushes would place Resident #14 at risk of dehydration. Interview on 11/06/24 at 2:33 PM with the ADON revealed she was not aware Resident #14's g-tube stoma had not been cared for. The ADON stated she was not aware LVN C had not completed Resident #14's water flushes at 8:00 AM or 12:00 PM. The ADON stated it was her expectation that Resident #14 and all residents with g-tubes have care to be done daily on the 6:00 PM-6:00 AM shift and according to physician's orders. The ADON stated Resident #14's g-tube was still in place and being utilized for hydration. She stated it was the nurse's responsibility to follow physician's orders. The ADON stated if the residents g-tubes were not being cared for it could lead to an infection. The ADON stated she was responsible to ensure nurses were completing their tasks in making sure resident g-tubes were being cared for, and nurses were following physician's orders. ADON stated the nurse that should have completed care on 11/04/24 was an agency staff, and she was not full time staff at the facility. 2. Record review of Resident #54's undated Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the right side of her body; her ability to swallow requiring her nutrition be provided via a feeding tube in the stomach; and affecting her speech. Record review of Resident #54's quarterly MDS, dated [DATE], reflected her BIMS score was not calculated due to her medical condition. Her Functional Status assessment indicated she was totally dependent on staff for all of her ADL needs. Record review of Resident #54's care plan, dated 07/11/24, reflected she required a feeding tube with Jevity 1.5 to run at 60 cc/hr. Resident #54 also had expressive aphasia meaning she was unable to speak but answered questions by nodding yes or no, and using communication boards. Observation on 11/04/24 at 10:39 AM revealed Resident #54's feeding pump was infusing at 50 cc/hr, while the bottle of Jevity 1.5 was labled with an infusion rate of 60 cc/hr. The bottle had been hung on 11/04 at 4:20 AM. Observations on 11/04/24 at 11:30 AM and 3:30 PM revealed Resident #54's feeding pump rate was infusing at 50 cc/hr. Observations on 11/05/24 at 7:07 AM and 10:50 AM revealed Resident #54's feeding pump continued to infuse at 50 cc/hr. The Jevity bottle was labeled as being hung on 11/05, no time noted, with a rate of 60 cc/hr. Interview on 11/05/24 at 10:55 AM with LVN B revealed Resident #54's physician order was for the Jevity to infuse at 60 cc/hr. She stated night shift hung the bottles, and she did not know why the pump was set for 50 cc/hr. LVN B stated she had re-started the pump earlier in the morning after it had been paused for morning care. LVN B stated she did not check the rate before pushing Restart on the pump. She stated the Restart button resumed the pump at the previous settings. She stated she was unaware the rate had been incorrect for over 24-hours. She stated the risk of the resident not receiving the correct amount of enteral feedings was weight loss and malnutrition. Interview on 11/05/24 at 11:15 AM with the ADON revealed she had been made aware of Resident #54's feeding pump infusing at the wrong rate. She stated LVN A had hung the bottle on the morning of 11/04/24, and an agency nurse had hung the bottle on 11/05/24. The ADON stated the risk of the resident not receiving the correct amount of nutrition could be malnutrition and weight loss. Observation on 11/05/24 at 12:10 PM of Resident #54 being weighed via a lift device reflected a 1.56% weight loss when compared to her weight on 10/05/24. Interview on 11/05/24 at 1:35 PM with LVN A revealed she had set the pump at whatever rate was ordered. She stated someone must have changed the rate after that. LVN A stated she could not speak to what happened after her shift. Record review of the facility's Enteral Nutrition policy, revised November 2018, reflected: .11. The nurse confirms that orders for enteral nutrition are complete. Complete order include: .e. Volume and rate of administration. .g. instructions for flushing (solution, volume, frequency, timing and 24-hour volume)

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Residents #14 and #33) observed for infection control. 1. LVN C failed to adhere to enhanced barrier precautions by failing to put on a gown prior to flushing Resident #14's g-tube with water. 2. CNA E failed to adhere to enhanced barrier precautions by failing to put on a gown prior to emptying Resident #33's colostomy bag. The failure could place residents at risk for the development of infections which could cause illness or hospitalization . Findings included: 1. Record review of Resident #14's face sheet, dated 11/06/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #14's quarterly MDS, dated [DATE], reflected she had a BIMS score of 12, which indicated her cognition was intact. She had active diagnoses which included Heart Failure (inability of heart to fill and pump blood), Hypertension (high blood pressure), Renal Insufficiency (kidney failure), Diabetes Mellitus (high blood sugar) Malnutrition (too few nutrients resulting in health problems) The MDS assessment Section GG Functional Abilities reflected Resident #14 required set up or clean up assistance. The MDS assessment Section K - Nutritional approaches reflected Resident #14 had parenteral/IV feeding, feeding tube and was also on a therapeutic diet. Record review of Resident #14's care plan, revised on 08/12/24, reflected: Focus: Resident #14 was dependent on tube feeding for hydration, with potential for complications, side effects. Goal: Will maintain adequate hydration status aeb weight stable, no signs or symptoms of dehydration through review date. Interventions: Administer tube feeding and water flushes as ordered. See doctor orders for current feeding orders. Monitor weight per protocol or as ordered and record. Notify doctor of significant weight changes. Observe, document, report to doctor as needed aspiration (food entering the respiratory tract instead of the gastrointestinal tract (pathway food entered the body)) signs and symptoms, tube dislodged, infection at tube site, self-extubating, tube dysfunction or malfunction, abnormal lab values, abdominal pain, distention, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, and dehydration. Registered Dietician to evaluate quarterly and as needed. Monitor caloric intake, estimated needs. Make recommendations for changes to tube feeding as needed. Observation and interview on 11/06/24 at 2:00 PM revealed Resident #14 had an enhanced barrier precaution sign at her door, with a bin of PPE. Observation of Resident #14's g-tube stoma (an opening in the abdominal that connects the bowel to the outside of the body) and water flush with LVN C revealed she completed hand hygiene and put on gloves. Without wearing a gown, LVN C flushed Resident #14's g-tube with water. LVN C was asked about the enhanced barrier precaution sign outside Resident #14's door, and she stated when providing care or the water flush for Resident #14, she should have worn gloves and a gown. LVN C stated not doing so placed Resident #14 at risk for spread of infection. 2. Record review of Resident #33's face sheet, dated 11/06/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #33's quarterly MDS, dated [DATE], reflected she had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS reflected Resident #33 was dependent on staff for toileting. Section H Bowel and Bladder indicated he had an Ostomy. His active diagnoses included Hypertension (high blood pressure), End Stage Renal Disease, Diabetes Mellitus (high blood sugar) muscle weakness, lack of coordination. His functional abilities included he required assistance with toileting, shower/bathing and lower body dressing. Record review of Resident #33's care plan, revised on 08/12/24, reflected: Problem: Infection -There is risk for developing and/or spreading infection related to my medical condition. Goal: Enhanced Barrier Precautions will reduce risk of the spread of organisms. Intervention: Utilize enhanced barrier precautions as ordered Every Shift by disciplines: Activities, Administration, CNA, Dietary, Hospice, Housekeeping, Nurse Practitioner, Nursing, Physician A ssistant, Physician, psych, Social Services, Therapy. Problem: Potential for complications, altered body image, knowledge deficit related to colostomy status. Goal: Will remain free from infection or other complications related to colostomy through review date. Intervention: Empty drainage bag as needed. Replace per protocol. Observation and interview on 11/04/24 at 12:15 PM revealed there was an enhanced barrier precaution sign on Resident #33's door, due to the resident having a colostomy. Resident #33 stated staff assisted with emptying the colostomy bag. Observation revealed Resident #33 was lying on his back in bed, a clear bag was underneath his colostomy bag at the bedside. The resident's shirt was lifted at his stomach revealing the colostomy bag contents. Observation and interview on 11/04/24 at 12:21 PM revealed a bin with drawers to the left of Resident #33's door. Inside the drawers was PPE, which included surgical gowns and gloves. Observation of Resident #33's door revealed a sign which indicated to use PPE when performing care prior to entering the room. CNA E entered Resident #33's room with items in hand to empty the resident's colostomy bag. CNA E washed his hands and put on a pair of gloves. Without wearing a gown, CNA E emptied Resident #33's colostomy bag. CNA E stated he was not aware he should also wear a gown when providing care or emptying Resident #33's colostomy bag. CNA E stated he had been trained on enhanced barrier precautions; however, he was not thinking about including the gown during this task. Interview on 11/04/24 at 1:00 PM with LVN F revealed Resident #33 was on enhanced barrier precautions due to him having a colostomy. LVN F stated signs were posted at the door which instructed staff to wear PPE including gloves and a gown when providing care to the resident. LVN F stated CNA E was the aide working with Resident #33, and he was responsible for emptying the resident's colostomy bag. LVN F stated she expected CNA E to wear gloves and a gown when emptying the bag and not doing so placed Resident #33 at risk for the spread of infection and illness. Interview on 11/06/24 at 2:43 PM with the ADON revealed there were signs posted along the hall that indicated which residents were on enhanced barrier protection. The ADON stated any resident that required tube feeding, had wounds, or openings to their skin would require all staff especially nurses and aides to use PPE when providing care. The ADON stated not wearing PPE when providing care would place residents at risk of infections. Record review of the facility's Enhanced Barrier Precautions policy, dated March 2024, reflected: Enhanced barrier precautions are utilized to reduce the transmission of multi-drug resistant organisms to residents. Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms to residents. 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. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: 1. dressing; 2. bathing/showering; 3. transferring; 4. providing hygiene; 5. changing linens; 6. changing briefs or assisting with toileting; 7. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and 8. wound care (any skin opening requiring a dressing). Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based upon the comprehensive assessment of a resident for one of three residents (Resident #54) reviewed for quality of care. Agency LVN E failed to properly insert Resident #54's Foley catheter on 03/13/24 by inflating the balloon in the resident's urethra causing urethal trauma and significant bleeding. Resident #54 had to be transported to the hospital where a CT Scan revealed the urinary catheter balloon had been inflated in the resident's urethra causing trauma to the area. Due to the blood loss, the resident had to receive a blood transfusion to stabilize his vitals. An Immediate Jeopardy (IJ) situation was identified on 06/12/24. While the IJ was removed on 06/14/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for an adverse outcome to resident care or services and may also include the potential for physical and psychosocial harm. Findings include: Record review of Resident #54's, undated, Admission Record reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #54 had active diagnoses which included traumatic spinal cord dysfunction, quadriplegia (paralysis below the neck), hidradenitis suppurative (chronic inflammatory skin condition), muscle weakness, neuromuscular (disorders affect nerves or muscles) disfunction of bladder and iron deficiency anemia. Record review of Resident #54's quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated intact cognition. Section H - Bladder and Bowel reflected Resident #58 had an indwelling catheter and was always incontinent. Record review of Resident #54's Care Plan, revised 05/05/24, reflected: Problem: Category: Urinary Incontinence [Resident #58] has the Potential for complications related to indwelling urinary catheter. DX:N31.9 Neuromuscular dysfunction of bladder, unspecified. Goal: Will remain free s/sx of complications related to catheter through review date. Approach: Assess for patency and document daily. Assess for urine characteristics (volume, color, clarity, odor) and document daily. Change bag every 30 days or per facility protocol or as per MD orders. Maintain closed drainage system, with drainage bag lower that bladder level at all times. Monitor, document, notify MD PRN s/sx of complications related to catheter use, including UTI, trauma, bleeding. Record review of Resident #54 physician orders reflected: Change Catheter (16F/10cc) for leakage, blockage, or becoming dislodged. As needed. Document clinical reason for catheter change in the progress notes. Start date: 05/05/2023 - 04/02/2024 (DC Date). Observation and interview on 06/11/24 at 12:26 PM revealed Resident #54 lying in bed. The resident stated he was doing well. Resident #54 had a Foley catheter, observed catheter bag to have a privacy bag, the Foley tubing had yellowish color urine. Resident #54 denied any pain, he stated a couple of months ago he had to go to the hospital and had to get a blood transfusion. Resident #54 stated he could not recall much of the incident, but the nurse at the time attempted to change his catheter and caused bleeding. Resident #54 he stated he felt some discomfort. Resident #54 stated he could not recall the name of the nurse. Resident #54 stated he was unsure if he left to the hospital with the catheter inserted or not, he stated he could not recall as it had been a couple of months. Resident #54 stated because of that incident staff were not allowed to change his catheter. He stated he must go to the hospital to get it changed. Record review of Resident #54's progress note, dated 03/13/24 at 11:11 AM, by the PA reflected: [Recorded as Late Entry on 04/05/2024 11:11 AM] Patient Encounter Note . Encounter Date: 03/13/2024 Chief Complaint: Follow up encounter History of Present Illness: This is a [AGE] year-old Male resident of [Facility name] Nursing Home who presents for follow up and management of chronic medical problems. Interval Reports: - Per nursing, resident was found with a dislodged foley catheter without any urine return. - Nursing re-inserted foley catheter but only return bright red urine upon placement. - Resident reports severe discomfort. - Seen and examined at the bedside. - He is alert and oriented x4. - He has significant urethral injuries. Plans in place for SPT placement. - He has contractures to bilateral upper and lower extremities Dislodged Foley Catheter: Re-inserted but severe bloody urine and discomfort. - OK to send to ER for imagery and further evaluation. Record review of Resident #54 progress note, dated 03/13/24 at 18:21 [6:21 PM] by Agency LVN E, reflected: Nurse attempted to re-insert new 16 Fr. Cather using sterile technique blood return observed no urine return. Cath. [catheter] flushed only blood return.119/80, 129, 97.9, 98%, 18 RA 0/10 NP notified client own POA. NP new orders received send to ER for further treatment. Client left via medical transport on stretcher. Record review of Resident #54's EMS report reflected: Dispatch Information: Incident Date: 03/13/24 17:46 [5:46 PM] Complaint: Blood at site of catheter Compliant Type: Chief (Primary) Duration of Complaint: 10 Hours 17:59 [5:59 PM] Unit arrived on scene 18:16 [6:16 PM] Vitals: BP 97/64 P 127 18:20 [6:20 PM] Unit left scene - BP 105/69 P 127 18:37 [6:37 PM] Patient arrived at destination [hospital] Provider Impression: Primary Impression: Illness, unspecified Working Diagnosis: UTI Differential Diagnosis: Sepsis, Kidney Stones, Urethra Tear Record review of Resident #54's hospital reflected the following: Reason for visit: Chief Complaint on 03/13/24 6:44 PM: Urinary Catheter Problem (Pt from [Facility] staff attempted to insert foley, unsuccessful attempts per staff due to blood clots coming out, pt hypotensive and tachycardic upon EMS arrival) History of Present Illness 6:46 PM [Resident #54] is a 52 y.o. male with a h/o HTN, leukocytosis, and who comes to ED via EMS from [Facility] NH and c/o urinary catheter dysfunction that started today s/p multiple unsuccessful attempts. EMS denies any medical intervention en route. Pt denies feeling more fatigue than usual .Pt is quadriplegic (paralysis). 03/13/24 1853 [6:53 PM] ED Triage Vitas: BP 124/58 P 139 Physical exam: Constitutional: General: He is in acute distress (mild) Cardiovascular: Rate and Rhythm: Regular rhythm. Tachycardia present. Genitourinary: Comments: Foley in place with chronic appearing urethral tear with mild surrounding bleeding. Blood in foley tubing. 03/13/24 1914 [7:14 PM] RN Assessment: Abdominal Pain: GI Signs/Symptoms: pain; discomfort ABD Pain Location: generalized ABD Pain Character: Intermittent; Stabbing Genitourinary Assessment: Foley present upon arrival, blood cloths present PT hard stick, in process of obtaining access with sono[gram] at this time; Delay in CT scan due to pt condition and obtaining IV access at this time; 18G [gauge needle] placed in external jugular vein; Labs and blood cultures sent; CT notified pt ready 03/13/24 1922 [7:22 PM] Lab results showed HGB (Hemoglobin) of 7.9 Abnormal [Ref Range: 13.0 -17.0 g/dL] and HCT [Hematocrit] 25.6 Abnormal [Ref Range: 38.0 - 51.0%] ED Medication Administration: 03/13/24 1925 [7:25 PM] Normal Saline 1,797 mls [milliliters] as part of sepsis protocol. 03/13/24 1931 [7:31 PM] Maxipime (antibiotics) 2,000 mg IV started. 03/13/24 2013 [8:13 PM] CT abdomen and pelvis results: Impression: 1. Soft tissue attenuation in the left aspect of the urinary bladder concerning for blood clots or a soft tissue mass. Urology consultation is recommended. 2. Foley catheter present with the balloon inflated in the membranous or bulbous portion of the urethra. 3. Moderate bilateral hydronephrosis (urine is unable to drain from the kidney into the bladder) and hydroureter (abnormal enlargement of the ureter caused by any blockage that prevents urine from draining into the bladder). 4. Right nephrolithiasis (kidney stone). 03/13/24 2230 [10:30 PM] [NAME]: Discussed case w/ [Dr.], who is aware of assessment/workup in the ED and agrees to admit pt. 03/13/24 2240 [10:40 PM] ER nurse notified [Dr.] of being uncomfortable removing foley due to pt anatomy. [Dr.] notified and aware of hematuria and elevated troponin. New orders received - urology and cardiology consult Per [Dr.] ok to leave foley in at this time and wait for urology to see patient. 03/13/24 2316 [11:16 PM] Urology at bedside; Previous foley removed by urology; New foley by urology at this time 03/13/24 2344 [11:44 PM] Notified by ED monitor tech BP 66/43- reassessed BP and BP 72/44. Patient given Ringer's lactate 1 L bolus and episode resolved 03/13/24 2356 [11:56 PM] Pt states he got lightheaded when urology irrigated bladder and then BP was noted to be low. 03/14/24 0026 [12:42 AM] ICU NP @ bedside. States to change bed to cardiac PCU so pt may receive low dose levophed (raise blood pressure) if needed. Bed control notified of change. Two sono PIVs placed in R arm. Seeing how pt responds to IV bolus at this time prior to starting Levophed per NP and ER physician. Record review of Resident #54's Discharge Summary (Notes from 03/14/24 through 03/17/24 reflected: Hospital Problems: 1. Gross hematuria (blood in urine) with hydroureteronephrosis (dilation of the ureter due to obstruction of urine outflow) secondary to mispositioned Foley-resolved s/p Foley placed by cysto and CBI, follow-up with Urology. 2. Possible sepsis secondary to complicated UTI with chronic indwelling Foley - completing course of empiric antibiotics per ID recommendation, cultures negative but urine cultures collected after CBI. 3. Acute blood loss anemia-possibly secondary to hematuria, H&H remained stable after transfusion of PRBC 3/14, consider GI workup if needed, no signs of acute GI bleed during hospitalization . 4. Hypotension-resolved, related to acute issues and possible sepsis, resolved with treatment Presenting HPI: .presents to the emergency room with a history of gross blood in the Foley catheter that started yesterday. There was no history of trauma or manipulation of the Foley catheter. Patient denies any fevers or chills. Initial vital signs include a blood pressure 124/58, pulse of 139 and temperature 97.5 F . Labs significant for a high sensitivity troponin of 522 up from 377, procalcitonin of 0.14, white count of 20000, with a neutrophil count of 85%, hemoglobin of 7.9/26, down from 8.9/30 on 02/20/2024, chest x-ray that showed no acute radiographic cardiopulmonary abnormality. CT abdomen pelvis without contrast shows soft tissue attenuation in the left aspect of the urinary bladder concerning for blood clots soft tissue mass. Foley catheter present with balloon inflated in the membrane is a bulbous portion of the urethra. Moderate bilateral hydro nephrosis hydro ureter. In the emergency room patient was given cefepime 2 g (grams) IV, IV Tylenol 1000 mg, normal saline 1.8 L bolus, and is being admitted for urology consult for Foley catheter replacement and proper positioning, irrigation of bladder, empiric antibiotic therapy. During the process of Foley catheter placement, the patient had hypotensive episode with blood pressure dropped to systolic 70s. He was given a Ringer's lactate 1 L bolus and his blood pressure 96/57 from 89/52. Antibiotic therapy with extended and patient was placed on IV ampicillin 2 g. Pulmonary has been consulted, will also consult Cardiology for up trending of high sensitivity troponins. Record review of Resident #54 clinical records for the month of January 2024 and February 2024 reflected Resident #54 was not admitted to the hospital for catheter related issues. Interview on 06/12/24 at 9:43 AM by phone with Agency LVN E revealed from what he recalled Resident #54 asked for his Foley catheter to be changed because it was not draining. Agency LVN E stated he removed the old catheter and attempted to reinsert the new catheter, but he could not. He stated he was not able to get any urine return, but there was bleeding and blood clots noted. Agency LVN E said he did not recall if he had inflated the balloon or gotten any resistance. Agency LVN E stated when he tried to flush and did not get anything in return, he called the DON for assistance. He stated he obtained physician orders to send the resident to the hospital. Agency LVN E stated he could not recall if Resident #54 was sent to the hospital with the catheter inserted. Agency LVN E stated he had been trained on how to insert/change a catheter, he stated inserting a catheter was a sterile technique, and the catheter should be inserted about 4 to 6 inches and wait for urine return. Interview on 06/12/24 at 9:22 AM with LVN D revealed she assisted Agency LVN E with flushing Resident #54's Foley catheter. LVN D stated Agency Nurse E re-inserted Resident #54's Foley catheter, but he was not able to flush the catheter and caused it to bleed. LVN D said she did not attempt to re-insert the catheter since Agency Nurse E had already attempted. LVN D stated she attempted to help flush the catheter once Agency Nurse E inserted the catheter. She stated there was fresh blood coming out in the line and bag. She stated she was able to flush; however, they were just waiting for the urine to clear because it was only blood. LVN D said they monitored Resident #54 and was then sent out to the hospital. LVN D stated she was not present when Resident #54 was discharged to the hospital. LVN D stated Resident #54's penis was flayed all the way to the bottom making it tricky to insert the catheter. She stated prior to this incident they had not had any issues with inserting the catheter when it had come out. LVN D further stated after the incident (03/13/24) Resident #54 was being sent to the hospital to have his catheter replaced. Interview on 06/12/24 at 9:10 AM with CNA C revealed he had been assigned to Resident #54 on 03/13/24 and recalled the time Agency LVN E had tried to replace the catheter and the agency nurse could not get it in. He stated he was in the room with Agency Nurse E and LVN D when the incident happened. He stated Agency Nurse E had set up the catheter kit, he removed the old catheter, and he inserted the new catheter in, but it started bleeding. He stated there was blood in the tube of the catheter, it was clogged, and Agency Nurse E tried to flush it and the water got all over the bed. CNA C stated no urine was coming out, but only blood was noted in the catheter tubing. CNA C stated after the catheter was inserted, they placed the resident on observation and once they noticed it was not working, the resident was sent out to the hospital. He stated Resident #54 did not complained of any pain or distress at that time, because of his paralysis. CNA C stated in the past, Resident #54's Foley catheter had fallen out but had been replaced with no issues. Interview on 06/12/24 at 12:45 PM by phone with the previous DON B revealed she was called to Resident #54's room because Agency Nurse E was unable to insert a catheter. She stated when she went to the room, she did not try to insert the catheter because Agency Nurse E had already attempted. She stated she observed little blood on the line but because Resident #54 was having pain and there was resistance, they sent Resident #54 to the hospital. She stated Agency Nurse E had already tried to flush prior to her entering the room. She stated Resident #54 did not have the Foley inserted when he went out to the hospital, she stated Agency Nurse E had taken out the catheter and was not able to put it back in. She stated she did not think the catheter was inserted back in because they could not flush properly. She stated she could not remember what the hospital discharge summary indicated. She stated it had been some time since the incident. She stated she was unaware the catheter balloon was placed in the urethra if she had known she would have addressed it and education would have been done. She stated Resident #54 had always had trouble with his catheter, that was why the urologist changed his catheter. She stated Resident #54 required a suprapubic catheter, and if not placed resident would continue to have issues with trauma and having a large prostate. DON B stated she could not confirm or deny if the catheter was inserted, she stated she did not have any recollection of the event. She stated her expectation was for nurses to stop if they got any resistance when inserting the catheter. Interview on 06/12/24 at 9:55 AM with ADON A revealed she was not present at the time when Resident #54's catheter was changed. She stated she was brought in at the end. From what she recalled, Resident #54 said his catheter was bothering him. She stated they were going to replace the catheter because the resident felt his bladder was not emptying/draining and that was why they tried to flush it. After inserting the catheter, ADON A said Agency Nurse E attempted to flush the catheter, but he was not able to flush it. She stated there was not a lot of blood and could not tell if the catheter was in place. The DON was called and had requested to send the resident to the hospital. She stated LVN D was called in to help as well, and she was able to flush the catheter. She stated she believed the resident left to the hospital with the catheter inserted. ADON A stated hospital discharge records were reviewed and stated they should not replace the Foley catheter after this incident. She stated the Foley catheter was not placed correctly. ADON A stated Resident #54 was contracted to place a Foley catheter in a nursing home. ADON A stated if the Foley catheter balloon was inflated in the urethra, it could cause pain and bleeding. ADON A stated she was not sure if they had completed an in-service on Foley catheters after this incident. Interview on 06/12/24 at 1:11 PM with DON A revealed she had been employed at the facility since 04/23/24. She stated she was not made aware of the incident regarding Resident #54 Foley catheter until today (06/12/24). She stated her expectation was for LVNs to remove the old catheter and reinsert the new one and receive a good flow of urine. She stated they completed skill check-offs with everyone. She stated she would expect competency-based skills check-offs to be provided before getting into the field for agency nurses. She stated the agency nurses' competencies were completed by their agency. DON A stated she had not had the opportunity to review Resident #54's hospital records. She stated by inflating the catheter balloon in the urethra, it could cause trauma in the urethra. Interview on 06/12/24 at 12:33 PM with Regional Nurse Consultant revealed at the time of the incident she was not made aware of the situation with Resident #54. She stated she was made aware of the urology appointment. She stated they had a urology appointment set for Resident #54 ; however, the insurance would not cover the appointment and family would not pay out of pocket. She stated Resident #54 was recommended to get a suprapubic catheter due to how the resident's penis and urethra were. The Regional Nurse Consultant stated the Foley catheter should be inserted until it reached the Y of the catheter. She stated from what she understood Resident #54's trauma was when the nurse attempted to insert the catheter. She stated she was unaware the balloon was inflated in the urethra. She stated the previous DON was in the room at the time, but she was unaware what was done. She stated the risk of inflating the balloon in the urethra was that it could cause trauma. The Regional Nurse Consultant stated Resident #54's catheter could not be changed at the facility, the resident's catheter should be changed at the hospital due to the pre-existence trauma to his penis. Interview on 06/12/24 at 10:28 AM with PA revealed he was aware of Resident #54's catheter incident; however, it was addressed by another doctor. He stated when he came on board, hospital records were reviewed but the discharge instructions did not provide much detail. The PA stated Resident #54 was recommended to get a suprapubic catheter; however, the resident refused. He stated when inserting a catheter, it could sometimes cause little trauma when inserting and cause bleeding. He stated he was not surprised the resident was sent out to the hospital due to resident's anatomy. The PA stated the process of when inserting a Foley catheter required a sterile technique, lubrication, insertion measurement, and then inserting the catheter based on the measurements and then inflating the balloon. Once urine was observed, that was an indication the catheter was in and should not proceed further than that. The PA stated nurses would need more than 4-6 inches when inserting a catheter. He stated if the catheter balloon was inserted in the urethra, it would cause excessive bleeding. The PA stated he was unaware the catheter balloon was intact at the hospital. He stated he thought it was the trauma of the penis that caused the bleeding. The PA stated if the balloon was inflated in the urethra, it could cause kidney failure and trauma. Follow-up interview on 06/14/24 at 11:16 AM by phone with the PA revealed he was aware of Resident #54 anemia. He stated the resident had an order for ferrous sulfate; however, since the resident refused the medications, the medications were discontinued. The PA stated he was aware of Resident #54's anatomy and if the resident's Foley catheter was not inflated it would have come out on its own. If the balloon was inflated, the catheter would not fall unless tampered with. Interview on 06/12/24 at 12:41 PM with the Administrator revealed at the time of the incident he was at the facility and was made aware of the incident. He stated the agency nurse attempted to insert Resident #54's catheter; however, he was not sure if the agency nurse was able to do so. The Administrator stated Resident #54 was discharged to the hospital and when Resident #54 returned he was on leave. The Administrator stated he was not aware the catheter balloon was place in Resident #54's urethra. He stated the DON and the ADON were responsible for the skills check-offs and to provide orientation to the agency nurses. Interview on 06/14/24 at 1:48 PM by phone with the Hospital RN revealed she recalled the resident very well. The Hospital RN stated the resident arrived with the urinary catheter in place. She stated she did not manipulate the catheter and most especially did not inflate the balloon. She stated the resident was there for a traumatic catheter insertion, so she was very aware of the catheter. She stated she charted/documented the resident arrived at the hospital with the Foley catheter in place. When they received the CT Report indicating the balloon was in the urethra, both she and the ER physician felt uncomfortable with removing the catheter and consulted urology. The catheter was left untouched until urology removed it and replaced it with a new catheter. Record review of EMT Statement dated 06/20/24 reflected: as an EMT for [Company Name] Mobile Healthcare on 3/13/24 responded to a call for service at [facility address]. Facility reports they attempted to reinsert patient's urinary catheter, though they are unable to and have notice blood clots coming out. [I] made contact with a black male who was identified as [Resident #54] DOB: 09/06/1971. Patient was moved to stretcher, moved to ambulance, transported [Hospital Name]. PT was safely moved to ED bed, report was given to facility RN and transfer of care was at 1847 hours [6:47 PM] to Hospital RN. At no time during this call did I ever removed, place, insert, deflate, inflate, or manipulate the patients foley catheter in any manner. Record review of Agency LVN E's Skills competency checklist dated 03/05/24, reflected he was Proficient/Expert/Highly skilled in the area of Catheterization/foley catheter care. Record review of the facility's Catheterization, Intermittent, Male Resident policy, revised October 2010, reflected the following: The purpose of this procedure is to provide guidelines for the aseptic insertion of an intermittent catheter .21. Insert the catheter gently into the meatus (approximately 5-7 inches) until urine begins to flow from the bladder. When urine beings to flow advance the catheter 2 inches. This was determined to be an Immediate Jeopardy (IJ) on 06/12/24 at 1:40 PM. The Administrator and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 06/12/24 at 2:00 PM. The following Plan of Removal submitted by the facility was accepted on 06/13/24 at 9:33 AM: The facility failed to ensure nursing staff had appropriate competencies and skills sets necessary to care for resident's needs, as identified through resident assessments and described in the plan of care, when a LVN failed to properly insert a urinary catheter for a male resident resulting in the resident having to be transferred to the hospital after experiencing severe bleeding requiring a blood transfusion. On 6/12/24 The facility Administrator notified the Medical Director of immediate jeopardy. On 6/12/24 the facility DON (Director of Nursing)/designee assessed Resident #54 and all other residents in the facility with Foley Catheters that their catheters were functioning properly. On 6/12/24 the DON (Director of Nursing)/Designee, initiated Foley Catheter Insertion competencies for all nurses. These will continue until all nurses have completed their competencies before their next scheduled shift. On 6/12/24 the RNC /Designee initiated the in-servicing of all nurses including PRN and Agency nurses regarding not to perform catheter insertion unless a competency has been completed or provided. o The Foley Catheter insertion competency of the Agency nurse must be verified by the DON/designee via hand delivery or email from the Agency or Agency nurse prior to performing the skill. If a nurse that does not have competency on file is working, and the need for Foley insertion arises, the DON must be notified, and the DON/designee will come to insert the Foley catheter. o The clinical management team will discuss staffing to include new agency nurses who will be covering the floor during the morning meeting. Any changes in coverage during the day will be discussed with the DON/designee. Ad-Hoc QAPI meeting was held on 06/12/24, with the Medical Director, Regional Nurse Consultant, Director of Nursing & Assistant Director of Nursing to review the alleged deficiencies, policy and procedure and the plan of removal of immediacy. The policies pertaining to Foley Catheter insertion were reviewed on 6/12/24 by the RNC, Facility Administrator and Director of Nursing. No changes were made to the policy. The RNC will monitor for compliance on all residents with Foley Catheters weekly x 4 weeks and send any trends or issues to the ADHOC QAPI Meeting for review. The RNC (Regional Nurse Consultant) will ensure this plan is completed on 6/12/24. Monitoring of the facility's Plan of Removal included the following : Interviews on 06/12/24 from 2:00 PM-2:10 PM with Resident #5, Resident #48, and Resident #118 revealed no concerns regarding their Foley catheters. Record review of the progress notes for Resident #5, Resident #19, Resident #48, and Resident #118, who all had Foley catheters, reflected they were assessed by the DON on 06/12/24 with no concerns reported. Record review of Admit/Discharge Report, from 04/11/24-06/12/24, reflected sample residents had not been to the hospital for catheter related issues. Record review of the facility's in-services, dated 06/12/24, reflected training for Foley Insertion Competencies Completed and Suprapubic Catheter Replacement. In-services reflected all staff completed the trainings . The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Nursing staff competency: Catheter, insertion of indwelling completed on 06/12/24 reflected: Performance Criteria included .22. Inserts catheter through meatus. A. Males 1) Lifts penis to position perpendicular to patient/resident's body. 23. Advance catheter 2-3 inches in females and 7-9 inches in males or until urine flows out of catheter end. 24. Inflates balloon. 25. Attaches catheter to collection device and lowers bag below level of bladder . Record review of the facility's Ad Hoc Meeting for Foley Catheters reflected the meeting was completed on 06/12/24. Interviews conducted on 04/13/24 from 2:40 PM through 6:31 PM and 04/14/24 from 9:24 AM through 10:20 AM with LVN B, LVN D, LVN F, ADON A, ADON B, LVN H, LVN I, LVN K, LVN L, RN M and DON who work the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM revealed nurses were able to verify education was provided to them, nursing staff were able to accurately summarize what to do when changing a foley catheter. Nurses indicated it was sterile technic, insert catheter until urine began to flow and advance the catheter 2 inches. If resistance when inflating the balloon they must deflate the balloon, remove the catheter, and notify the physician. DON A stated she would be responsible for ensuring PRN Nurses and Agency Nurses competency checkoffs were obtained and verified prior to working the floor and if she was on leave the ADONs would be responsible for competency checkoff were obtained and verified. The Administrator and Regional Nurse Consultant were informed the Immediate Jeopardy was removed on 06/14/2024 at 11:00 AM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated 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 failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents reviewed (Resident # 1) for abuse, neglect and sexual exploitation. The facility failed to properly monitor and supervise resident relationships and interactions which resulted in an incident of unwanted sexual conduct. Resident #1 reported being sexually assaulted and was sent to the hospital where a SANE exam was performed. As a result of the sexual incident, Resident #1 reported to hospital staff that she was experiencing emotional distress, pain, and no longer wanted to remain at the facility as she did not feel safe. This failure resulted in an identification of an Immediate Jeopardy on 10/20/23 at 6:40 PM. While the IJ was removed on 10/21/23 at 12:47 PM, the facility remained out of compliance at a level of isolated with actual harm due to the facility's need to complete additional education, interventions and monitoring that include counseling and psych referrals to evaluate the effectiveness of the corrective system. This failure placed residents at risk of sexual assault and mental anguish including trauma victimization. Findings included: Review of Resident #1's Face Sheet revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 had diagnoses that included: schizoaffective disorder (Mental Disorder of abnormal thoughts), bipolar disorder (manic depression mental disorder), Borderline Personality (emotionally unstable disorder), Major Depression Disorder (low mood), Muscle wasting, and atrophy (loss of skeletal muscle mass), and post-traumatic stress disorder (mental and behavioral from traumatic experiences). Review of Resident #1's MDS, dated [DATE], revealed she had a BIMS score of 15 indicating she was cognitively intact. Her Functional Status indicated she required extensive assistance for ADLs and independence for eating, no assistance required. Resident # 1s MDS reflected physical, verbal and other behaviors as-sociated with mood disorder. Review of Resident #1's care plan, dated 08/23/23, revealed she desired to live in room with her significant other who was a resident at the facility. She had behaviors related to schizophrenia DX AFB that includes acts of pseudo (non-genuine) seizures, (changes in brain that causes involuntary movement) or she will act non-responsive, physical altercations with staff pulling hair and striking. Resident has episodes of anxiety and was at risk of fluctuations in moods and complications related to anxiolytic (medication that reduces anxiety) use. Resident at risk of injury to self-related to suicidal ideations. Interventions include encourage to express feelings and establish trusting relationship. Resident at risk for alteration in comfort and pain. Risk of falls. Record review of Resident #1's MD orders reflected the Invega Sustenna order dated 10/20/23 syringe: 156 mg/mL; amt:1 ml; administer every 28 days to treat schizophrenia in adults. *Duloxetine 30 mg order date 10/20/23 delayed release capsule once daily for depression. *Fluphenazine 5 mg order dated 10/20/23 tablet once daily to treat schizophrenia. Record review of Resident #1's progress notes by the dated 10/19/23 at 12:28 PM reflected When resident was assisted with dressing, she complained of having something on her thigh. A wet wipe was used to clean the area. The wipe and the ADON gloves were put into the empty trash can next to resident's bed. When police officer and EMT's arrived, I made them aware of the wipe and gloves and pointed out the trash can. Police officer acknowledged the can that contained the items. Record review of Resident #1's progress note dated 10/19/23 at 12:21 PM by the ADON reflected This writer was made aware that resident had phoned her [family members] stating she had been involved in sexual encounter with a male resident. the ADON went directly to the room, ensured resident safety, then the ADM entered the room to interview this resident. the ADON said stated that she (Resident #1) and male resident (Resident #2) were kissing and then she (Resident #1) performed oral sex. Male resident then pulled her leg up in the air, she told him he was hurting her hip, so he stopped and ejaculated on her left thigh. Resident was upset and crying. Much moral support given. Pseudo seizures are displayed on and off during the interview. Exam was conducted by this nurse and RN. No bruising, redness, swelling, or bleeding are noted. She can move all extremities as normal. MD notified, police are called, EMT's are called. The ADM is an active participant in this process and RNs aware of all happenings. [family members] of resident were notified by herself, as she called them. Resident was transported to [Hospital] by EMT/stretcher. She remains at the hospital at this time. Record review of Resident #1's progress notes dated 10/20/23 at 2:48 PM by CRN reflected Resident was readmitting from [hospital] today. She stated she does not wish to remain in this facility. She was offered alternate living choices and chose another placement (HH). Resident #1 remained with CRN and the ADM in the conference room, being attended at all times. Resident #1s PO, MD, Judge, and family were notified of the move. Record review of Resident #1's progress note dated 10/20/23 at 6:29 PM by CRN Late Entry on 10/21/2023 12:36 PM reflected she spoke with the DON of receiving Nursing Home .to report sexual assault incident that occurred by male resident. In an interview with Resident #1 on 10/20/23 at 2:00 PM, at the facility while waiting to transfer to HH, she stated that she does not want to remain at the facility as she did not feel secure. She stated that Resident #2 asked her 3 months ago if she would be his girlfriend, and she said yes. She told him she loved him, and he proceeded to kiss on her hair and pushing her head down while putting his penis in her mouth. Resident #1 stated that she did not agree to any sexual encounters or touching. She told Resident 21 to stop when he was kissing her hair, and he did not. Resident #2 proceeded to pull her sock and pants off, and she told him he was hurting her leg. Resident #1 said she yelled for help, and he ejaculated on her leg near her again. Resident #2 went in the bathroom located in her room. She called FM-D and told him Resident #2 raped me. Resident #1 said it was at that time Resident #2 took the phone from her and told FM-D she was unstable. He left the room and FM-D notified the ADM. She stated that both the ADM and the ADON came immediately, she was crying and having pseudo seizures. She stated LE was called and EMS arrived and transported her to the hospital where she agreed to a sexual examination. She does not know the results of the exam. She said she felt like it was my fault for being his friend, she felt pressured to be his girlfriend and that was why she said yes. She stated that she requested to be his roommate at one point, however she no longer wanted to be in a relationship or remain at the facility after he sexually assaulted her. Resident #1 said this has never happened before while being at the facility She started to cry, and the interview ended. Resident #2 Record review of Resident #2's face sheet dated 10/20/23 reflected a [AGE] year-old male admitted to the facility on [DATE], his diagnosis includes Alzheimer's disease, Parkinson's Disease, Edema, Muscle wasting and atrophy, insomnia, cognitive communication deficit, arthritis, Schizoaffective Disorder, Bipolar Disorder, cur-rent episode of hypomanic, anxiety disorder, Review of Resident #2's MDS, dated [DATE], revealed he had a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he independent for task requiring supervision for ADLs. Resident behaviors reflected other, for refusing medications. Record review of Resident #2's updated care plan dated 10/19/23 reflected problem: Resident has had a con-sensual relationship with female resident at facility. Resident voices God sent her to me to staff, attends activities and meals together and wants to be in her presence as much as possible. Resident #2 states no intent to have relations with any other residents and verbalizes that his relationship with this said female resident should and would be consensual. Resident will respect privacy of other resident and allow staff to intervene as needed to provide care. Record review of Resident #2's MD orders reflected the following: *an order dated 09/15/23 Document the Behavior Code and # of Episodes each shift for antipsychotic. Codes: 0=none, 1=verbal/physical aggression, 2=constant crying or yelling, 3=hallucinations (visual & auditory), 4=inappropriate sexual behavior, 5=refusal to cooperate in routine care, 6=insomnia, 7=sudden angry outburst, 8=suspicious or distrustful of others, 9=taking belongings or food item from others, 10=hoarding items, 11=withdrawn, 12=other . Order dated 09/15/23 interventions for antipsychotic: 0=none, 2=redirection, 3=offer food/snack, 4=diversion activity, 5=discuss behavior with resident, 6=quiet time, re-[NAME] noise/distraction, 7=re-orientation to current situation, 8=leave alone and re-approach, 9=clothing/bedding change, 10=problem solving with resident, 11=assisted to toilet, 12=simplified task into short steps, 13=allow time to complete tasks, 14=explain need prior to beginning, 15=other, 16=medication as needed prescription Lasix (furosemide) tablet; 20 mg; amt: tab 1; oral Once A Day. *An Order dated 05/31/23 Target Behavior: obsessive. At the end of each shift mark Frequency-how often behavior occurred & Intensity-how resident responded to redirection. Intensity Code: 0=Did Not Occur; 1=Easily Altered; 2=Difficult to Redirect. Special Instructions: Staff Note: Add Frequency & Intensity med notes to order for tracking. Every Shift Day, Night. *An Order dated 02/14/23 Anti-Psychotic Medication Use - Observe resident closely for significant side effects: Common - Sedation, Drowsiness, Dry Mouth, Constipation, Blurred Vision, Extra Pyramidal Reaction, Weight Gain, Edema, Postural Hypotension, Sweating, Loss of Appetite, Urinary Retention. Special Instructions: Special Attention For: Tardive Dyskinesia, Seizure Disorder, Chronic Constipation, Glaucoma, Diabetes, Skin Pigmentation, Jaundice. Every Shifts. *An Order date 02/14/23 Hypnotic/Sedative/Tranquilizer Medication Use - Observe resident closely for significant side effects: Common - Sedation, Drowsiness, Morning Hangover, Ataxia (drunk walk). Special Instructions: Special Attention: If given with other sedatives, hypnotics, or alcohol. Special Instructions: Special Attention: In use with other CNS depressant drugs or residents who develop fever blood dyscrasias. Every Shift Orders . Geodon (ziprasidone hcl) capsule; 20 mg; 1 tablet; oral Special Instructions: give one cap po twice daily Twice a Day 09:00, 21:00 1 of 5 Linked Orders 05/31/23. Record review of Resident #2's Psychiatric visit; dated 10/21/23 12:46 PM reflected was asked to see for psychiatric evaluation and psychotropic medication management. The patient was last seen on October 16, 2023. History of Present Illness: The patient is a [AGE] year-old African American with diagnosis of anxiety, major depressive disorder, schizoaffective disorder, insomnia, and anxiety disorder. Was notified by staff that the patient had a sexual encounter with a female resident. The patient is alert and oriented to time and place. He denies any anxiety or depressive symptoms. He denies any suicidal ideation. He stated that he has been in a relationship with the female residents for 3 months now. That they have kissed but never had any sexual intercourse .That she did not take her medications which caused her to have increased depression. The patient verbalized that on that they kissed but he never had any sexual encounter with a female resident. CARE PLAN / ASSESSMENT ICD (international classification of Disease) 10 or DX (Diagnosis) : 1. Major depressive disorder, single episode, mild, Primary insomnia, anxiety disorder due to known physiological condition, schizoaffective disorder, bipolar type, Alzheimer's disease, unspecified the patient is not a threat to other residents or staff at this moment Continue Trazadone 50mg at bedtime. Zoloft 100mg daily. Depakote 375mg at bedtime for aggressive behavior. Geodon 20 mg twice daily Restoril 7.5 mg at bedtime Xanax 0.25 milligrams at bedtime Continue supportive non-pharmacological interventions Assess for pain during periods of agitation. -Reorient as needed. -Gentle redirection as needed. Maintain daily routine as much as possible. -Communicate simply about aspects of care/activities/changes -Keep familiar or favorite objects/pictures around. -Behavior monitoring and documentation. Record review of Resident #2's progress note dated 10/21/23 at 11:46 AM from the ADM reflected on 10/20/2023, this writer educated resident to notify staff if he has any desire to start consensual relationships with other residents. Record Review of Resident #2's progress note reflected a note from the ADM. Resident acknowledged the ADM 10/19/23 at 12:35 PM. This writer and ADM spoke with resident (Resident # 2) regarding alleged event that took place immediately prior. fell ow female resident (Resident #1) alleges this resident and herself had a sexual encounter. Allegation includes kissing, oral sex and pulling her leg up in the air. Female resident told him he was hurting her, and he stopped, then ejaculated on her left thigh. This resident admits to having con-sensual sex with the female resident. He also states she said he was hurting her hip and he stopped. When asked what else took place, resident states nothing. One on one began immediately. Police were notified and resident was located to front office while police questioned him about the female resident. After questioning both residents, the police officer stated they did not have reason to arrest anyone based on the interview results. Resident responsible party was notified, MD was notified CRN was aware of the situation. Record review of the ADM progress note Resident #2's dated 10/19/23 at 8:05 PM reflected This ADM spoke with resident with facility RN in the room as well. Discussion was held regarding alleged event today regarding he and a female resident. Resident stated that he would speak to the other resident upon her return, this writer advised resident to gain that residents approval before he attempted to speak to her. One on one observations halted at this time. This took place at 4:20 pm. Resident has voiced no concerns. An observation of Resident #2 on 10/20/23 at 11:30 AM revealed he was not in his room. Further search observed him in the dining room with other residents in an activity of Karaoke. He was sitting at the table with another male, no reactions or engagement with others at the time. In a second attempted interview on 10/20/23 at 3:28 PM revealed Resident #2 in his room. Resident # 2 denied having any sexual interactions with Resident #1 during their 3-month consensual boyfriend and girl-friend relationships. Resident #2 stated that it was Resident #1 that asked if he would be her boyfriend and he said yes. He said, I love her. He maintained he was not involved in a sexual interaction with the Resident #1 on 10/19/23. He denied reporting that he and the resident had sex in her room to the ADM. He stated he was placed on 1 on 1 supervision by the ADM on 10/19/23 but could not remember the time. He said he was inter-viewed by LE and told him that he has not had any sexual interactions with Resident #1. In an interview with Resident #2 on 10/21/23 at 3:28 PM he said he felt safe and told the ADM that he did not want to move to a new facility last night because this was his home. Resident #2 denied having sex interactions with Resident #1. He said several leadership staff have met with him on 10/19/23 and 10/20/23, and he has provided the same information to the ADM, the CRN, and the RDO. He was currently on 1 on 1 supervision. Resident #1 has never asked him for sex, and he has not spoken to her. He denied telling FM-D that he stated, I didn't stick it in her he ejaculated on her leg. Interview on 10/20/23 at 9:28 AM with the ADM, the ADON, and the CRN revealed they were covering the roles of the DON and SW until a new hire was located. In an interview on 10/20/23 at 9:30 AM with the ADON revealed she and the ADM arrived at Resident #1's room she was crying hysterically and yelling get me dressed first. Once the ADON cleaned the thick liquid substance off the Resident's thigh, she called the ADM to enter and interview. The ADON said Resident #1 reported she and Resident #2 were kissing and then she performed oral sex on him. Resident #2 then pulled her legs up in the air, she told him that he was hurting her hip, so he stopped and ejaculated on her left thigh. The Resident was observed crying, pseudo seizures on and off. Moral support provided to resident. The ADON RN D conducted an exam and there was no bruising, redness, swelling, or bleeding noted, and she was able to move all extremities. The MD was notified, police, and EMT initially. Resident notified her family member herself. She said Resident #2 was placed on 1 on 1 by the ADM. Law enforcement arrived and resident was transported to hospital for a consented the SANE exam. In an interview with the ADM on 10/20/23 at 9:40 AM revealed he received a call from Resident #1's family member around on 10/19/23 at 12:20 PM stating that she called and reported Resident #2 had raped her. The ADM said he and the ADON went immediately to ensure resident safety. Resident #2 was standing in the hall outside the door. The ADM then placed Resident #2 on 1 on 1 supervision with RN D while he spoke with Resident #1. The ADM said Resident #1 reported she and her boyfriend (Resident #2) had a sexual encounter today with Resident #1. She said the resident tried to have oral sex with her, and then he pulled her leg up in the air. Resident #1 said he was hurting her and asked Resident #2 to stop. The ADM said Resident #2 said he stopped when she made the request and ejaculated on her thigh. The ADM said Resident #2 admit-ted to having consensual sex with Resident #1. The ADM said the resident had no more information, so the interview ended, Resident #1 was placed on 1-on-1 monitoring immediately with RN D. Police were notified. Resident was interviewed by law enforcement, then released from supervision after LE reported that based on his interviews and investigation he would not be making an arrest. He said the report would be available in 10 business days and provided the report # and his badge number. In an interview with VA on 10/21/23 at 11:38 AM revealed she was the victims advocate that met with Resident #1 on 10/19/23. Resident #1 reported that her boyfriend came to the nursing home and sexually assaulted her in her room. VA said Resident #1 refused the sane exam 2 times as she was very emotional and crying. The SANE nurse was notified and would attempt again later. Resident was provided and advocate so she would not be alone. VA provided contact information for the SANE nurse to be contacted. In an interview with hospital the SANE RN J on 10/24/23 at 4:03 PM, she said a forensic exam was conducted on 10/20/23 at 10:12 AM on Resident #1. Resident #1 told the SANE nurse P that they were kissing, and he was pressing down on her and put his penis in her mouth. She said the notes stated that they were making out and proceeded to pull down her pants, fondled her breast and her vagina with his finger, attempted to insert his penis, when she said no, and it felt like he ejaculated on her vagina. Resident #1 said he Resident #2 did not penetrate her vagina with his penis. After ejaculating he went into the restroom, and she called a family member to report she was raped because she was afraid. Resident #1 consented to a physical exam that yield no injuries; however, she refused the speculum exam (tool used to investigate body orifices (an opening or tube, in body). She said evidence was collected and sent to crime lab. The SANE exam does not confirm or deny sexual assault, the victim reports what occurred and the nurse documents. In an interview with SANE RN-P on 10/25/23 at 11:09 AM revealed Resident # 1 presented toER on [DATE] at 1:05 PM with chief complaints of chronic hip pain and sexual assault. Resident #1 refused sexual exam examination upon arriving on 10/19/23, as she was crying and very and yelling that she wanted to be left alone. would not consent to exam. The SANE RN-P said Resident #1 agreed to sexual assault exam kit on mid-morning. Resident #1 was examined with a rape kit, physical and with labs and swabs. Due to pain and distress with the speculum exam she refused after attempts were made. 10/20/23 agreed to sexual assault ex-am without a speculum. All evidence was collected in the sexual assault kit and sent to the crime lab. Resident #1 reported that she was in her room at the facility feeling sick when Resident #2 entered and proceeded to kiss all over her face and hair. Resident #1. She said Resident #2 was her like her best friend. She told Resident #2 don't touch me. Resident #2 put his penis in her mouth. Resident #2 removed penis from her mouth, removed her pants, and climbed top of her in bed trying to put his penis inside of her vagina. She said no! Resident #1 said Resident #2 pulled back his penis and ejaculated on outside of her vagina. Resident #1 said he did not penetrate the vagina. She said she tried to fight but she had no energy. She yelled for help, but no one heard. Resident #1 called FM-D and Resident #2 told him she had a mental health outburst. SANE RN P conducted the sexual exam kit and crime lab determines the conclusion of rape. She said based on her professional rape assault experience, Resident #1's behaviors, labs, and physical exam was consistent with sexual assault. In an interview on 10/24/23 at 4:09 PM, with LE revealed Resident # 1 stated that she and Resident #2 had been dating for 3 months. On 10/19/23 Resident #2 entered her room, they were making out kissing and rubbing became more aggressive. Resident #2 pulled his penis out, and she performed oral sex on him. Resident #1 reported that she consented to the oral sex. As Resident #2 started to undress her, she said no, and he stopped and ejaculated on her foot. LE said when Resident #2 complied when she withdrew consent it was not a sexual assault/rape. LE consulted with a sex crimes investigator with findings from his interviews with the residents and staff and concluded that the interaction was consensual. He did not collect any evidence be-cause the nurse cleaned a clear sticky substance off the resident's leg with a chemical wipe, therefore, damaging the evidence. LE said Resident #2 confirmed that he and Resident #1 had been in a relationship for 3 months, and he denied any sexual encounter with Resident #1 today and in the 3 months period. Record review of the online LE Report on 10/25/23 at 7:30 AM. Resulted in a report with demographics of Resident #1 and unlawful sexual assault. There was no documentation in the summary section addressing the incident Status (empty) .victim summary (empty) .Resident #1 demographics. In an attempted follow-up interview with LE on 10/25/23 at 8:05 AM to confirm the time of the incident on the online report was initiated and a detailed message to return surveyors call. On 10/20//23 at 6:45 PM, the ADM was notified an Immediate Jeopardy Situation and an IJ template was provided. The facility's Plan of Removal was accepted on 10/21/23 at 12:2 PM and included: Plan to remove immediate jeopardy. Facility failed to properly monitor and supervise resident relationships and interactions that resulted in an incident of unwanted sexual misconduct that led up to allegations of sexual assault. F689 On 10/20/2023 the ADM and the ADON notifies Medical Director of immediate jeopardy. On 10/20/2023 Resident #2 was assessed by the ADON and the ADM. Resident #2 denies any desire to be with other residents in the facility and no inappropriate sexual behavior was noted toward other residents or staff, Medical Director and Responsible Party updated. Behavioral services evaluated patient for any signs or symptoms of inappropriate sexual behaviors or desire to have sex with any other residents in the facility - no findings. Resident #2 will be seen by psychiatric/counseling services weekly x 4 weeks and if stable, will have visits as needed after this. Resident #2 is alert and oriented x 3 without behavioral disturbances. Resident was educated by the ADM to notify staff if he has any desire to start consensual relationships with other residents and verbalized understanding importance to respect other resident's rights. This was completed on 10/20/23. One on one supervision was initiated at the time of the allegation and restarted again on 10/20/23 at 6pm. Will continue with one-on-one monitoring for 72 hours to ascertain if there is a pattern of behaviors. If no behavioral disturbance patterns are observed, IDT team will discuss with Medical Director to discharge one on one supervision. IDT will continue to monitor this resident and any other resident for behavioral disturbances with daily rounds. The ADM will oversight this task completion. On 10/20/2023 all residents in the facilities were assessed by the Assistant Director of Nursing/Designee for any allegations unwanted sexual misconduct or sexual assault. Four other residents were identified to be in consensual relationships without allegations of unwanted sexual behaviors or not feeling safe, plan of care reviewed and is appropriate. All residents feel safe, and no allegations were reported or identified, findings were communicated to the Medical Director. On 10/20/2023 the RDO completed 1:1 in-service on Abuse/Neglect, including unwanted sexual misconduct, and appropriate interventions with the ADM and the Assistant Director of Nursing. Starting on 10/20/2023 the ADM/Designee will initiate in-services with staff on prevention of abuse and neglect, including unwanted sexual misconduct, and reporting to Abuse Coordinator (ADM). All staff, including new hire, PRN, and Agency will be in-service prior to start work. The ADM will oversight this completion by 10/21/2023. Ad-Hoc QAPI meeting was held on 10/20/2023, with the Medical Director, NHA (Nursing Home ADM), RDO (Regional Director of Operations), RNC (Regional Nurse Consultant), and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Starting on 10/20/2023, IDT (Interdisciplinary team), including the ADM, the Assistant the Director of Nursing, and the MDS Coordinator will review any allegations or sexual behaviors daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if sexual relationships is consensual, timely notification of any allegations or grievances, timely investigation and reporting allegation of abuse timely. The findings will be immediately brought up to the ADM for further action, if necessary. On 10/20/2023 the RDO (Regional Director of Operations) will start reviewing grievance log and IDT notes for any identified sexual relationships between residents for validation of thorough review of consensual relationships, person-centered plan of care for both involved parties, safety and mental wellbeing, timely identification of allegation of abuse weekly for four (4) weeks followed by monthly x 2 months. 10/20/2023 the RDO will provide physical oversight at facility weekly x4 weeks and then monthly x 2 months. The ADM/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks. This was initiated on 10/20/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The ADM will be responsible for ensuring this plan is completed on 10/20/2023. The RDO will provide oversight of the ADM to ensure that the items on the plan of removal are reviewed and completed. Monitoring plan of Removal continued and included interviews with staff on both day and night shifts. In an interview with the ADM and the ADON on 10/21/23 at 3:30 PM revealed they had completed training and in-servicing of all staff on 1:1 supervision of Resident #2, Abuse/Neglect, including unwanted sexual misconduct, and appropriate interventions with the ADM and the Assistant Director of Nursing. That would include inquiring if the resident felt safe in the relationship, notifying ADM and nurse of consensual and non-consensual interactions to be further assessed and educated on relationships. The ADM stated staff were asked to give examples of interactions, for example, if a resident was touching another resident leg affectionately, intervene and ask the receiving resident if they agreed to the interactions. The ADON stated staff that were not at work were contacted via phone for education. The ADON stated it was her expectation for staff to report resident relationships as well as observe and report concerns to the abuse coordinator immediately to assess safety of the relationships. She said the ADM starting on 10/20/2023 the ADM/Designee will initiate in-services with staff on prevention of abuse and neglect, including unwanted sexual misconduct, and reporting to Abuse Coordinator Interview on 10/21/23 at 2:56 PM RN A stated she received training on 10/20/23 at 4:00 PM. The training reviewed abuse and neglect again, reporting, what to report: abuse, neglected financial, sexual. If the resident feels any unwanted or undesired touching statements report to the administration. She stated the aides and residents were educated to report to the nurse. Interview on 10/21/23 at3:03 PM the HSK attended training today about 8 am, The HSK stated when they saw resident PDA ask the resident if they are comfortable and notify the ADM immediately to assess for safety. Interview on 10/21/23 at 3:07 PM with the DC stated that she does know the residents and they were in a relationship. No reports of sexual. DC stated that she learned in the training to monitor physical resident interactions and confirm consensual interactions for safety and report to administrator resident relationships. Interviews on 10/21/23 at 3:24 PM CNA M stated she attended in-services 10/21/23 at 10:00 AM on abuse and neglect. She said she was to communicate with the residents and make sure they feel safe in the relation-ship and report abuse and neglect to the abuse coordinator when observed and communicating all forms of abuse and sexual misconduct. She said if the ADM was not available report to designee or the ADON. Interviews on 10/21/23 at 3:19 PM AD revealed she had been in-serviced by the ADM on abuse, neglect, and sexual incidents or touching of residents. If a resident reported that contact was not consensual, fear, or further concerns, notify the ADM or designee, separate residents and remain with residents until the ADM arrive to take over. Interviews on 10/21/23 at 3:48 PM with CNA A revealed he attended an in-service on 10/21/23 at 2:30 PM today. The training reflected information on reporting abuse, neglect, and sexual harassment and touching. He said all concerns with relationships or touching and interactions the ADM should be notified immediately. Interviews on 10/21/23 at 3:52 PM revealed he CNA J (agency staff) was in-serviced today at 2:45 PM and was educated about reporting abuse, neglect, sexual abuse, and harassment. Observe residents and engage in a conversation to determine that both residents agree with the relationship and touching, then report the out-come to the ADM and remain with the resident until the ADM

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 of 5 residents (Resident #1 ) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was not sexually assaulted by Resident #2 when he was temporarily relocated to another room. An Immediate Jeopardy (IJ) situation was identified on 08/23/23. While the IJ was removed on 8/24/2023 at 1:54 AM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings include: A record review of Resident #1's Continuity of Care Document dated 08/24/23 revealed a [AGE] year-old male. Resident #1 was admitted to the facility on [DATE]. His diagnoses included Amyotrophic lateral sclerosis (a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord), Atelectasis (the collapse of part or all of a lung), and Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). A record review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS of 15, indicating cognitively intact. Resident #1 was totally dependent on staff to help with activities of daily living. Resident #1's walk-in room and walk-in corridor did not occur. Record Review of Resident #1's care plan last edited 07/18/23 revealed the resident required extensive total staff assistance. Resident #1 had impaired expressive or receptive communication related to Amyotrophic lateral sclerosis (ALS). Resident #1 will have his communication device with him at all times to communicate effectively with staff and others. A record Review of Resident #1's progress note dated 08/21/23 at 4:05 pm reflected [Resident #1] states he was in a temporary room and was inappropriately touched by his roommate. A resident was interviewed about the incident via the communication device. Resident #1 stated he felt safe at the time of the interview. Resident stated he was not physically hurt, but was emotionally hurt. The resident was offered counseling and psychiatric service, resident denied wanting the services, completed by a sister facility administrator. A record review of Resident #2's Continuity of Care Document dated 08/23/23 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Parkinson Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Cognitive Communication deficit (difficulty with thinking and how someone uses language), and Dysphagia (swallowing difficulties). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident was cognitively intact. Resident #2 required limited assistance of one person with activities of daily living. A record review of Resident #2 care plan with the problem date of 04/27/2022, revealed Resident #2 had behavioral symptoms. Resident #2 behavioral problems related to the potential for self-harm due to the resident potentially inserting clothes hangers into the perineal area or rectum. The facility approach included intervening as needed to protect the rights and safety of others. Remove from the situation and take to another location as needed. Resident #2 was witnessed by staff watching porn on his phone. A record review of an event report dated 08/21/23 at 2:00 PM, for Resident #2 revealed Reported by a temporary roommate that resident sexually inappropriate touched him. Resident denies touching roommate. Moved the roommate out of the room immediately. Notified the physician, family, and management, New orders for psych evaluation. Completed by LVN A. An interview with LVN A on 08/22/23 at 10:04 AM revealed she was the primary nurse for Resident #1 on 08/21/23. Resident #1 was placed in another room after the wound care nurse requested Resident #1 be placed in a bed. Resident #1 did not have a bed inside of his room, per the resident and family's request. Resident #1 stayed in his electric wheelchair. Resident #1 was taken into another room with a resident and placed into a bed. Resident #1 was placed into the bed, however, his communication device was included in the temporary room change. Resident #1 was taken into the room by CNA B. After the assessment from the wound care physician, she informed the resident needed to be moved back to his room because the assessment was complete. LVN A revealed she did not know how long Resident #1 was left alone in the room. LVN A revealed there was no reason why Resident #1 was placed in the room with another resident, instead of any other room with a bed. When she entered the room Resident #1's condom catheter was on the floor. Resident #1 did not have the ability to remove the catheter. An observation and interview with the Scheduler/CNA C on 08/22/23 at 10:28 AM revealed she received a text message on 08/21/23 at 12:16 PM from Resident #1. An observation of the text messages provided by the Scheduler/CNA C revealed (Resident #1) when he was in the room after the doctor came and looked at his back. The male resident in the room came over and started messing with his catheter bag, and then started pulling on the tube. The resident pulled on his right leg, thigh and rubbed on his penis. After she received the text message she went down to Resident #1's room. Resident #1 had returned to his original room. Resident #1 was being interviewed by several unknown management staff members about the incident. He did not have his communication device while in the temporary room. She heard Resident #2 would touch himself inappropriately, however, she had not seen any evidence of the behavior. An interview with CNA B on 08/22/23 at 11:09 AM revealed she was the assigned aide for Resident #1 on 08/21/23. CNA B revealed she had temporarily moved Resident #1 into another room, following the request from the wound treatment nurse. CNA B stated Resident #1 was taken into another room without his communication device . CNA B stated without his communication device, it was impossible to understand or communicate with Resident #1. She was alerted by a nurse on 08/21/23 that the resident had been sexually assaulted by Resident #2 in the temporary room. When she entered the room, she noticed Resident #1 condom catheter was lying on the floor . An interview or communication on 08/22/23 at 1:49 PM. with Resident #1 using a communication device. Resident #1 communicated he was sexually assaulted by the resident in the room. An aide entered the room as he was being assaulted, however, because he didn't have his communication device he was unable to tell what happened. An interview with CNA R on 08/22/23 at 2:28 PM revealed she entered the room on 08/21/23 with Resident #1 and Resident #2 to retrieve a Hoyer lift. Upon entering the room, she saw Resident #2 at the foot of Resident #1's bed, rolling back to his side of the bed. Resident #1 was trying to mumble something, however she could not understand the resident because he did not have his communication device. She left the room and informed LVN A. An interview with the Chief Operating Officer (COO) on 08/22/23 at 2:41 PM revealed at the time of the incident, the facility did not have a DON or Administrator. The sister facility administrator was called to interview Resident #1 following the incident. The COO revealed the facility did not have a policy for ensuring residents always had their communication devices. However, the staff had been educated on 08/21/23 regarding that matter. This was determined to be an Immediate Jeopardy (IJ) on 08/22/23 at 9:00 p.m. The COO was notified. The COO was provided with the IJ template on 08/23/23 at 3:36 PM . The following Plan of Removal submitted by the facility was accepted on 08/24/23 at 1:54 p.m. : Immediate Action taken On 8/23/2023 the COO (Chief Operation Officer) notified Medical Director of immediate jeopardy. On 8/23/2023 The Regional Quality Consultant, RN/Designee assessed Resident #1 for any changes in condition - no findings noted, MD notified, and Responsible Party updated on patient stable condition. On 8/23/2023 the Regional Quality Nurse/Designee completed Safe Surveys with all residents in the facility for any s/s of abuse. No residents had any concerns or grievances regarding the identified citation. All residents in the facility were negative for s/s of abuse during the Safe Survey, Medical Director updated on the Safe Surveys results. On 8/23/2023 the COO completed 1:1 in-service on abuse prevention, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences with IDT (intra-disciplinary team), which includes Assistance Director of Nursing, MDS Coordinator, Business Office Director, RDO (Regional Director of Operations), RQC (Regional Quality Consultant), Activity Director, HR, and Maintenance Director. Starting on 8/23/2023 the Regional Quality Consultant/Designee will initiate in-service with all staff on abuse prevention, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences. The training was initiated on 8/23/2023 and will be completed on 8/23/2023. Staff will not be allowed to work until they receive training. Ad-Hoc QAPI meeting was held on 8/23/2023, with the Medical Director, COO, RDO (Regional Director of Operations), Regional Quality Consultant, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policies pertaining to Abuse/neglect were reviewed on 8/23/2023 by the COO, RQC, and Medical Director. Starting on 8/23/2023, IDT (Interdisciplinary team), including Assistant Director of Nursing, MDS Coordinator, Business Office Director, HR, and Activity Director will meet with all residents daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any allegations of abuse arise for 4 weeks, then PRN . The findings will be brought up to the RDO for further action within 24 hours if necessary. Grievances will be reviewed during the morning meetings with RDO and IDT team members for any follow-up needed. All grievances will be entered into the Grievance log by RDO starting 8/23/2023 and the investigation form will be filled out by RDO accordingly as an on-going process. On 8/23/2023 the RDO will start reviewing the Grievance log and investigation forms weekly for four (4) weeks followed by monthly reviews after this will be ongoing. The RDO/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks. This was initiated on 8/23/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The RDO will be responsible for ensuring this plan is completed on 8/23/2023. The COO will provide oversight of RDO to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the POR included the following: Interviews with staff members on 08/24/23 from 12:15 pm to 2:30 pm with LVN A, CNA B,, CNA C, CNA E, LVN F. RN G, LVN H. who worked different shifts at the facility (6 am-6 pm or 6 pm to 6 am). The staff members revealed they received education regarding abuse. Staff were instructed to report any sexual behaviors to the nursing staff and abuse coordinator. An interview with the COO on 08/24/23 at 2:41 p.m. revealed she had completed 1:1 education with CNA B regarding ensuring residents were provided with their communication devices. On 08/23/23 an Ad-Hoc QAPI meeting, with the Medical Director, COO, RDO (Regional Director of Operations), Regional Quality Consultant, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Record review of Inservice education revealed all staff members were educated on 08/22/23 abuse and neglect. Record reviews of safe surveys were completed starting on 08/22/23 with residents of the facility. No resident reported any issues with not having their device. The COO was informed the Immediate Jeopardy was removed on 08/24/23 at 2:47 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, 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 failed to ensure the rights 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 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 had his communication device when he was temporarily transferred to another room. While in the room Resident#1 yelled for help, and Resident #1 was sexually assaulted. An Immediate Jeopardy (IJ) situation was identified on 08/23/23. While the IJ was removed on 8/24/2023 at 1:54 AM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for psychosocial and physical harm. The findings were: A record review of Resident #1's Continuity of Care Document, dated 08/24/23, revealed a [AGE] year-old male. Resident #1 was admitted to the facility on [DATE]. His diagnoses included Amyotrophic lateral sclerosis (a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord), Atelectasis (the collapse of part or all of a lung), and Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). A record review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS of 15, which indicated he was cognitively intact. Resident #1 was totally dependent on staff to help with activities of daily living. Resident #1's walk-in room and walk-in corridor did not occur. Record review of Resident #1's care plan, last edited 07/18/23, revealed the resident required extensive total staff assistance. Resident #1 had impaired expressive or receptive communication related to Amyotrophic lateral sclerosis (ALS). Resident #1 will have his communication device with him at all times to communicate effectively with staff and others . A record review of Resident #1's progress note, dated 08/21/23 at 4:05 PM, reflected (Resident #1) stated he was in a temporary room and was inappropriately touched by his roommate. The resident was interviewed about the incident via the communication device. Resident #1 stated he felt safe at the time of the interview. Resident #1 stated he was not physically hurt, but was emotionally hurt. The resident was offered counseling and psychiatric services. The resident denied wanting the services, completed by a sister facility administrator. An observation and interview on 08/22/23 at 9:34 AM with Resident#1's RP, revealed Resident #1 had used his communication device on 08/21/23 to inform her via text message, Resident#1 was moved to another room and was molested by another resident. An observation of the RP's cellular phone reflected the message was received at 1:09 p.m. on 08/21/23. Resident #1 revealed he was okay following the attack. However, the male resident had tried to jack me off and rubbing on my thigh. An interview with LVN A on 08/22/23 at 10:04 AM revealed she was the primary nurse for Resident #1 on 08/21/23. Resident #1 was placed in another room after the wound care nurse requested Resident #1 be placed in a bed. Resident #1 did not have a bed inside of his room, per the resident and family's request. Resident #1 stayed in his electric wheelchair. Resident #1 was taken into another room with a resident and placed into a bed. Resident #1 was placed into the bed, however, his communication device was not included in the temporary room change. Resident #1 was taken into the room by CNA B. After the assessment from the wound care physician, she was informed the resident needed to be moved back to his room because the assessment was complete. LVN A revealed she did not know how long Resident #1 was left alone in the room. LVN A revealed there was no reason why Resident #1 was placed in the room with another resident, instead of any other room with a bed. An observation and interview with the Scheduler/CNA C on 08/22/23 at 10:28 AM revealed she received a text message on 08/21/23 at 12:16 PM from Resident #1. An observation of the text messages provided by the Scheduler/CNA C revealed (Resident #1) when he was in the room after the doctor came and looked at his back. The male resident in the room came over and started messing with his catheter bag, and then started pulling on the tube. The resident pulled on his right leg, thigh and rubbed on his penis. After she received the text message she went down to the Resident #1 room. Resident #1 had returned to his original room. Resident #1 was being interviewed by several unknown management staff members about the incident. He did not have his communication device while in the temporary room. An interview with CNA B on 08/22/23 at 11:09 AM revealed she was the assigned aide for Resident #1 on 08/21/23. CNA B revealed she had temporarily moved Resident #1 into another room, following the request from the wound treatment nurse. CNA B stated Resident #1 was taken into another room without his communication device . CNA B stated without his communication device, it was impossible to understand or communicate with Resident #1. She was alerted by a nurse on 08/21/23 that the resident had been sexually assaulted by the resident in the temporary room. When she entered the room, she noticed Resident #1 condom catheter was lying on the floor. An interview or communication on 08/22/23 at 1:49 PM with Resident #1 using a communication device, Resident #1 communicated he was sexually assaulted by the resident in the room . An aide entered the room as he was being assaulted, however, because he didn't have his communication device he was unable to tell what happened. An interview with CNA R on 08/22/23 at 2:28 PM revealed she entered the room on 08/21/23 with Resident #1 and the temporary roommate to retrieve a Hoyer lift. Upon entering the room, she saw the roommate at the foot of Resident #1 bed, rolling back to his side of the bed. Resident #1 was trying to mumble something however she could not understand the resident because he did not have his communication device. She left the room and informed a nurse. An interview with the COO on 08/22/23 at 2:41 PM was revealed at the time of the incident, the facility did not have a DON or Administrator. The sister facility administrator was called to interview Resident #1 following the incident. The COO revealed the facility did not have a policy for ensuring residents always had their communication devices. However, the staff had been educated on 08/21/23 regarding that matter. This was determined to be an Immediate Jeopardy (IJ) on 08/22/23 at 9:00 p.m. The COO was notified. The COO was provided with the IJ template on 08/23/23 at 3:36 PM. The following Plan of Removal submitted by the facility was accepted on 08/24/23 at 1:54 PM: Immediate Action taken On 8/23/2023 the COO (Chief Operation Officer) notified Medical Director of immediate jeopardy. On 8/23/2023 The Regional Quality Consultant, RN/Designee assessed Resident #1 for any changes in condition - no findings noted, MD notified, and the Responsible Party updated on the patient's stable condition. On 8/23/2023 the Regional Quality Nurse/Designee completed Safe Surveys with all residents in the facility for any s/s of abuse and any other residents to utilize communication devices. No residents had any concerns or grievances regarding the identified citation. All residents in the facility were negative for s/s of abuse during the Safe Survey, The Medical Director updated on the Safe Survey results and plan of care for residents in the facility who utilize communication devices. Three other residents identified to have communication deficits were assessed by RQC RN/Designee on 8/23/2023 for any changes in condition and the plan of care was reviewed to make sure appropriate interventions were in place for communication, including communication devices if appropriate and monitoring for any changes in condition. Speech therapy assessed all residents and interventions in place. On 8/23/2023 the COO completed 1:1 in-service on abuse prevention and residents who utilize communication devices, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the resident's goals and preferences with IDT (intra-disciplinary team), which includes Assistance Director of Nursing, MDS Coordinator, Business Office Director, RDO, RQC, Activity Director, HR , and Maintenance Director. Starting on 8/23/2023 the Regional Quality Consultant/Designee will initiate in-service with staff on abuse prevention and communication with residents who utilize communication devices, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences. The training was initiated on 8/23/2023 and will be completed on 8/23/2023. Staff will not be allowed to work until they receive training. Ad-Hoc QAPI meeting was held on 8/23/2023, with the Medical Director, COO, RDO (Regional Director of Operations), Regional Quality Consultant, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policies about Abuse/neglect and communication were reviewed on 8/23/2023 by the COO, RQC, and Medical Director. Starting on 8/23/2023, IDT (Interdisciplinary team), including the Assistant Director of Nursing, MDS Coordinator, Business Office Director, HR, and Activity Director will meet with all residents daily Monday to Friday, and the Manager on Duty Saturday and Sunday to determine if any allegations of abuse arise and any residents with communication devices have changes in condition, including review of new admissions who utilize communication devices for 4 weeks, then PRN . The findings will be brought up to the RDO for further action within 24 hours if necessary. Grievances and new admissions who need communication devices will be reviewed during the morning meetings with RDO and IDT team members for any follow-up needed starting 8/23/2023 as an on-going process. On 8/23/2023 the RDO will start reviewing the Grievance log, new admissions with the need for communication devices and plan of care, and investigation forms weekly for four (4) weeks followed by monthly reviews after this will be ongoing. The RDO/designee will monitor compliance by completing an audit of ten (5) residents per week for four (4) weeks. This was initiated on 8/23/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The RDO will be responsible for ensuring this plan is completed on 8/23/2023. The COO will provide oversight of RDO to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the POR included the following: Interviews with staff members on 08/24/23 from 12:15 PM to 2:30 PM with LVN A. CNA B, CNA C, CNA E, LVN F, RN G, LVN H. who worked different shifts at the facility (6 AM-6 PM or 6 PM to 6 AM). The staff members revealed they had received education regarding making sure residents were provided with their communication devices at all times . An interview with the COO on 08/24/23 at 2:41 p.m. revealed she completed 1:1 education with CNA B regarding ensuring residents were provided with their communication devices. On 08/23/23 an Ad-Hoc QAPI meeting, with the Medical Director, COO, RDO (Regional Director of Operations), Regional Quality Consultant, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Record review of In-service education revealed all staff members were educated on 08/22/23 regarding ensuring residents with communication devices had them at all times. Record reviews of safe surveys were completed starting on 08/22/23 with residents of the facility. No resident reported any issues with not having their device. The COO was informed the Immediate Jeopardy was removed on 08/24/23 at 2:47 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 (Resident #1) of 5 residents reviewed for medication errors. The facility failed to ensure Resident #1's critical medications were sent with him and failed to notify the family that the resident left the facility without his medications when the facility believed Resident #1 had left on pass. An Immediate Jeopardy was identified on 08/01/23. While the IJ was removed on 08/02/23 the facility remained out of compliance at a scope of Isolated and a severity level of Immediate Threat because all staff had not been trained on sending medications with residents on pass. This failure led to Resident #1 being without his medications for three days and placed him at risk of a hypertensive crisis, diabetic ketoacidosis, hospitalization , or death. Findings included: Review of Resident #1's Face Sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 had diagnoses that included stroke affecting swallowing, high blood pressure, and diabetes. Review of Resident #1's MDS, dated [DATE], revealed he had a BIMS score of 8 indicating severe cognitive impairment. His Functional Status indicated he required minimal assistance with all of his ADLs except eating which required total dependence. The resident received nothing by mouth, all nutrition and medications were received via gastric tube. Review of Resident #1's EHR revealed on 07/03/23 his BIMS was recalculated to 13, indicating he was cognitively intact. Review of Resident #1's care plan, dated 06/13/23, revealed he was high risk for choking on food and drink, related to stroke. He was at risk for social isolation related to refusing to socialize, He was at risk for falls related to stroke. He had behavioral issues, refusing gastric tube feedings and demanding regular food. Review of Resident #1's physician orders revealed he was prescribed Coreg and diltiazem for blood pressure control, Eliquis as a blood thinner for an irregular heart rhythm, and Insulin and Jardiance for his blood sugar control. Resident #1 required his blood glucose level to be checked before each meal and his insulin dosage was determined by his glucose levels. Interview on 08/01/23 at 8:00 AM with ADON O revealed she had noted Resident #1's medications were still in the cart on 07/5/23 but assumed he had been sent with everything he needed while he was on pass. She stated she had assumed the nurse had dispensed the number of pills he would need while on pass, and left the medication cards in the cart. Interview on 08/01/23 at 11:56 AM with LVN D revealed she had noticed Resident #1's medications were still in the cart on 07/06/23 which prompted her to call the family of Resident #1 to inquire about him having his medications; resulting in discovering he was not on pass but had eloped. Interview on 08/01/23 at 9:25 AM with the family member of Resident #1 revealed the resident left the facility without his medications, and he had not returned to the facility for his medications. She did not know how he managed his medical problems without his medications. She stated the facility assumed Resident #1 left the faciity on pass with his family on 07/03/23, when in fact, he had eloped with a friend. Resident #1 was not discovered to have eloped until 07/06/23 when she was contacted about his whereabouts. Interview on 08/01/23 at 12:04 PM with LVN B revealed she had noticed Resident #1's medication in the cart on 7/03/23, but had assumed LVN C sent the pills that Resident #1 would need while he was on pass. She stated she did not feel a need to contact the family to follow up. Interview on 08/01/23 at 10:50 AM with LVN L revealed the process of sending a resident out-on-pass included sending any medications they might need, along with them. Interview on 08/01/23 at 11:00 AM with LVN M revealed the process of sending a resident out-on-pass was to send their medications with them, usually the whole card of pills so they did not get lost, mixed up, etc If a resident's medications were still in the cart, when they were supposed to be out of the facility, the DON had to be contacted. Interview on 07/18/23 at 10:46 AM with the Physician revealed the initial concern for Resident #1 being without his medications was a seizure. The Physician sstated a person could start to have seizures after missing their medication for only one day. The next concern would be his blood pressure, being without his medication could cause his blood pressure to rise and possibly cause a hypertensive crisis (uncontrolled extremely high blood pressure). The final concern would be the resident's diabetes, not having his insulin could cause his blood sugar to rise and lead to diabetic ketoacidosis (diabetic coma). Review of the facility's Dispensing Medications to Residents on Leave/Pass policy, dated April 2007, reflected: .Policy Statement- The facility shall provide residents with necessary when they leave the facility temporarily. 1. Residents who are away from the facility during medication passes will be given scheduled and PRN medications to take with them. 2. The Charge nurse will provide verbal and written directions to the resident and/or the person signing out the resident regarding any dispensed medications. 3. The nursing staff will document the resident's absence from the facility on the resident's MAR if the resident is absent during one or more medication passes On 08/01/23 at 6:00 PM, the Regional Director of Operations was notified an Immediate Jeopardy, in the area of Pharmaceutical Services was identified. The facility's Plan of Removal was accepted on 08//02/23 at 1:24 PM and included: Plan to remove immediate jeopardy. The facility failed to ensure a resident was free of significant medication errors. The resident left the facility without medication from facility causing a significant medication error. This failure is likely to result in serious harm if immediate action is not taken to prevent residents out on pass have all prescribed medications. F760 On 8/1/2023 at 18:00 the Director of Nurses notified Medical Director of immediate jeopardy. On 8/1/2023 the head count of all residents currently residing in the facility was completed by the Director of Nursing. All residents are present. On 8/1/2023 Regional Nurse Consultant completed 1:1 in-service with Director of Nursing on Signing residents out with medication policy and procedure. Starting on 8/1/2023 the Director of Nursing/Designee will initiate in-service with licensed nurses on Signing Resident out with medications on 8/1/23. Ad-Hoc QAPI meeting was held on 8/1/2023, with the Medical Director, RDO (Regional Director of Operations), Regional Nurse Consultant (RNC), [NAME] President of Clinical Services (VPCS), Chief Operation Officer (COO), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. Starting on 8/1/2023, IDT (Interdisciplinary team), including Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review headcount of all residents residing in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents went out on pass with Medications, and if on pass with not his/her legal representative. The findings will be immediately brought up to the Director of Nursing for further action, if necessary. On 8/1/2023 the Director of Nursing will start reviewing out on pass binder for any resident who left facility on pass for validation of medications were given as needed while on pass. The audit will be completed weekly for four (4) weeks followed by monthly x 2 months. 8/1/2023 RDO will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Regional Nurse Consultant (RNC) will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks who left on pass with or without medications. This was initiated on 8/2/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Director of Nursing will be responsible for ensuring this plan is completed on 8/1/2023. The RDO will provide oversight of Director of Nursing to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Immediate Jeopardy continued with interviews of nursing staff and administration. Interview on 08/02/23 at 1:35 PM with LVN L revealed she had been in-serviced by the VP of Clinical Services on the process of sending residents out-on-pass, which included sending residents out-on-pass with their medications, and what to do if a resident's medications were still in the cart when they were out-on-pass. Interview on 08/02/23 at 1:40 PM with ADON P revealed she had been in-serviced by the VP of Clinical Services on the process of sending residents out-on-pass, which included sending their medications with them and what to do if a resident out-on-pass was discovered to have left their medications behind. Interview on 08/02/23 at 1:45 PM with RN N revealed she had been in-serviced by the VP of Clinical Services on the process of sending esidents out on pass. She stated all medications, including controlled substances, that the resident would need while out of the facility had to be sent with them along with directions on when and how to take them. All medications would be checked back in when they returned. During medication pass, if the medications for a resident out-on-pass were discovered still in the cart the DON was to be notified immediately. An Immediate Jeopardy was identified on 08/01/23. While the IJ was removed on 08/02/23 the facility remained out of compliance at a scope of Isolated and a severity level of Immediate Threat because all staff had not been trained on sending residents out on pass.

Based on interview and record review, the facility failed to provide adequate supervision for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to supervise Resident #1 to prevent him from eloping from the facility, allowing him to walk out the front door undetected. The resident was missing for three days without his medications. This failure resulted in an identification of an Immediate Jeopardy on 07/17/23. While the IJ was removed on 07/18/23, the facility remained out of compliance at a Immediate Jeopardy and a scope identified as isolated due to the facility's need to completed in-services training and evaluate the effectiveness of the corrective system. This failure placed residents at risk of eloping, serious injury, hospitalization , or death. Findings included: Review of Resident #1's Face Sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 had diagnoses that included stroke affecting swallowing, high blood pressure, and diabetes. Review of Resident #1's MDS, dated [DATE], revealed he had a BIMS score of 8 indicating severe cognitive impairment. His Functional Status indicated he required minimal assistance with all of his ADLs except eating which required total dependence. The resident received nothing by mouth, all nutrition and medications were received via gastric tube. Review of Resident #1's EHR revealed on 07/03/23 his BIMS was recalculated to 13, indicating he was cognitively intact. Review of Resident #1's care plan, dated 06/13/23, revealed he was high risk for choking on food and drink, related to stroke. He was at risk for social isolation related to refusing to socialize, He was at risk for falls related to stroke. He had behavioral issues, refusing gastric tube feedings and demanding regular food. The care plan interventions were not available. Interview on 07/18/23 at 2:20 PM with CNA K revealed on 07/03/23 Resident #1 asked her to make his bed and get him some ice. CNA K stated the resident told her he was going to go out to the courtyard for a while. Around 8:00 PM, the resident was not in his room, and she asked LVN B if she had seen him. LVN B told her Resident #1 had gone out-on-pass. CNA K stated she checked the sign-out book and the resident was not signed out. On 07/05/23, CNA K stated when she came into work, she noticed Resident #1 was still not there. When she pulled up her list of residents, Resident #1 was still green and unassigned. She stated when residents were on leave, they were grayed out and you can't chart on them. She stated she asked LVN C if Resident #1 was on leave, and she said he was. CNA K stated she thought it was odd but let it go. Interview on 07/17/23 at 3:00 PM with the family member of Resident #1 stated she had been contacted on 07/06/23 by the Administrator asking her when Resident #1 would be returning to the facility. She informed the Administrator that Resident #1 was not with her or any family member. She was notified that the resident had left the faciity on the evening of 07/03/23 on pass with family. The family member stated the resident had not left the facility with family and was not with any family; his location was unknown. The family member stated she was able to make contact with Resident #1 on 07/07/23 and learned he was hiding from them at a friend's house because he did not want to go back. She stated he did not have his medications from the facility and had not taken his medications in the time he had been gone from the facility. Interview on 07/17/23 at 3:25 PM via phone with Resident #1 revealed he did not leave the facility on pass, did not leave with his family, did not take anything with him, including his medications, did not tell anyone he was leaving, and did not sign anything. He stated he waited until the office staff was gone for the day, called his friend to pick him up, and walked out the front door. Interview on 07/17/23 at 4:37 PM with the Administrator revealed she was made aware that Resident #1 was not in the facility during thier morning meeting, the ADON stated he had gone out on pass on 07/03/23 and had not returned. The Administrator contacted the family of Resident #1 to inquire as to when Resident #1 would return and was advised they had not taken him out of the facility, and he was not with any of the family; they did not know where he was. The Administrator stated staff had been under the assumption Resident #1 was out on leave, not that he had eloped. The Administrator stated she had interviewed the two nurses who worked on 07/03/23 and received conflicting stories. LVN B stated she had been told by LVN C that Resident #1 was going out-on-pass with his family. LVN C stated she had not told LVN B that Resident #1 was going out-on-pass; there was another resident that was going out-on-pass she had told her about. On 07/17/23 at 5:45 PM, the Administrator was notified an Immediate Jeopardy in the area of Quality of Care was identified. The facility's Plan of Removal was accepted on 07/18/23 at 1:26 PM and included: Plan to remove immediate jeopardy. The facility failed to ensure a resident was provided with adequate supervision to prevent a resident from leaving the facility. F689 On 7/17/2023 the Administrator and Director of Nurses notifies Medical Director of immediate jeopardy. On 7/17/2023 the head count of all residents currently residing in the facility was completed by the Administrator. All residents are present. Starting on 7/17/2023 the Director of Nursing/Designee will initiate in-service on adequate supervision to prevent a resident from leaving the facility, including policies on elopement/missing resident, resident out on pass, timely notification of RP/Family of residents who are on pass without his/her legal representative. Ad-Hoc QAPI meeting was held on 7/17/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. Starting on 7/17/2023, IDT (Interdisciplinary team), including Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review headcount of all residents residing in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents went out on pass, and if on pass with not his/her legal representative - timely notification was completed to his/her legal representative. The findings will be immediately brought up to the Administrator for further action, if necessary. Starting on 7/18/2023, The Administrator/designee will contact law enforcement any time a resident is known to be missing. On 7/18/2023 the RDO (Regional Director of Operations) will start reviewing leave of pass binder for any resident who left facility on pass for validation of timely notification of RP weekly for four (4) weeks followed by monthly x 2 months. 7/17/2023 RDO will provide physical oversight at facility weekly x4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks who are at risk of Elopement and left on pass with or without RP, timely notification of RP if left without legal representative. This was initiated on 7/17/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 7/17/2023. The DON was unavailable for interview during POR monitoring. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal continued and included interviews with staff on both day and night shifts. Interview on 07/18/23 at 2:40 PM with the Administrator revealed their Social Worker quit on 07/17/23 and she was in the process of setting up interviews. She and the DON would cover her roles until a replacement could be found. Resident #3 had eloped on 06/22/23, he went out the front door and down the sidewalk. CNA had noted him outside when she was coming into work, and he was brought back inside. He did not leave the property. Lab work showed he had a UTI, he was started on antibiotics and was now back to his baseline. No previous elopement attempts by this resident. The alarm on the front door was replaced with the current loud alarm after Resident #1 eloped form the building. She stated Resident #1 was not reported to family or HHSC because the belief was that he was out on leave. It was not until he did not return after 48 hours that they became concerned. Any resident with decreased mental capacity is considered an elopement if they left the facility. Resident #1 had a BIMS of 13. Residents received an Elopement Risk evaluation on admission, quarterly, and with any significant change. Elopement risks evaluations were put in a binder that was located at each nurses' station and at the receptionist's desk. The receptionist's desk was not manned since pandemic restrictions were lifted. They had a bid to install a keypad lock on the front door, no date for completion had been set. Interview on 07/18/23 at 3:20 PM with LVN D revealed she had been in-serviced by the Administrator on elopement/missing residents, residents on pass, and timely reporting to the responsible party/family if a resident eloped. When sending a resident out-on-pass, they were to notify the Administrator or DON, provide medications needed and educate on when to take them, have the resident and whomever they were leaving with sign the sign-out book with an estimate of when they would return. Interview on 07/18//23 at 3:27 PM with CNA E revealed she had been in-serviced by the Administrator on elopement/missing residents and what to do if a resident eloped. If a resident was suspected of eloping, she was to report to the nurse immediately, search the facility and then the grounds for the resident. Interview on 07/1823 at 3:29 PM with CNA F revealed she had been in-serviced by the Administrator on elopement/missing residents. She knew to familiarize herself with the binder that had the high-risk residents in it and keep an eye on them. If a resident was missing to search the facility and then the grounds, report to the nurse if they were missing. Interview on 07/18/23 at 3:31 PM with CNA G revealed she had been in-serviced by the Administrator on elopement/missing residents, and residents on pass. She knew to look at the binder so she knew who the high risk residents were and to keep an eye on them. If a resident could not be located, they were supposed to check the facility and grounds immediately and help with the head count. Interview on 07/18/23 at 3:34 PM with the ADON O revealed she had been in-serviced by the Administrator on elopement/missing residents and residents on pass. She stated there was a binder with the high risk residents in it so they knew who to keep an eye out for. If a resident went out on pass, they were supposed to notify the DON. ADON O stated they were supposed to send any medications with the resident they might need, have them sign out with an estimate of when they would return, and create a note so everyone knew about the resident. Interview on 07/18/23 at 3:37 PM with MA H revealed she had been in-serviced by the Administrator about elopement, She knew to look at the binder for the high risk residents. If a resident was suspected of being missing, they were supposed to check the facility and grounds to locate them and notify the nurse if not found. Interview on 07/18/23 at 3:45 PM with LVN I revealed she had been in-serviced by the Administrator on missing residents and elopements. LVN I stated they were supposed to be aware of the high risk residents in the binder, search for anyone thought to be missing and notify the DON if not found. She stated the process of sending residents on pass was also covered. Interview on 07/18/23 at 3:50 PM with LVN J revealed she had been in-serviced by the Administrator on elopement and missing residents. If anyone was missing, they were supposed to check the premises and report to the DON if not located. If residents were leaving on pass, the residents needed to sign out with an ETA of their return. LVN J stated they were also supposed to send all medications with the resident that they would need. An Immediate Jeopardy was identified on 07/17/23. While the IJ was removed on 07/18/23, the facility remained out of compliance at a scope of isolated and a severity level of Immediate Threat because all staff had not been trained on elopement, residents on pass and timely reporting.

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries to 1 of 3 residents (Resident #5) reviewed for wound care, in that: The facility failed to ensure that Resident #5 was provided with daily wound care on 7/30/2023 as ordered by his physician which resulted in the worsening of the wound's condition. This deficient practice could place residents at risk for deterioration of existing wounds. Findings include: Record Review of Resident #5's face sheet dated 7/31/2023 revealed a [AGE] year-old male, admitted to the facility 5/5/2023. Resident #5 was admitted with the following diagnoses: Quadriplegia (inability to move or feel his body from the shoulders down). Two stage 4 (open wound involving muscle and bone) pressure sores; one to the lower back and 1 to the right ankle (resolved). Record Review of Residents #5's quarterly MDS assessment dated [DATE] revealed Resident #5 had a BIMS score of 15 meaning no cognitive impairment. Resident #5 was dependent on staff for bed mobility, transfers, and bathing. Required assistance from one staff member for dressing, eating, toileting and personal hygiene. Resident #5 was identified as one to reject care 1 - 3 days. Resident #5 was incontinent of bowel. Record Review of Resident #5's care plan, dated 6/30/2023, reflected [Resident #5] was at risk for actual pressure ulcers or altered skin integrity r/t decreased mobility as evidenced by the presence of pressure ulcers. Record Review of Resident #5's physician's orders reflected: as of 7/18/2023 Wound Care: clean stage 4 pressure wound to coccyx (region of the lower back above the gluteal crease) with wound cleanser, pat dry, skin prep to peri wound allow to dry then apply Anasept (gel to prevent infection) & collagen (powder promote healing) mix (5cc collagen powder, 5cc anasept gel) to wound bed. Cover with dry dressing qday. Record review of Resident #5's progress notes revealed no documentation of refusals regarding treatments scheduled for 7/30/2023. Review of Resident #5's MAR (Medication Administration Record) dated July 2023 revealed the absence of documentation for 7/30/2023. Review of Residents #5's wound report dated 7/24/2023 revealed coccyx wound measured 4.0 cm x 3.0cm surface area of 12.0cm. Wound reported as improved as evidenced by decreased surface area, decreased slough (dead tissue) and increased granulation (healing tissue). During an interview on 7/31/2023 at 09:15 AM, Resident #5 stated that he did not get wound care over the weekend, its scheduled everyday. Resident #5 refused wc on Saturday 7/292023 and nobody offered to do wound care on 7/30/2023. Resident #5 knew he would see the WCP on Monday 7/31/2023, and he did not provide wound care. An observation on 07/31/2023 at 09:40 AM, revealed Resident #5 was turned to his left side. The dressing on the wound covering the region of the back just above the gluteal crease, was a dressing dated 7/28/2023. The dressing was removed and noted to be fully saturated with serous (thin, watery clear or yellowish drainage), WCP did not note obvious signs of infection. WCP measured wound to be 5.0 x 4.0 cm surface area 20.0cm larger than the previous evaluation. During a telephone interview on 07/31/2023 at 2:49 PM, RN A stated that when she gave her report on 7/30/2023, she told the oncoming nurse (LVN B) that she was not able to do treatments r/t staffing. RN A reported that for several hours it was her and one CNA in the building. RN A reported to the oncoming agency nurse that wound care needed to be done. During a telephone interview on 7/31/2023 at 4:43 PM, LVN B stated when she arrived to the facility on [DATE] she placed a call to the DON, because of staffing. LVN B, stated Resident #5's room was not included in her initial assignment. LVN B remembered RN A telling her to look through the system because she was not sure everything got done. LVN B does not recall being told specifically that wound care was not done. During a telephone interview on 07/31/2023 at 4:08 PM, the WCP, stated Resident #5's dressing was dated 7/28/2023 which was the last day the dressing was changed. WCP stated the wound was bigger than when he last saw Resident #5 on 7/24/2023, no obvious signs of infection was noted during the evaluation. He stated not changing the dressing for 3 days was not good for the wound, the wound could become infected. During an interview on 7/31/2023 at 4:39 PM, the DON stated she was not aware that wound care was not done during the weekend until after ADON came and told her after rounding with WCP. Review of facility policy, revised 10/2010, and titled Wound Care, .wound care is provided as prescribed by the physician.

Based on interviews, and record reviews, the facility failed to immediately inform the physician and the resident's representative when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #1) of five residents reviewed for physician notification. The facility failed to ensure LVN A notified the physician when Resident #1 suffered a fall with injury that resulted in the resident developing a subdural hematoma which ultimately resulted in her death on [DATE]. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of and a severity level of Immediate Jeopardy because all staff had not been trained on change in condition, timely assessments, physician notification, and treatments based on physician orders. This failure placed residents at risk of a delay in treatment, and a worsening of their condition. Findings included: Review of Resident #1's Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke, dementia, difficulty swallowing, and difficulty speaking. Review of Resident #1's admission MDS assessment, dated [DATE] revealed her BIMS score was not calculated due to her medical condition. Her Functional Status indicated she required limited assistance with her ADLs, including walking on the unit. Review of Resident #1's care plan, dated [DATE], revealed she was at risk for falls related to previous history of falls, alteration in bleeding related to anticoagulant use, and stroke related to previous stroke. Review of facility's Accident & Injury report for [DATE] revealed Resident #1 had suffered two falls on [DATE] and was transported to the hospital on [DATE] with stroke-like symptoms. Review of nursing progress notes revealed LVN A documented a fall on [DATE] at 9:30 AM and again at 9:50 AM, both resulted in no injury to the resident. There was no documentation of notification made to the physician or the resident's representative. Review of nursing progress notes revealed LVN B documented on [DATE] at 10:00 AM Resident #1 was demonstrating stroke-like symptoms with a left facial droop, left-sided gaze, and a decrease in her level of responsiveness. Resident #1 was assessed by the ADON and the NP, and 911 was called. Review of Nurse Practitioner notes on [DATE] revealed he assessed the resident as Unlike her baseline, she is non-verbal and non-engaging. Physical examination remarkable for edema to the right face and upper lip concerning for fall. Review of the EMS report revealed they transported Resident #1 on [DATE] at 10:55 AM to the hospital. The Paramedic assessment revealed the resident had presence of facial droop and swelling to the right upper lip. Review of hospital records for Resident #1's admission, dated [DATE], revealed the ER physician documented swelling to right upper lip, laceration to the inner aspect of the lip, swelling to right cheek, and decreased responsiveness. Review of MRI results for Resident #1 revealed the resident had a hematoma to the back of her head, a left-sided subdural hematoma that was expanding and causing swelling in her brain. Interview on [DATE] at 2:20 PM with the family member of Resident #1 revealed they had not been informed of any events with Resident #1 until they were notified on [DATE] that the resident was being transported to the hospital with stroke-like symptoms. They stated Resident #1 had swelling to her right upper lip, right cheek, and the back of her head when they saw her in the ER. The resident was admitted to the hospital with bleeding and swelling of the brain. They were told there was nothing that could be done at that point to evacuate the bleeding from the brain as she would continue to bleed. The family opted to transfer her to hospice. The family member submitted three photos to the surveyor's phone revealing swelling to the right upper lip, bruising to the inner lip, and swelling to right cheek. A text message on [DATE] at 11:49 AM from the family member of Resident #1 stated the resident continued to deteriorate in hospice and had passed away on the evening of [DATE]. Interview on [DATE] at 12:00 PM LVN B stated Resident #1 would try to stand up from her wheelchair occasionally, but usually just moved around the unit using her feet to propel the wheelchair. LVN B stated her assessment of Resident #1's capabilities were that if she fell to the floor she would not be able to get herself up, making it unlikely that Resident #1 could have fallen without anyone knowing. LVN B stated she entered Resident #1's room on [DATE] around 10:00 AM to give her morning medications and she noted the resident was not responding to her and the resident had a left sided facial droop. She called the ADON and the NP to the bedside and they confirmed the resident appeared to be suffering a stroke. 911 was called and the resident was transported to the hospital. LVN B stated she thought there was swelling to the upper lip, but she was not sure because of the facial distortion caused by the facial droop. Interview on [DATE] at 1:00 PM CNA C stated on [DATE] at 9:30 AM she found Resident #1 face down on the floor in front of her wheelchair. She stated she called LVN A to the room, and they were able to get Resident #1 into her wheelchair again. She did not notice any swelling to the resident's face at that time. CNA C stated she was called back to the room at 9:50 AM by LVN A who stated Resident #1 had started to get up from her wheelchair, but she was able to grab her and lower the resident to the floor. Resident #1 was again lying face down on the floor. LVN A, CNA C and CNA D were able to get the resident into bed after the second fall. CNA C stated she noted swelling to the resident's upper lip, The three of them left Resident #1's room together and CNA C stated she did not see LVN A perform any type of assessment on the resident. CNA C stated Resident #1 remained in bed the rest of the shift, did not want lunch or dinner when they were offered; all of which was abnormal for Resident #1. Interview on [DATE] at 1:25 PM, via phone, LVN A stated Resident #1 had suffered no injury after both falls. Therefore there was not a reason to call the physician. LVN A stated she did a head-to -toe assessment and found no injury. She was sure the resident did not hit her head on the second fall because she had lowered the resident to the ground. She was not able to document the events immediately because the facility internet was down. LVN A returned the next afternoon to document the event. Interview on [DATE] at 2:25 PM via phone, LVN A again stated she had performed a head-to-toe assessment on Resident #1 after both falls and denied any injury. She denied seeing any swelling to the lip after the second fall. LVN A stated she started to do neuro checks on Resident #1 but did not follow through because she got busy. Interview on [DATE] at 2:45 PM CNA D stated she was called to Resident #1's room to help get her up after a fall. When she entered the room she noted the resident was face down on the floor. She stated she, CNA C and LVN A were able to get the resident up an into bed. CNA D stated there was swelling to Resident #1's upper lip and her right cheek was red. CNA D stated the three of them left the room together and she did not observe LVN-A assess the resident. CNA D had never worked with Resident #1 before so she was unable to state if the resident was acting normal. Interview on [DATE] at 3:35 PM the Administrator stated she had been made aware of Resident #1 being transported to the hospital with a stroke, and she was aware of the two falls the previous day but no one had reported any injuries to her. The Administrator stated she had been told the swelling to Resident #1's lip was likely due to her biting her lip during the night according to the ADON. She stated she felt there was no further action needed based on what she had been told. She stated she was aware of the requirement to report injuries to HHSC. Interview on [DATE] at 8:30 AM the Physician stated he was notified after Resident #1 had been sent to the hospital for stroke like symptoms. He had not been made aware of the swelling to the lip until the Administrator called him on [DATE]. He stated if he had been notified he would have advised the nurse to hold the resident's anticoagulation medications, monitor her neurological status for 24 hours and report any changes to him. The Physician stated had he be been made aware of Resident #1's injuries he would have deferred treatment to the hospice physician about transporting her to the hospital because there were no medications to reverse her anticoagulants and likely would not have altered the resident's outcome. On [DATE] at 10:30 AM the Administrator was notified that an Immediate Jeopardy in the area of Resident Rights. The facility submitted the following acceptable Plan of Removal on [DATE] at 3:03 PM: F580 - The facility failed to notify the physician of a change in condition after a resident fell and sustained injuries, which resulted in the resident sustaining a subdural hematoma and her subsequent death on [DATE]. On [DATE] the Administrator and Director of Nurses notifies Medical Director of immediate jeopardy. On [DATE] the Director of Nurses suspended Nurse who responded to the fall on [DATE] but didn't report any injury and failed to conduct a thorough assessment of neurological checks to assess the resident for injuries to include head trauma. On [DATE] all residents in the facility will be assessed by the Director of Nursing/Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions. orders. Starting on [DATE] the Director of Nursing/Designee will initiate in-service with nurses on changes in condition, including timely assessment, physician notification, and treatment as ordered by physician. Ad-Hoc QAPI meeting was held on [DATE], with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Change in condition and timely reporting was reviewed on [DATE] by the NHA (Nursing Home Administrator), Director of Nursing, RDO (Regional Director of Operations), and Medical Director. Starting on [DATE], IDT (Interdisciplinary Team), including Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought up to Administrator for further action, if necessary. On [DATE] the RNC (Regional Nurse Consultant) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly x 2 months. On [DATE] RDO will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance by completing audit of ten (10) residents per week for four (4) weeks. This was initiated on [DATE]. Any identified concern will be addressed immediately and if trends and patters are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. Administrator will be responsible for ensuring this plan is completed on [DATE]. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal continued and included interviews with staff on both day and night shifts. Interview on [DATE] at 6:00 AM with LVN E, she stated she had been in-serviced by the DON, covering falls, reporting of falls, and fall procedures. She stated she had to assess the resident for injuries before moving them. If the resident had any injuries she was to contact the physician and follow his orders. Interview on [DATE] at 6:10 AM with RN F, he stated he had been in-serviced by the DON at the beginning of his shift. The in-service covered falls, fall protocols, and notifications. In the event of a fall he would assess the resident for any injuries and notify the physician. If there was an obvious injury that would need to be treated at the hospital, he would call 911 and then notify the physician and DON. Interview on [DATE] at 6:18 AM with LVN G, she stated she had been in-serviced by the DON prior to starting her shift. The in-service covered falls, neglect, and fall protocols. She stated if a resident had a fall she would assess them before moving them to determine if there were any injuries. After rescuing the resident, she would notify the physician and see what his orders were. If neuro checks were ordered, they would continue for 72 hours. Interview on [DATE] at 9:20 AM with RN H she stated she had been in-serviced by the DON this morning. They covered abuse and neglect, fall prevention and reporting, and fall protocols. In the event of a fall, she is supposed to assess the resident for injuries and determine if they can be picked up off the floor safely. If there are obvious injuries that are not critical, she calls the physician and follows his orders. If there are critical injuries, they can call 911 prior to contacting the physician. Monitoring of neuro status is usually for 72 hours after the fall to monitor for any changes in condition. Interview on [DATE] at 9:30 AM with RN I, she stated she had been in-serviced by the DON yesterday. The in-service covered reporting falls, documentation of falls, and post-fall procedures. In the event of a resident fall she is to notify the DON and the physician once she has assessed the resident for injuries. After contacting the physician, she would follow his orders, including starting neuro checks. She reports the incident to the on-coming shift via verbal report as well as the 24-hour log. Interview on [DATE] at 9:42 AM with RN J, she was in-serviced by the DON yesterday. The In-service covered abuse, neglect, and exploitation and falls. In the event of a resident falling, she will assess them for any injuries before getting them off the floor. Un-witnessed falls and falls with injuries have to be reported to DON and physician. Review of facility Ad-Hoc QAPI meeting agenda, held on [DATE], had the Administrator; the DON; the Medical Director; the ADON; and the RDO in attendance. Review of residents assessed by the DON and ADON for changes in condition revealed all 62 residents had been assessed, with one resident found with a change in condition related to abnormal labs and the physician had been contacted. Resident was sent to the hospital for abnormal lab. An Immediate Jeopardy (IJ) was identified on [DATE] at 10:30 AM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction.

Based on interview and record review. the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #1) of five residents reviewed for quality of care. The facility failed to ensure LVN A performed an assessment of Resident #1 after she suffered two falls that resulted in in the resident developing a subdural hematoma, resulting in the resident dying on 06/05/23. An IJ was identified on 06/07/23. While the IJ was removed on 06/08/23, the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because all staff had not been trained on change in condition, timely assessments, physician notification, and treatments based on physician orders. This failure placed the resident at risk of an unreported injury and worsening of her condition. Findings included: Review of Resident #1's Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke, dementia, difficulty swallowing, and difficulty speaking. Review of Resident #1's admission MDS assessment, dated 02/28/23 revealed her BIMS score was not calculated due to her medical condition. Her Functional Status indicated she required limited assistance with her ADLs, including walking on the unit. Review of Resident #1's care plan, dated 04/22/23, revealed she was at risk for falls related to previous history of falls, alteration in bleeding related to anticoagulant use, and stroke relate to previous stroke. Review of facility's Accident & Injury report for May 2023 revealed Resident #1 had suffered two falls on 05/21/23 and was transported to the hospital on 05/22/23 with stroke like symptoms. Review of nursing progress notes revealed LVN A documented a fall on 05/21/23 at 9:30 AM and again at 9:50 AM, both resulted in no injury to the resident. There was no documentation of notification made to the physician or the resident's representative. Review of nursing progress notes revealed LVN B documented on 05/22/23 at 10:00 AM Resident #1 was demonstrating stroke like symptoms with a left facial droop, left sided gaze, and decrease in level of responsiveness. Resident was assessed by the ADON and the NP, and 911 was called. Review of Nurse Practitioner notes on 05/22/23 revealed he assessed the resident as Unlike her baseline, she is non-verbal and non-engaging. Physical examination remarkable for edema to the right face and upper lip concerning for fall. Review of EMS report revealed they transported Resident #1 on 05/22/23 at 10:55 AM to the hospital. Paramedic assessment revealed presence of facial droop and swelling to the right upper lip. Review of hospital records for Resident #1's admission revealed the ER physician documented swelling to right upper lip, laceration to the inner aspect of the lip, swelling to right cheek, and decreased responsiveness. Review of MRI results for Resident #1 revealed the resident had a hematoma to the back of her head, a left sided subdural hematoma that was expanding and causing swelling in the brain. Interview on 06/05/23 at 2:20 PM with the family member of Resident #1 stated they had not been informed of any events with Resident #1 until they were notified on 05/22/23 that the resident was being transported to the hospital with stroke like symptoms. They stated Resident #1 had swelling to her right upper lip, right cheek, and the back of her head when they saw her in the ER. The resident was admitted to the hospital with bleeding and swelling of the brain. They were told there was nothing that could be done at that point to evacuate the bleeding from the brain as she would continue to bleed. The family opted to transfer her to hospice. The family member submitted three photos to the surveyor's phone revealing swelling to the right upper lip, bruising to the inner lip, and swelling to right cheek. A text message on 06/06/23 at 11:49 AM from the family member of Resident #1 stated the resident continued to deteriorate in hospice and had passed away on the evening of 06/05/23. Interview on 06/06/23 at 1:25 PM, via phone, LVN A stated Resident #1 had suffered no injury after both falls, therefor there was not a reason to call the physician. LVN A stated she did a head-to -toe assessment and found no injury. She was sure the resident did not hit her head on the second fall because she had lowered the resident to the ground. Follow up interview on 06/06/23 at 2:25 PM via phone, LVN A again stated she had performed a head-to-toe assessment on Resident #1 after both falls and denied any injury. She denied seeing any swelling to the lip after the second fall. LVN A stated she started to do neuro checks on Resident #1 but did not follow through because she got busy. On 06/07/23 at 10:30 AM the Administrator was notified that an Immediate Jeopardy, Immediate Threat, and Substandard Quality of Care in the areas of Resident Rights and Facility Practice and Resident Behavior. The facility submitted the following acceptable Plan of Removal on 06/07/23 at 3:03 PM: On 06/07/20223 the Administrator and Director of Nurses notifies Medical Director of immediate jeopardy. On 06/07/2023 the Director of Nurses suspended Nurse who responded to the fall on 05/21/22023 but didn't report any injury and failed to conduct a thorough assessment of neurological checks to assess the resident for injuries to include head trauma. On 06/07/2023 all residents in the facility will be assessed by the Director of Nursing/Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions. orders. Starting on 06/07/2023 the Director of Nursing/Designee will initiate in-service with nurses on changes in condition, including timely assessment, to include neurological checks and physician notification, for changes of condition or serious injury following a fall to prevent serious injury, harm, impairment or death. On 6/7/2023 the RDO completed 1:1 in-service on Abuse/Neglect, investigation of any allegations, timely reporting, and appropriate interventions with Administratoor, Director of Nursing, Social Worker, and Assistant Director of Nursing. Ad-Hoc QAPI meeting was held on 06/07/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Abuse/Neglect, change in condition, fall management, and Timely reporting was reviewed on 6/7/2023 by the NHA (Nursing Home Administrator), Director of Nursing, RDO (Regional Director of Operations), and Medical Director. Starting on 6/7/2023, IDT (Interdisciplinary Team), including Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought up to Administrator for further action, if necessary. On 6/7/2023 the RNC (Regional Nurse Consultant) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly x 2 months. On 6/7/2023 RDO will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance by completing audit of ten (10) residents per week for four (4) weeks. This was initiated on 6/7/2023. Any identified concern will be addressed immediately and if trends and patters are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. Administrator will be responsible for ensuring this plan is completed on 6/7/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal continued and included interviews with staff on both day and night shifts. Interview on 06/08/23 at 6:00 AM with LVN E, she stated she had been in-serviced by the DON, covering falls, reporting of falls, and fall procedures. She stated she had to assess the resident for injuries before moving them. If the resident had any injuries she was to contact the physician and follow his orders. Interview on 06/08/23 at 6:10 AM with RN F, he stated he had been in-serviced by the DON at the beginning of his shift. The in-service covered falls, fall protocols, and notifications. In the event of a fall he would assess the resident for any injuries and notify the physician. If there was an obvious injury that would need to be treated at the hospital, he would call 911 and then notify the physician and DON. Interview on 06/08/23 at 6:18 AM with LVN G, she stated she had been in-serviced by the DON prior to starting her shift. The in-service covered falls, neglect, and fall protocols. She stated if a resident had a fall she would assess them before moving them to determine if there were any injuries. After rescuing the resident, she would notify the physician and see what his orders were. If neuro checks were ordered, they would continue for 72 hours. Interview on 06/08/23 at 9:20 AM with RN H she stated she had been in-serviced by the DON this morning. They covered abuse and neglect, fall prevention and reporting, and fall protocols. In the event of a fall, she is supposed to assess the resident for injuries and determine if they can be picked up off the floor safely. If there are obvious injuries that are not critical, she calls the physician and follows his orders. If there are critical injuries, they can call 911 prior to contacting the physician. Monitoring of neuro status is usually for 72 hours after the fall to monitor for any changes in condition. Interview on 06/08/23 at 9:30 AM with RN I, she stated she had been in-serviced by the DON yesterday. The in-service covered reporting falls, documentation of falls, and post-fall procedures. In the event of a resident fall she is to notify the DON and the physician once she has assessed the resident for injuries. After contacting the physician, she would follow his orders, including starting neuro checks. She reports the incident to the on-coming shift via verbal report as well as the 24-hour log. Interview on 06/08/23 at 9:42 AM with RN J, she was in-serviced by the DON yesterday. The In-service covered abuse, neglect, and exploitation and falls. In the event of a resident falling, she will assess them for any injuries before getting them off the floor. Un-witnessed falls and falls with injuries have to be reported to DON and physician. Review of facility Ad-Hoc QAPI meeting agenda, held on 06/07/23, had the Administrator; DON; Medical Director; ADON; and RDO in attendance. Review of residents assessed by the DON and ADON for changes in condition revealed all 62 residents had been assessed, with one resident found with a change in condition related to abnormal labs and the physician had been contacted. Resident was sent to the hospital for abnormal lab. An Immediate Jeopardy (IJ) was identified on 06/07/23 at 10:30 AM. While the IJ was removed on 06/08/23, the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction.

Based on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to provide interventions and supervision for Resident #1 from eloping from the facility on 10/15/22 and 02/16/23. Resident#1's location was unknown for 4 days. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 02/20/23. While the IJ was removed on 02/22/23, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm, and a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures put residents at risk of serious injury, hospitalization , or even death related to elopements Findings included: Record review of Resident #1's electronic Face Sheet revealed a [AGE] year-old male who admitted to the facility 04/18/22 with diagnoses that included Cerebral infarction(Stroke), Seizures, Drug induced tremor and schizoaffective disorder and Muscle Wasting and Atrophy (the shrinking of muscle or nerve tissue). Resident #1 eloped from the facility on 02/16/23. Record review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS score was 10 (scores 8 to 12 suggests moderately impaired).The resident required supervision or limited assistance with activities of daily living. Review of Resident #1's admission MDS dated [DATE] revealed a BIMS of 13 (A score of 13 to 15 suggests the resident was cognitively intact). Review of Resident #1's MDS dated [DATE] revealed a BIMS of 11, indication moderately impaired. Record review of Resident #1's care plan dated 04/18/22 reflected no information about Residents #1 cognition change. Resident #1's care plan revealed no information regarding the resident being at risk for elopement. Record review of Resident #1's progress note dated 10/15/22 at 8:40 AM revealed [Resident #1] was seen sitting on the side of the street by someone in the kitchen. Upon observation the resident was seen with a sweater and hat on stating he was wanting to go home to MS. Completed head to toe assessment. The resident does not have any skin issues and does not complain of pain.[Resident #1] stated he is ready to go home. Educated [Resident #1] on the proper procedure for signing out when wanting to go outside. [Resident #1] verbalized understanding. Will monitor the resident. Record review of Resident #1 electronic health record revealed no elopement assessment had been completed until 02/16/23 after Resident #1 had eloped from the facility. There was evidence a elopement assessment had been completed prior. Resident #1 had not sign out of the facility prior to leaving the facility on 02/16/23. Record review of an event report dated 02/16/23 for Resident #1 revealed On 2/16/23 at approximately 6:00 AM nurse identified that resident was not in his room. Nurse alerted other staff members and a search was conducted throughout the facility, facility grounds and outside areas surrounding facility. Staff unable to locate resident. Nurse notified DON and DON notified Administrator. At approximately 7:00 AM police and family were notified. Resident was last seen by nurse at 4:30 AM in his room in bed and then again at 4:45 AM heading toward the break room to go get himself a drink. Review of Resident #1's Continuity of care document dated 02/21/23 revealed Resident #1 was prescribed Depakote 250 mg tablet, once a day, with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23 at 9:28 PM. Resident #1's was prescribed Depakote 500 mg tablet, at bedtime with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23 at 9:28 PM. Resident #1 was prescribed oxcarbazepine 150 mg, once a day with the start date of 04/18/22 for seizures, last administered on 02/15/23 at 9:28 PM. Resident #1 was missing due to elopement on 02/16/23. An interview with the ADM in 02/17/23 at 1:23 PM revealed Resident #1 had eloped from the facility the morning of 02/16/23. The ADM did not know where Resident #1 may have traveled. The ADM had contacted Resident #1's family member, the family member would contact the facility if Resident #1 had contact them. The local police department was notified. The ADM was not aware of Resident #1 eloping from the facility previously. The ADM stated Resident #1 walked around the facility freely. She revealed Resident #1 did not have an elopement assessment completed. The ADM stated the MDS Coordinator or the charge nurse should have completed the elopement assessment and updated Resident #1 care plan. The ADM revealed the document incident with Resident #1 dated on 10/15/22 had not investigated as an elopement , because she was told the resident remained on the premises. An interview with the DON on 02/17/23 at 1:44 PM revealed Resident #1's care plan had not been updated to reflect the resident was at risk for elopement . Resident #1 was allowed to go in and out of the facility. Resident #1 was allowed to sit on the front covered outside of the building and was able to sit out on the courtyard. The DON stated he was aware of Resident #1 leaving the facility on 10/15/22 and being located by a kitchen staff. The DON stated his understanding was Resident #1 had not traveled outside of the premises of the facility. The had not completed an elopement assessment following the incident. He had not educated staff regarding Resident #1 being located sitting on the side of the street. Resident #1 care plan had not being updated. An interview with LVN A on 02/17/23 at 1:58 PM revealed she worked with Resident #1 since his admission to the facility. Resident #1 was allowed to go out of the facility and sit under the covered patio. Resident #1 was allowed to sit in the courtyard area of the facility. Resident #1 would usually come back inside the facility after 30 minutes. She was not aware of an elopement assessment not being completed for Resident #1. Resident #1 was not asked to sign out, each time he went outside the facility. An additional interview with the ADM on 02/20/23 at 10:11 AM revealed she had spoken with Resident #1's family member and revealed on 02/17/23 at 5:00 PM Resident #1 had traveled to the family members home and was turned away. The address of the family member home was approximately 10 miles from the facility. Review of Google maps on 02/20/23 revealed the address of the family member from the facility was 9.7 miles away and would take to 3 hours to walk. An interview with the MD on 02/21/23 at 2:23 PM revealed Resident #1 required seizure medication. Resident #1 had eloped from the facility on 02/16/23, it could be very dangerous for Resident #1 to go 4 days without his seizure medication. The MD stated he was told by the facility that Resident #1 had left the faciity on [DATE], however he was not told the resident had eloped. Record review of the weather. com website revealed the low temperature on 02/16/23 was 37 degrees. On 02/17/23 the temperature low was 29 degrees. Review of the Care plan, Comprehensive Person Centered policy dated 12/16 revealed 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change. Review of facility's Wandering, Unsafe resident policy dated 08/14 revealed The residents care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. The Administrator was notified on 02/20/23 at 12:50 PM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 02/20/23 at 12:51 PM . The facility's Plan of Removal was accepted on 02/22/23 at 9:42 AM and included: 2/17/23 All residents were assessed for elopement risk/potential by LVN MDS Coordinator and verified by Director of Nursing. All residents identified as a risk were immediately added to elopement book by Administrator and Activity Director. 2/18/23 All residents identified as an elopement risk/potential had care plans updated by the MDS coordinator and reviewed by DON. Any resident identified unsafe, and wandering will be transferred to a more secure facility. On 2/20/23 one resident was identified as an elopement risk, one on one was initiated from nursing staff and the resident was transferred on 2/20/23 to a secured facility. MD notified. Family in agreement of transfer to secured facility. 2/20/23 Chief Operating Officer in serviced Administrator, DON, and Wound Care LVN on Elopement Policy and Procedure, elopement assessment and frequency, and elopement binder and location. 2/20/23 Director of Quality, RN in serviced LVN MDS Coordinator on elopement assessments and frequency of assessment as well as updating care plans. 2/20/23 LVN, Wound Care Nurse Educated staff on Elopement Risk and assessment which were initiated at approximately 1pm for all staff as well as where to find the elopement binder. 2/20/23 LVN, Wound Care Nurse educated all staff on reporting responsibilities and who and how to report. Staff will not be allowed to take an assignment until in-services are completed. Monitoring: Administrator/DON will review all new admits, readmits and any resident with a significant change to ensure that an elopement risk assessment and care plan is completed. Administrator/MDS will review all residents quarterly to ensure an elopement risk assessment and care plan is completed. Any negative findings will be reported to monthly QAPI meeting for further recommendation and review. On 02/22/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of sampled residents health records, revealed care plans and elopement assessments were completed and or updated for all residents. Review of education dated 02/20/23 Elopement Risk and assessments signed by the facility staff Review of education dated 02/20/23 completed by the Director of Quality, educated provided to the MDS coordinator, his signature was documented. Review of the Inservice education Elopement Policy and Procedure, dated 02/20/23 reveled the ADM, DON and LVN D was in serviced on Elopement. Both the ADM and DON sign in attendance. Review of the resident roster revealed one resident was discharged to another facility on 02/20/23 after being identified at risk for elopement. An interview with facility staff members on 02/22/23 from 10:00 AM to 12:00 PM LVN A, LVN D, HSK Z, HSK Y, LVN B, CNA C, CNA F, CNA G, LVN H, CNA I, HR L and AD M. Each revealed they had been educated regarding elopements. The charge nurses would ensure each resident had an elopement assessment completed upon admission, quarterly and after a change in condition. If a resident was seen outside, the charge nurse must be notified. Each resident must sign out before leaving outside the facility if there was no or little risk for elopement. An interview with LVN D on 02/22/23 at 12:10 PM revealed she had completed education with staff regarding the elopement policy and procedure. The facility had implemented elopement binders at each nurses station and one binder at the front desk. The residents face sheet and picture was located in each binder, residents in the binders were not allowed to leave the facility without supervision. Observation on 02/20/23 of one binder at the north nurses station and one binder at the south nurses' station and one binder was located at the front desk. An interview with the DON on 02/22/23 at 10:38 AM revealed he had been in serviced regarding reporting of elopements by the ADM. The facility had implemented elopement binders at each nurses station and one binder at the front desk. The residents face sheet and picture was located in each binder, residents in the binders were not allowed to leave the facility without supervision. The facility had implemented that the charge nurses would ensure each resident had an elopement assessment completed upon admission, quarterly and after a change in condition. If a resident was seen outside, the charge nurse must be notified. Each resident must sign out before leaving outside the facility if there was no or little risk for elopement. An interview with the MDS Coordinator on 02/20/23 at 12:29 PM revealed he had been educated regarding resident care plans being updated after a change in condition. He must ensure all residents had an elopement assessment completed upon admission, quarterly and after a change in condition. An interview with the ADM on 02/22/23 at 12:45 PM revealed the facility had implemented that the charge nurses would ensure each resident had an elopement assessment completed upon admission, quarterly and after a change in condition. If a resident was seen outside, the charge nurse must be notified. Each resident must sign out before leaving outside the facility if there was no or little risk for elopement. She had been educated by the CEO regarding reporting and investigating elopements. Resident #1 had been located on 02/21/23 at 3:00 PM. Resident #1 did not want to return to the facility. On 02/22/23 at 1:10 PM the ADM was notified the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate their corrective actions.

Based on observation, interview, and record review, the facility failed to provide services to prevent neglect for 1 of 5 residents (Resident #1) reviewed for neglect. Resident #1 had an elopement attempt on 10/15/22 where he sat on the facility side street and when found he voiced that he wanted to go home and he had a decrease in his BIMS on 11/10/22 from 13 to 11. The facility failed to address the concerns, assess for elopement, or revise care plan. Resident #1 eloped from the facility on 2/16/23 and his location was unknown for 4 days during freezing temperatures with lows of 27 degrees. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 02/20/23. While the IJ was removed on 02/22/23, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm, and a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for continued neglect, undetected neglect and/or decline in feelings of safety and well-being, and psychosocial harm. Findings included: Review of the facility's undated Abuse Prevention program policy revealed the residents have the right to be from abuse, neglect. Neglect is defined as a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident #1's progress note dated 10/15/22 at 8:40 AM completed by Nurse O revealed [Resident #1] was seen sitting on the side of the street by someone in the kitchen. Upon observation the resident was seen with a sweater and hat on stating he was wanting to go home to Mississippi Completed head to toe assessment. The resident does not have any skin issues and does not complain of pain.[Resident #1] stated he is ready to go home. Educated [Resident #1] on the proper procedure for signing out when wanting to go outside. [Resident #1] verbalized understanding. Will monitor the resident. Review of an event report dated 02/16/23 for Resident #1 completed by LVN H revealed On 2/16/23 at approximately 6:00 AM nurse identified that resident was not in his room. Nurse alerted other staff members and a search was conducted throughout the facility, facility grounds and outside areas surrounding facility. Staff unable to locate resident. Nurse notified DON and DON notified Administrator. At approximately 7:00 AM police and family were notified. Resident was last seen by nurse at 4:30 AM in his room in bed and then again at 4:45 AM heading toward the break room to go get himself a drink. Record review of Resident #1's electronic Face Sheet revealed a [AGE] year-old male who admitted to the facility 04/18/22 with diagnoses that included Cerebral infarction(Stroke), Seizures, Drug induced tremor and schizoaffective disorder(a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and Muscle Wasting and Atrophy (the shrinking of muscle or nerve tissue). Resident #1 discharged from the facility on 02/16/23. Record review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS score was 10 (scores 8 to 12 suggests moderately impaired).The resident required supervision or limited assistance with activities of daily living. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS of 13 (A score of 13 to 15 suggests the resident was cognitively intact). Review of Resident #1's MDS dated [DATE] revealed a BIMS of 11, indication of being moderately impaired with cognition. Record review of Resident #1's care plan dated 04/18/22 did not address Resident #1's cognition change. Resident #1's care plan revealed no information regarding the resident being at risk for elopement. Record review of Resident #1 electronic health record revealed no elopement assessment had been completed until 02/16/23 after Resident #1 had eloped from the facility. There was no evidence an elopement assessment had been completed prior. Record review of the facility resident sign out binder on 02/17/23 revealed Resident #1 had not sign out of the facility prior to leaving the facility on 02/16/23. Record review of Resident #1's Continuity of care document dated 02/21/23 revealed Resident #1 was prescribed Depakote 250 mg tablet, once a day, with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23 at 9:28 PM. Resident #1's was prescribed Depakote 500 mg tablet, at bedtime with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23 at 9:28 PM. Resident #1 was prescribed oxcarbazepine 150 mg, once a day with the start date of 04/18/22 for seizures, last administered on 02/15/23 at 9:28 PM. Resident #1 was missing due to elopement on 02/16/23. Record review of Resident #1's February 2023 Medication Administration Record revealed Depakote 250 mg tablet, once a day, with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23. Resident #1's was prescribed Depakote 500 mg tablet, at bedtime with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23. Resident #1 was prescribed oxcarbazepine 150 mg, once a day with the start date of 04/18/22 for seizures, last administered on 02/15/23. Review of all staff education revealed Elopement training was completed on 05/29/22 and again on 02/16/23 after Resident #1 had eloped. An interview with the ADM in 02/17/23 at 1:23 PM revealed Resident #1 had eloped from the facility the morning of 02/16/23 . The ADM stated LVN H had observed Resident #1 at 4:45 am. The ADM did not know where Resident #1 may have traveled. The ADM had contacted Resident #1's family member, the family member would contact the facility if Resident #1 had contact them. The local police department was notified. The ADM was not aware of Resident #1 eloping from the facility previously. The ADM stated Resident #1 walked around the facility freely. She revealed Resident #1 did not have an elopement assessment completed. The ADM stated the MDS coordinator, or the charge nurse should have completed the elopement assessment and updated Resident #1 care plan. The ADM stated facility had not provided education to the facility staff after the 10/15/22 incident .The ADM was told the Resident #1 did not leave the facility premises and was an elopement. The ADM stated when Resident #1 had change in cognition, an elopement assessment should have been completed before allowing the resident to walk throughout the facility without supervision. An interview with the DON on 02/17/23 at 1:44 PM revealed Resident #1's care plan had not been updated to reflect the resident was at risk for elopement . Resident #1 was allowed to go in and out of the facility. Resident #1 was allowed to sit on the front covered outside of the building and was able to sit out on the courtyard. The DON stated he was aware of Resident #1 leaving the facility on 10/15/22 and being located by a kitchen staff. The DON stated his understanding was Resident #1 had not traveled outside of the premises of the facility . The had not completed an elopement assessment following the incident. He had not educated staff regarding Resident #1 being located sitting on the side of the street. Resident #1's care plan was not updated. An interview with LVN A on 02/17/23 at 1:58 PM revealed she worked with Resident #1 since his admission to the facility. Resident #1 was allowed to go out of the facility and sit under the covered patio. Resident #1 was allowed to sit in the courtyard area of the facility. Resident #1 would usually come back inside the faculty after 30 minutes. She was not aware of an elopement assessment not being completed for Resident #1. Resident #1 was not asked to sign out, each time he went outside the facility. An interview with the MDS Coordinator on 02/20/23 at 1:24 PM revealed it was his responsibility to update residents care plans. He worked with the nursing team to come up with interventions. He was responsible for ensuring the elopement assessments were completed. He stated Resident #1's care plan had not been updated since his admission. Resident #1 had a change in cognition since first arriving at the facility. However was not documented on the care plan. He stated following Resident #1 being found sitting on street on 10/15/22, no elopement assessment was completed, no care plan was updated, no staff education regarding Resident #1 change in cognition and his attempted elopement. Review of the Care plan, Comprehensive Person Centered policy dated 12/16 revealed 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change. Review of facility's Wandering, Unsafe resident policy dated 08/14 revealed The residents care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. The Administrator was notified on 02/20/23 at 12:50 PM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 02/20/23 at 12:51 PM . The facility's Plan of Removal was accepted on 02/22/23 at 9:42 am and included: 2/17/23 All residents were assessed for elopement risk/potential by LVN MDS Coordinator and reviewed by RN Quality Nurse. All residents identified as a risk were immediately added to elopement book by LVN MDS Coordinator. 2/18/23 All residents identified as an elopement risk/potential had care plans updated by LVN MDS Coordinator and reviewed by Director of Nursing. Any resident identified unsafe, and wandering will be placed on one on one supervision until transferred to a more secure facility. On 2/20/23 one resident was identified as an elopement risk, one on one was initiated from nursing staff and the resident was transferred on 2/20/23 to a secured facility. MD notified. Family in agreement of transfer to secured facility. 2/20/23 Chief Operating Officer educated Administrator, DON, and Wound Care LVN on Abuse and Neglect Policy and Procedure and responsibilities of Abuse Coordinator. 2/20/23 Chief Operating Officer educated Administrator on reporting potential allegations of Abuse and Neglect. 2/20/23 Chief Operation Officer educated Administrator on notifying Regional Director of Operations if there is any question regarding reporting Abuse and Neglect. 2/20/23 Chief Operating Officer educated Licensed Social Worker educated on reporting of incidents to Nursing, DON, or Administrator. 2/20/23 LVN, Wound care nurse educated all staff on Abuse and Neglect which was initiated at approximately 1pm for all staff as well as where to find the elopement binder accessible to all nursing staff members. 2/20/23 LVN, Wound Care nurse educated all staff on reporting responsibilities and who and how to report Abuse and Neglect as well as who the Abuse Coordinator is at Trail Lake Nursing and Rehab. 2/20/23 All residents were provided a copy of who the Abuse Coordinator is and to whom to report allegations This was provided by the Administrator and the Activity Director. If a resident is determined that a resident is an elopement risk, the resident will be placed on 1 on 1 until a more secure facility can be obtained for the resident. Family and MD will be notified. Staff will not be allowed to take an assignment until in-services are completed. Monitoring: Administrator/DON will review all new admits, readmits and any resident with a significant change to ensure that an elopement risk assessment and care plan is completed. Administrator/MDS will review all residents quarterly to ensure an elopement risk assessment and care plan is completed. Any negative findings will be reported to monthly QAPI meeting for further recommendation and review. On 02/22/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of sampled residents health records, revealed care plans and elopement assessments were completed and or updated for all residents. Review of education dated 02/20/23 Abuse and Neglect revealed the ADM was educated on notifying Regional Director of Operations if there was any question regarding reporting Abuse and Neglect presented by the Director of Operations. Review of education dated 02/20/23 completed by the CEO revealed the Administrator was educated on reporting potential allegations of Abuse and Neglect. Review of the Inservice education Abuse and Neglect Policy and Procedure, dated 02/20/23 reveled the ADM, DON was in serviced on Elopement. Both the ADM and DON sign in attendance. An interview with Resident #2 on 02/22/23 at 9:45 am revealed he had been educated on reporting neglect. Record review of the Inservice education Abuse and Neglect Policy and Procedure, dated 02/22/23 revealed staff had been educated regarding neglect. How to report abuse and neglect and to who to report. An interview with facility staff members on 02/22/23 from 10:00 AM to 12:00 PM LVN A, LVN D, HSK Z, HSK Y, LVN B, CNA C, CNA F, CNA G, LVN H, CNA I, HR L and AD M. Each revealed they had been educated regarding neglect. Each were able to articulate with examples of neglect. All allegations of neglect must be reported to the abuse coordinator. An interview with the DON on 02/22/23 at 10:38 AM revealed he had been in serviced regarding reporting of elopements by the ADM. The DON was educated regarding neglect. He explained that failing to provide residents with goods and services was neglect. All nursing staff were responsible for reporting neglect to the abuse coordinator. An interview with the MDS Coordinator on 02/20/23 at 12:29 PM revealed he had been educated regarding resident care plans being updated after a change in condition. He was required to report neglect to the ADM. An interview with the ADM on 02/22/23 at 12:45 PM revealed the facility had implemented that the charge nurses would ensure each resident had an elopement assessment completed upon admission, quarterly and after a change in condition. All staff had been educated regarding neglect and reporting. She had been educated by the CEO on investigating neglect and reporting neglect. On 02/22/23 at 1:10 PM the ADM was notified the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate their corrective actions.

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #11) of four residents reviewed for accidents and supervision. CNA G and MA F failed to transfer Resident #11 appropriately, resulting in her leg being fractured. On 05/22/20 Resident #11 was transferred twice in an unknown manner by CNA G and MA F and during the transfer hit her leg. Within 12 hours, Resident #11 developed a bruise on her shin/knee that was red, painful and swollen. She was diagnosed in the ER with a fractured right tibia (the larger of two bones in the lower leg). This failure placed residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included: Review of Resident #11's quarterly MDS assessment dated [DATE] revealed she was a [AGE] year old female admitted to the facility 06/18/13. Her active [DIAGNOSES REDACTED]. She had adequate hearing, impaired vision, clear speech and comprehension. Her BIMs score was 06, indicating severe cognitive impairment. She had no issues related to [MEDICAL CONDITIONS], verbal or physical behaviors and no rejection of care. She required two-person physical assistance for bed mobility, transfers and ADLs. She required physical assistance in her use of a wheelchair. Review of Resident #11's Care Plan dated 05/22/17 and last reviewed 06/01/20 reflected she required the use of a Hoyer/mechanical lift for transfers and was at risk for injury. Interventions included Resident #11 would be safely transferred and be free from significant injury, two staff at all times for transfers with mechanical lift; and notify charge nurse immediately of an injury/ issue. Review of Resident #11's nursing progress notes reflected on 05/23/20 Bruise -Nurse alerted to residents' room by CNA, resident c/o of pain to right leg. Resident has purple discoloration to right shin and surrounding area. Area is warm to touch and swollen. Nurse attempted ROM, unable to complete ROM due to pain. Resident yelled when nurse touched leg. Pedal pulse present. Resident has an order for [REDACTED]. Contacted DON, per DON, contact (PHY) regarding patients increased pain. Per (PHY) send resident to hospital. A note dated 05/23/20 reflected, EMS in facility, resident transferred to (hospital), DON and (RP) notified. On 05/24/20 the note reflected, Pt returned from (hospital) with right Fx Tib. Pt has soft cast on area, will have hard cast placed on Tuesday. Review of the provider investigation of the incident dated 05/28/20, revealed MA F claimed she and CNA G did a two-person physical transfer from Resident #11's electric wheelchair to manual wheelchair, and then from the manual wheelchair to her bed. She claimed no Hoyer lift was used. An interview with Resident #11 during the provider investigation revealed she said, The girl who was putting me into the chair when weighing me, bent my leg on the iron part of the chair. She did not use a lift. They just picked me up. It happened in the evening sometime the other day when they were weighing me. I do not know her name but she has a big butt. Nobody else was in the room and I did not tell anyone. An interview with the DON on 08/10/20 at 4:13 PM revealed Resident #11 sustained a fracture while she was being weighed on 05/22/20. Resident #11 did not report any pain at that time, but around five o'clock in the morning, a CNA reported to the nurse that Resident #11 had a bruise on her leg. The nurse went in, asked Resident #11 what happened, and resident said she did not know and must have bumped it on something. On the next shift, Resident #11 was complaining of pain and the PHY ordered an x-ray on the 6:00 AM -2:00 PM shift. When the 2:00 PM-10:00 PM shift came in, Resident #11 reported increased pain to her leg. At that point, the DON was notified and the PHY sent Resident #11 to the hospital. The facility was notified that she had a fracture. When the facility did their investigation, it was discovered CNA G and MA F did a physical two-person transfer from Resident #11's electric wheelchair to a manual wheelchair because they claimed her sling was bunched up underneath her and not accessible to hook up to the Hoyer lift. After they got Resident #11 weight, they claimed they then did a two-person transfer to the resident's bed where she was laid down for the night. The DON said the resident denied falling. She said Resident #11 was a two person transfer for a Hoyer lift. The DON said if staff could not use the Hoyer lift for some reason, then they could do a two-person physical lift. Observation and interview with Resident #11 on 08/10/20 at 5:31 PM revealed she was upright in bed and was eating her dinner. Resident #11 stated she broke her leg because a girl hit it on the scale when she was weighing me. Resident #11 said the scale was brought to her doorway and she was in her electric chair. Resident #11 did not remember if she had a sling under her. She said the staff did not use the sling or the Hoyer lift but the one girl just stood her up on her own and put her on the scale and made her stand there. Resident #11 said she could not stand on her own. She said the girl took her off the scale and when she did, she hit Resident #11's leg on the metal part, then she put her in her chair. She said it hurt really bad and she told the CNA, but she did not respond. She said that CNA no longer worked at the facility. Interview with Resident #11's LAR on 08/14/20 at 4:25 PM revealed he received a phone call from a charge nurse on 05/23/20 who reported Resident #11 was being sent to the hospital. He said the hospital diagnosed her with a broken tibia and she had to wear a custom fitted soft brace for 20 weeks. He said it took several days to find out what had happened. He was told by the ADM they were completing an investigation. The LAR claimed no one talked to Resident #11 about the incident. He said Resident #11 had told him that only one aide was working with her during the incident, CNA G. She said MA F was weighing another female resident at the time. The LAR said he was under the impression that when Resident #11 was weighed, she needed two staff because she was non-ambulatory. The LAR said Resident #11 told him CNA G used a Hoyer lift to put her in the bed and when she did, the lift swung and her leg hit the metal part of the machine. He said when he had seen the staff use the lift before, they had always used two people to avoid any swinging motion of her legs while in the sling. He said Resident #11 told him CNA G hooked the sling only on the back part and had her arms under her like she was guiding her into the bed but there was no one there to check her legs. He reported the ADM submitted a different report to the state that did not include that information. He stated the incident was not handled well at all. Interview with ADON A on 08/10/20 at 5:50 PM revealed if a CNA could not perform a mechanical lift transfer, they were supposed to notify the charge nurse. At that point, if there was an issue, the nurse could contact the therapy department. ADON A said under no circumstances would CNAs perform a physical lift on their own. She stated Resident #11 required a Hoyer lift. ADON A said Resident #11 had contractures and her legs could not bend easily so they stretched out. An interview with MA F on 08/14/20 at 2:28 PM revealed she came to work an extra shift on the day of the incident to help get residents' weights that were missing. She said she asked CNA G to help her with Resident #11's weight and transfer. She said it was around eight o'clock at night because residents were being laid down for bedtime and she wanted to get Resident #11's weight before that happened. She said there was a portable scale she used, and it was in the hallway. She said Resident #11 required a two-person Hoyer lift. MA F said she noticed Resident #11's Hoyer sling and handles were all the way underneath her, like it had bunched up, so they could not use the Hoyer lift. She said they would have had to pick her up manually and readjust the sling in order to be able to use it, which they did not do. MA F said she and CNA G had to transfer her as a two-person transfer to the manual wheelchair. She said Resident #11 could not stand on her own or walk, could not bear weight and had no function of her legs. MA F then stated when they got her up to weigh her, they were able to get the sling from the electric wheelchair and place it under her on the manual wheelchair. They then weighed her and used the Hoyer lift to lay her in bed for the night. She said the next morning, she got a phone call from the DON who indicated Resident #11 said she and CNA G had hurt her leg while transferring her and hit her leg on the weight bench. MA F said Resident #11 did not indicate she had been injured during the weight/transfer/Hoyer lift and she felt the resident was the type of person who would say something if she was hurt. CNA G said she came in for her next shift, she asked Resident #11 about the injury and Resident #11 said CNA G had picked her up and broken her leg. Interview with CNA G on 08/14/20 at 5:49 PM revealed she was not assigned to work with Resident #11 the day of the incident, but the medication aide needed help with her weight, and asked her for assistance. She initially said Resident #11's Hoyer lift was not working, then she said Resident #11's sling for the Hoyer had slid down underneath her. She said they did a two-person transfer as a result. Then MA F got her weight and from the scale, they laid her down in bed not using the Hoyer lift. She said Resident #11 was weighed right outside the door of her room, in the hall. She said Resident #11 never said her leg was hurting, but she said her bottom was hurting. She said, We never used the Hoyer lift at all. CNA G was then told that the statements given by her and MA F during the incident conflicted with her current statement. At that point, she then said it was so long ago, maybe they did use the Hoyer lift for the second transfer of Resident #11 from the manual wheelchair to her bed, she could not remember for sure. An interview with the ADM on 08/10/20 at 5:27 PM revealed she obtained witness statements from CNA G and MA F and they told her they did a two-person physical transfer with Resident #11 from her electric wheelchair into a manual wheelchair used for weights. They told her Resident #11's sling was underneath her and they could not access it and that was why they did a two-person transfer. The ADM said that was wrong and they should not have done it. The ADM said the two aides then told her once Resident #11 was in the manual wheelchair , they took her to the back of the facility to weigh her, then brought her back to her room where they both did a second two-person physical transfer from the manual wheelchair to the bed. She said both aides indicated they did to use the Hoyer lift for either transfer. She said CNA G quit shortly after the incident to work at another facility. Review of the facility's policy titled Safe Lifting and Movement of Residents revised February 2014 reflected, In order to protect the safety and well-being of staff and residents, and to promote care, the facility uses the appropriate techniques and devices to lift and move residents .2. Manual lifting of residents shall be eliminated when feasible; . Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary .8. Enough slings, in the sizes required by the residents in need, will be made available at all times

Based on interview and record review, the facility failed to have evidence that all alleged violations involving abuse, neglect, exploitation or mistreatment were thoroughly investigated, and failed to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation was in progress for one (Resident #2), of twelve residents reviewed for abuse. 1. The former Administrator, who was the Abuse Prevention Coordinator, and the ADON, failed to thoroughly investigate an allegation that CNA B slapped Resident #2. 2. The former Administrator failed to protect the residents when he did not prevent CNA B having further access to residents upon learning of the allegation, by allowing her to continue to perform her normal duties. An Immediate Jeopardy was identified on 12/14/16. While the IJ was removed on 12/16/16, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures had the potential to place all 83 residents who resided at the facility at risk for further abuse. Findings included: 1. Review of the Face Sheet dated 12/14/16 for Resident #3 reflected she was a [AGE] year-old female, readmitted on [DATE]. She had [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] for Resident #3 reflected she had minimal difficulty hearing with a hearing aid, and was able to be understood by others. Her vision was impaired to the extent she could see large print in written material with glasses. She was severely cognitively impaired. Resident #3 exhibited fluctuating inattention, disorganized thinking, and altered level of consciousness. Resident #3 required extensive one-person assistance for transfers, dressing, and toilet use. An interview with Resident #3 on 12/14/16 at 1:46 PM revealed she had a problem with CNA B and complained one time before, and went to the ADON on the morning of the interview to tell her she didn't get along with CNA B. She said CNA B was real cross and slammed the curtains aside and always acted like she was mad. Resident #3 said CNA B sometimes wanted her to go to bed at 6:30 PM, and she could not go to sleep that early. She went along with it, because she didn't want to argue, but the CNA also objected to her keeping her light on at night to read. She thought the CNA worked in the evenings, and she was still working, because she saw her recently. She said CNA B was never rough with her, but she's just got attitude. She said she did think she heard the CNA slap her roommate (Resident #2) once, and her roommate cried out, so she told LVN C about it. Resident #3 was forgetful in her interview, repeated some details, was not able to recall specific dates, and estimated time frames with questionable accuracy. She was able to recall first names of staff, including that of CNA B, and staff she had spoken with about her concerns. Review of Resident #3's nursing notes for the months of November and December of 2016 revealed no documentation of the allegation. 2. Review of the Face Sheet dated 12/14/16 for Resident #2 reflected she was a [AGE] year-old female, admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] for Resident #2 reflected she was able to understand others without a hearing aid, and was able to be understood by others. Her vision was highly impaired with glasses. She had moderate cognitive impairment. Review of Resident #2's nursing notes for the months of November and December of 2016 revealed no documentation of a concern or potential abuse allegation. Observation and attempt to interview Resident #2 on 12/14/16 at 1:46 PM revealed she was in her bed, in a nightgown. Her affect was flat, and when addressed, she looked away and did not speak. The resident was unable to be interviewed. 3. An interview on 12/14/16 at 3:10 PM with CNA B revealed there were two residents she got the most complaints from: Resident #1 and Resident #3. She said Resident #1 used to complain a lot, but she stopped. CNA B said she just quit trying to do things, because of her (Resident #1's) rights, and if the resident fell because she did not have an alarm on, that's the way it is. CNA B said she told the resident she did not care what the first shift let the resident do, she had to use her call light. However, the resident did not want to. She said the facility did not let her do her job with the resident, and the resident did not use her alarms, and did what she pleased. CNA B said Resident #3 told someone she (CNA B) hit her roommate, and the ADON told her about the allegation about a week or week and a half ago, she thought. At that time she was told to stay out of the resident's room, but they did not suspend her. She said because there were only two to three people to work the hall, it was too hard, and she had to go into the room to do her job. She always took someone else in with her. She said she felt like she couldn't catch a break and people complained about her not smiling. She said it was not realistic to expect her to smile all the time. She said the CNAs were stressed and could not do a good enough job, and she had worked three weeks straight and was tired. She denied having any physical altercations with any residents. An interview on 12/14/16 at 4:43 PM with the ADON revealed when asked about the allegation Resident #3 had made, she said the resident just told her about the allegation of slapping on the morning of 12/14/16. When informed that CNA B stated she was told of the allegation a week to a week and a half ago, the ADON confirmed it was earlier that she was informed of the allegation by LVN C. She did not know it needed to be reported to the state. She said she talked to the Administrator about it, and he told her to go talk to the resident. She checked on the resident, and did not specifically ask her about the allegation, but rather asked her if she could tell me about any bad things going on. The resident said she was fine, just tired, and did not mention the alleged slap. She said all abuse or neglect allegations went straight to the Administrator. She said the Administrator did not believe CNA B would do something like that, and the resident was probably just thinking about something else or dreaming. She confirmed CNA B was not removed from duties which required resident contact. She thought she told LVN C to document the allegation, but if the surveyor did not see any, there was none, and it didn't get done. She said documentation was a problem in the facility. She had no documentation of the allegation or steps taken afterwards. An interview on 12/14/16 at 5:47 PM with LVN C revealed Resident #3 had told her she didn't like a particular CNA very well. Resident #3 could not remember the CNA's name, but it was the CNA who put her to bed. Resident #3 later said she thought the CNA had slapped her roommate, and her roommate yelled out. The resident was not able to say when it happened. LVN C said she immediately informed the former Administrator and the ADON, and someone went to talk to Resident #3 right away. She said she knew it was being investigated. She said the resident never made an allegation like that before, and had not talked about it since. LVN C did not tell the current, interim Administrator after the former Administrator left the facility (12/08/16 was his last day worked), and thought it had been taken care of. An interview on 12/14/16 at 5:50 PM with the current, interim Administrator revealed he was not aware of the allegation made by Resident #3. He said his expectation of his staff was to call him if they called in anything to the state, or if there was any gray area. When the allegation was described to him, he said it sounded like something that should have been reported. He said the Administrator was ultimately responsible for investigations of abuse or neglect allegations. The facility's current Operational Policy and Procedure Manual for Long-Term Care Resident Behavior and Facility Practices Manual, dated 2001 and provided on 12/14/16 by the DON, reflected: 3. The person conducting the investigation will, at a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident as medically appropriate; f. Interview the resident's attending physician .; g. Interview staff (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care and services, and; j. review all events leading up to the alleged incident .5. Witness reports will be obtained in writing .8. Employees of the facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. 11. The results of the investigation will be recorded on approved documentation forms. .1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse .be reported to the facility, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The state licensing/certification agency responsible for surveying/licensing the facility . . An IJ was identified on 12/14/16 at 6:24 PM, and the DON, MDS F, and the ADON were informed. A Plan of Removal was requested at that time The Plan of Removal was accepted on 12/15/16 at 11:00 AM, and reflected the following steps taken to remove immediacy: · In-service training with return demonstration for all staff on the process of reporting and investigating allegations of abuse or neglect. · Continued quarterly Abuse and Neglect in-services for all staff. · Facility Abuse and Neglect protocol was initiated for the previously unreported allegation (including terminating the alleged perpetrator, which was not written into the Plan of Removal.) · All residents were given satisfaction surveys. Review of an employee counseling form dated 12/14/16 for CNA B reflected Employee has several allegations of abuse verbal, Employee suspended pending investigation, and in the employee statement area, I quit! It was noted on the form that the CNA refused to sign the form. Review of an employment separation form dated 12/14/16 for CNA B reflected, Employee quit after being informed that she was suspended pending investigation due to allegations of abuse. An interview on 12/15/16 at 8:05 AM with the current, interim Administrator and the DON revealed CNA B was terminated on the previous night (12/14/16). The DON said she only heard about the slapping allegation after the fact, when LVN C told her about the incident that had occurred before she started working at the facility. The DON said when she asked the ADON about it, she was assured it had been taken care of, but she did not pursue the matter to see if it had been properly investigated and reported. An interview on 12/15/16 at 9:39 AM with the former DON revealed she did not have any knowledge of the allegation made by Resident #3, and said her last day was 11/18/16. She said it must have happened after she left the facility. An interview on 12/15/16 at 10:03 AM with the former Administrator revealed he remembered the allegation, and asked the ADON to do an assessment of Resident #2. She completed an assessment and talked with Resident #3. He said he talked with Resident #3 as well, and asked general questions about her care. He asked her if there was something he needed to know, anything bad, and the resident did not say anything about the allegation. He said he did not think it met the qualifications for abuse because he went to validate it that morning, and it was not validated. He said he gave Resident #3 several opportunities to tell him, and she did not. He did not suspend CNA B after the allegation was made. He made no documentation of the allegation or steps taken afterward. An interview on 12/15/16 at 12:46 PM with the Medical Director revealed he did not know how the IJ occurred, because the former Administrator and former DON were usually good at reporting everything to him. He was not made aware of the allegation by Resident #3. An interview on 12/15/16 at 3:05 PM with the ADON revealed she felt the problem was caused by a communication breakdown between administration and nursing. She felt she should not have assumed the former Administrator would take care of it. She did not know what she could have done differently in the investigation, and when she interviewed Resident #3, the resident was given the opportunity to say she heard a slap. An interview on 12/15/16 at 5:20 PM with the current, interim Administrator revealed he reiterated his previously stated expectations of his staff, and explained he would expect the new Administrator, who had been hired but had not yet started, to call him about everything, until he felt comfortable with their judgment. He said he would be further stressing transparency in the facility, and was making sure any staff knew they could call his number if they felt other staff was trying to hide anything or not doing what they were supposed to be doing. He stated they would be spot-checking Abuse and Neglect knowledge, for the future, to make sure staff knew it. An interview on 12/15/16 at 5:40 PM with the DON revealed she felt the former DON and former Administrator did not pay as much attention to detail as they should have, and they did not communicate or follow up as they should have. She acknowledged the interviews could have been stronger, and it was possible they did not want to have to report the allegation; but she was not at the facility at that time, so she did not know. Review of an incident report by the ADON dated 12/14/16, and provided on 12/15/16 by the DON reflected: approximately three weeks ago, it was reported that resident had heard her roommate being hit. It was reported to ADON, and she reported it the administrator. Administrator informed ADON to go in, and talk to resident. After lunch, ADON and CNA went in, and started speaking to resident. When ADON asked how she was doing resident stated she was OK. The resident was asked if anything bad had happened during the night, resident stated that she was tired and couldn't sleep last night, but she was OK and nothing had happened. On 12/16/16, the DON provided sign-in sheets for in-services she provided staff from the evening of 12/14/16 through the morning of 12/16/16 on Abuse and Neglect identification, reporting and investigation. The in-service consisted of written and spoken material. The staff was informed to report to the Administrator, and if the Administrator was not available, to report to the next person in the chain-of-command (which was clarified.) The staff was instructed to call the current, interim Administrator even after the new Administrator arrived, if they ever felt anything was not being dealt with. It was stressed that all suspicions, whether the employee was sure it was abuse or not, were to be reported immediately. They were informed the responsibility for investigating was on the Administrator or his/her designee, and if it was an employee who was alleged to have committed abuse, they were to be suspended immediately for the duration of the investigation. Review of a list, and a letter, provided by the DON via email on 12/16/16 reflected all staff were in-serviced except for five who were on vacation or medical leave. One PRN staff member would require a language interpreter and would be in-serviced on 12/20/16 before they worked a shift; and seven PRN staff, who had not yet returned her call, were left messages they would not be able to work until after they were in-serviced. On 12/16/16 at 8:55 AM, the current, interim Administrator stated if the PRN employees were not able to be contacted for in-servicing, they would be removed from the PRN list because some of them had not been in the facility for a long time. On 12/15/16 and 12/16/16, 19 staff were interviewed by the surveyor. They were asked standard Abuse and Neglect policy and protocol questions, about types and signs of abuse, signs of employee burnout, monitoring staff-employee interactions, handling combative residents, what types of observations they would report as possible abuse concerns, to whom they would report, what they would do if they reported to the Abuse Prevention Coordinator of their designee, and the report was not acted on. In addition, they were asked questions about how they would know if something they reported to the Abuse Prevention Coordinator or their designee and the allegation was handled properly, and they were asked to describe the Abuse and Neglect training they just received. All staff were able to correctly answer questions. The following staff members were interviewed from the 6:00 AM to 2:00 PM shift: · On 12/15/16 at 10:37 AM, LVN H · On 12/15/16at 10:46 AM, RA I · On 12/15/16 at 11:14 AM, COTA J · On 12/15/16 at 11:21 AM, CNA K · On 12/15/16 at 11:32 AM, CNA L · On 12/15/16 at 11:41 AM, RN M · On 12/15/16 at 2:12 PM LVN C The following staff members were interviewed from the 2:00 PM to 10:00 PM shift: · On 12/15/16 at 2:01 PM, CNA N · On 12/15/16at 2:30 PM, CNA O · On 12/15/16 at 2:40 PM, LVN P · On 12/15/16 at 2:53 PM, CNA Q · On 12/15/16 at 3:22 PM, CNA R · On 12/15/16 at 3:47 PM,LVN S The following staff members were interviewed from the 10:00 PM to 6:00 AM shift: · On 12/15/16 at 4:00 PM, LVN T · On 12/16/16at 5:55 AM, MA U · On 12/16/16 at 6:05 AM, CNA V · On 12/16/16 at 6:15 AM, LVN W · On 12/16/16 at 6:22 AM, LVN X On 12/16/16 at 6:39 AM, Hskp. Y, who worked various shifts, was interviewed. Review of resident satisfaction surveys dated 12/14/16 and 12/15/16 reflected 80 residents were surveyed. Included in the surveys were comments by Resident #1 (The CNA with the white headband (CNA B) puts me to bed when I do not want to.) and Resident #3 (I complained about (CNA B), we just clash, acts like she is mad all the time. Fusses because I keep my light on to read. I never have any trouble with anyone else.) Review of DADS Provider Self-Reporting of Incidents documentation reflected the allegation made by Resident #1 on 12/14/16, and the previously unreported allegation made by Resident #3 were both reported to DADS on 12/15/16. An interview on 12/14/16 at 2:32 PM with LVN A revealed the CNAs shifted to work on the other halls periodically, so they could work in any part of the building. On 12/16/16 at 9:19 AM the current, interim Administrator and the DON were informed the IJ was lifted. Review of the CMS form 672 provided on 12/16/16 by MDS F reflected a census of 83 residents.

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (Resident #2) of twelve residents reviewed for abuse. 1. The former Administrator failed to thoroughly investigate an allegation of physical abuse. 2. The former Administrator failed to protect the residents when he did not remove CNA B from her duties upon learning of the allegation. 3. The former Administrator and the ADON failed to report the allegation of abuse to DADS. 4. The former Administrator failed to implement the facility's Abuse and Neglect Policy and Procedure. 5. The ADON failed to follow up on the status of the allegation. An Immediate Jeopardy was identified on 12/14/16. While the IJ was removed on 12/16/16, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures had the potential to place all 83 residents who resided at the facility at risk for further abuse. Findings included: The facility's current Operational Policy and Procedure Manual for Long-Term Care Resident Behavior and Facility Practices Manual, dated 2001 and provided on 12/14/16 by the DON, reflected: .2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. .1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact, or will be suspended until the findings of the investigation have been reviewed by the Administrator. 2. Within five (5) working days, the facility will give the resident, the resident's representative (sponsor), the ombudsman, state survey and certification agencies, accused individuals, etc., a written report of the findings of the investigation And summary of corrective action taken to prevent such incident from recurring. .The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures.8. Employees of the facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. 11. The results of the investigation will be recorded on approved documentation forms. 1. Review of the Face Sheet dated 12/14/16 for Resident #3 reflected she was a [AGE] year-old female, readmitted on [DATE]. She had [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] for Resident #3 reflected she had minimal difficulty hearing with a hearing aid, and was able to be understood by others. Her vision was impaired to the extent she could see large print in written material with glasses. She was severely cognitively impaired. Resident #3 exhibited fluctuating inattention, disorganized thinking, and altered level of consciousness. Resident #3 required extensive one-person assistance for transfers, dressing, and toilet use. An interview with Resident #3 on 12/14/16 at 1:46 PM revealed she had a problem with CNA B and complained one time before, and went to the ADON on the morning of the interview to tell her she didn't get along with CNA B. She said CNA B was real cross and slammed the curtains aside and always acted like she was mad. Resident #3 said CNA B sometimes wanted her to go to bed at 6:30 PM, and she could not go to sleep that early. She went along with it, because she didn't want to argue, but the CNA also objected to her keeping her light on at night to read. She thought the CNA worked in the evenings, and she was still working, because she saw her recently. She said CNA B was never rough with her, but she's just got attitude. She said she did think she heard the CNA slap her roommate (Resident #2) once, and her roommate cried out, so she told LVN C about it. Resident #3 was forgetful in her interview, repeated some details, was not able to recall specific dates, and estimated time frames with questionable accuracy. She was able to recall some first names of staff, including that of CNA B, and staff she had spoken with about her concerns. Review of Resident #3's nursing notes for the months of November and December of 2016 revealed no documentation of the allegation. 2. Review of the Face Sheet dated 12/14/16 for Resident #2 reflected she was a [AGE] year-old female, admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] for Resident #2 reflected she was able to understand others without a hearing aid, and was able to be understood by others. Her vision was highly impaired with glasses. She had moderate cognitive impairment. Review of Resident #2's nursing notes for the months of November and December of 2016 revealed no documentation of a concern or potential abuse allegation. Observation and attempt to interview Resident #2 on 12/14/16 at 1:46 PM revealed she was in her bed, in a nightgown. Her affect was flat, and when addressed, she looked away and did not speak. The resident was unable to be interviewed. 3. An interview on 12/14/16 at 3:10 PM with CNA B revealed there were two residents she got the most complaints from: Resident #1 and Resident #3. She said Resident #1 used to complain a lot, but she stopped. CNA B said she just quit trying to do things, because of her (Resident #1's) rights, and if the resident fell because she did not have an alarm on, that's the way it is. CNA B said she told the resident she did not care what the first shift let the resident do, she had to use her call light. However, the resident did not want to. She said the facility did not let her do her job with the resident, and the resident did not use her alarms, and did what she pleased. CNA B said Resident #3 told someone she (CNA B) hit her roommate, and the ADON told her about the allegation about a week or week and a half ago, she thought. At that time she was told to stay out of the resident's room, but they did not suspend her. She said because there were only two to three people to work the hall, it was too hard, and she had to go into the room to do her job. She always took someone else in with her. She said she felt like she couldn't catch a break and people complained about her not smiling. She said it was not realistic to expect her to smile all the time. She said the CNAs were stressed and could not do a good enough job, and she had worked three weeks straight and was tired. She denied having any physical altercations with any residents. An interview on 12/14/16 at 4:43 PM with the ADON revealed when asked about the allegation Resident #3 had made, she said the resident just told her about the allegation of slapping on the morning of 12/14/16. When informed that CNA B stated she was told of the allegation a week to a week and a half ago, the ADON confirmed it was earlier that she was informed of the allegation by LVN C. She did not know it needed to be reported to the state. She said she talked to the Administrator about it, and he told her to go talk to the resident. She checked on the resident, and did not specifically ask her about the allegation, but rather asked her if she could tell me about any bad things going on. The resident said she was fine, just tired, and did not mention the alleged slap. She said all abuse or neglect allegations went straight to the Administrator. She said the Administrator did not believe CNA B would do something like that, and the resident was probably just thinking about something else or dreaming. She confirmed CNA B was not removed from duties which required resident contact. She thought she told LVN C to document the allegation, but if the surveyor did not see any, there was none, and it didn't get done. She said documentation was a problem in the facility. She had no documentation of the allegation or steps taken afterwards. An interview on 12/14/16 at 5:47 PM with LVN C revealed Resident #3 had told her she didn't like a particular CNA very well. Resident #3 could not remember the CNA's name, but it was the CNA who put her to bed. Resident #3 later said she thought the CNA had slapped her roommate, and her roommate yelled out. The resident was not able to say when it happened. LVN C said she immediately informed the former Administrator and the ADON, and someone went to talk to Resident #3 right away. She said she knew it was being investigated. She said the resident never made an allegation like that before, and had not talked about it since. LVN C did not tell the current, interim Administrator after the former Administrator left the facility (12/08/16 was his last day worked), and thought it had been taken care of. An interview on 12/14/16 at 5:50 PM with the current, interim Administrator revealed he was not aware of the allegation made by Resident #3. He said his expectation of his staff was to call him if they called in anything to the state, or if there was any gray area. When the allegation was described to him, he said it sounded like something that should have been reported. He said the Administrator was ultimately responsible for investigations of abuse or neglect allegations. An IJ was identified on 12/14/16 at 6:24 PM, and the DON, MDS F, and the ADON were informed. A Plan of Removal was requested at that time. The Plan of Removal was accepted on 12/15/16 at 11:00 AM, and reflected the following steps taken to remove immediacy: · In-service training with return demonstration for all staff on the process of reporting and investigating allegations of abuse or neglect. · Continued quarterly Abuse and Neglect in-services for all staff. · Facility Abuse and Neglect protocol was initiated for the previously unreported allegation (including terminating the alleged perpetrator, which was not written into the Plan of Removal.) · All residents were given satisfaction surveys. Review of an employee counseling form dated 12/14/16 for CNA B reflected Employee has several allegations of abuse verbal, Employee suspended pending investigation, and in the employee statement area, I quit! It was noted on the form that the CNA refused to sign the form. Review of an employment separation form dated 12/14/16 for CNA B reflected, Employee quit after being informed that she was suspended pending investigation due to allegations of abuse. An interview on 12/15/16 at 8:05 AM with the current, interim Administrator and the DON revealed CNA B was terminated on the previous night. The DON said she only heard about the slapping allegation after the fact, when LVN C told her about the incident that occurred before she started working at the facility. The DON said when she asked the ADON about it, she was assured it had been taken care of, but she did not pursue the matter to see if it had been properly investigated and reported. An interview on 12/15/16 at 9:39 AM with the former DON revealed she did not have any knowledge of the allegation made by Resident #3, and said her last day was 11/18/16. She said it must have happened after she left the facility. An interview on 12/15/16 at 10:03 AM with the former Administrator revealed he remembered the allegation, and asked the ADON to do an assessment of Resident #2. She completed an assessment and talked with Resident #3. He said he talked with Resident #3 as well, and asked general questions about her care. He asked her if there was something he needed to know, anything bad, and the resident did not say anything about the allegation. He said he did not think it met the qualifications for abuse because he went to validate it that morning, and it was not validated. He said he gave Resident #3 several opportunities to tell him, and she did not. He did not suspend CNA B upon learning of the allegation, and she continued to work on the hall where Resident #2 lived. He did not document the allegation, or steps taken after learning of it. An interview on 12/15/16 at 12:46 PM with the Medical Director revealed he did not know how the IJ occurred, because the former Administrator and the former DON were usually good at reporting everything to him. He was not made aware of the allegation by Resident #3. An interview on 12/15/16 at 3:05 PM with the ADON revealed she felt the problem was caused by a communication breakdown between administration and nursing. She felt she should not have assumed the former Administrator would take care of it. She did not know what she could have done differently in the investigation, and when she interviewed Resident #3, the resident was given the opportunity to say she heard a slap. An interview on 12/15/16 at 5:20 PM with the current, interim Administrator revealed he reiterated his previously stated expectations of his staff, and explained he would expect the new Administrator, who had been hired, but not yet started, to call him about everything, until he felt comfortable with their judgment. He said he would be further stressing transparency in the facility, and was making sure any staff knew they could call his number if they felt other staff was trying to hide anything or not doing what they were supposed to be doing. He stated they would be spot-checking Abuse and Neglect knowledge, for the future, to make sure staff knew it. An interview on 12/15/16 at 5:40 PM with the DON revealed she felt the former DON and former Administrator did not pay as much attention to detail as they should have, and they did not communicate or follow up as they should have. She acknowledged the interviews could have been stronger, and it was possible they did not want to have to report the allegation; but she was not at the facility at that time, so she did not know. Review of an incident report by the ADON dated 12/14/16, and provided on 12/15/16 by the DON reflected: approximately three weeks ago, it was reported that resident had heard her roommate being hit. It was reported to ADON, and she reported it the administrator. Administrator informed ADON to go in, and talk to resident. After lunch, ADON and CNA went in, and started speaking to resident. When ADON asked how she was doing resident stated she was OK. The resident was asked if anything bad had happened during the night, resident stated that she was tired and couldn't sleep last night, but she was OK and nothing had happened. On 12/16/16, the DON provided sign-in sheets for in-services she provided staff from the evening of 12/14/16 through the morning of 12/16/16 on Abuse and Neglect identification, reporting and investigation. The in-service consisted of written and spoken material. The staff was informed to report to the Administrator, and if the Administrator was not available, to report to the next person in the chain-of-command (which was clarified.) The staff was instructed to call the current, interim Administrator even after the new Administrator arrived, if they ever felt anything was not being dealt with. It was stressed that all suspicions, whether the employee was sure it was abuse or not, were to be reported immediately. They were informed the responsibility for investigating was on the Administrator or his/her designee, and if it was an employee who was alleged to have committed abuse, they were to be suspended immediately for the duration of the investigation. Review of a list, and a letter, provided by the DON via email on 12/16/16 reflected all staff were in-serviced except for five who were on vacation or medical leave. One PRN staff member would require a language interpreter and would be in-serviced on 12/20/16 before they worked a shift; and seven PRN staff, who had not yet returned her call, were left messages they would not be able to work until after they were in-serviced. On 12/16/16 at 8:55 AM, the current, interim Administrator stated if the PRN employees were not able to be contacted for in-servicing, they would be removed from the PRN list because some of them had not been in the facility for a long time. On 12/15/16 and 12/16/16, 19 staff were interviewed by the surveyor. They were asked standard Abuse and Neglect policy and protocol questions, about types and signs of abuse, signs of employee burnout, monitoring staff-employee interactions, handling combative residents, what types of observations they would report as possible abuse concerns, to whom they would report, what they would do if they reported to the Abuse Prevention Coordinator of their designee, and the report was not acted on. In addition, they were asked questions about how they would know if something they reported to the Abuse Prevention Coordinator or their designee and the allegation was handled properly, and they were asked to describe the Abuse and Neglect training they just received. All staff were able to correctly answer questions. The following staff members were interviewed from the 6:00 AM to 2:00 PM shift: · On 12/15/16 at 10:37 AM, LVN H · On 12/15/16at 10:46 AM, RA I · On 12/15/16 at 11:14 AM, COTA J · On 12/15/16 at 11:21 AM, CNA K · On 12/15/16 at 11:32 AM, CNA L · On 12/15/16 at 11:41 AM, RN M · On 12/15/16 at 2:12 PM LVN C The following staff members were interviewed from the 2:00 PM to 10:00 PM shift: · On 12/15/16 at 2:01 PM, CNA N · On 12/15/16at 2:30 PM, CNA O · On 12/15/16 at 2:40 PM, LVN P · On 12/15/16 at 2:53 PM, CNA Q · On 12/15/16 at 3:22 PM, CNA R · On 12/15/16 at 3:47 PM,LVN S The following staff members were interviewed from the 10:00 PM to 6:00 AM shift: · On 12/15/16 at 4:00 PM, LVN T · On 12/16/16at 5:55 AM, MA U · On 12/16/16 at 6:05 AM, CNA V · On 12/16/16 at 6:15 AM, LVN W · On 12/16/16 at 6:22 AM, LVN X On 12/16/16 at 6:39 AM, Hskp. Y, who worked various shifts, was interviewed. Review of resident satisfaction surveys dated 12/14/16 and 12/15/16 reflected 80 residents were surveyed. Included in the surveys were comments by Resident #1 (The CNA with the white headband (CNA B) puts me to bed when I do not want to.) and Resident #3 (I complained about (CNA B), we just clash, acts like she is mad all the time. Fusses because I keep my light on to read. I never have any trouble with anyone else.) Review of DADS Provider Self-Reporting of Incidents documentation reflected the allegation made by Resident #1 on 12/14/16, and the previously unreported allegation made by Resident #3 were both reported to DADS on 12/15/16. On 12/16/16 at 9:19 AM the current, interim Administrator and the DON were informed the IJ was lifted. Review of the CMS form 672 provided on 12/16/16 by MDS F reflected a census of 83 residents.

Based on interview and record review, it was determined the facility failed implement written policies and procedures for investigating and reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property for one (Resident #2) of twelve residents reviewed for abuse. 1. The former Administrator, who was the Abuse Prevention Coordinator, failed to investigate and report to DADS an allegation that CNA B slapped Resident #2. 2. The former Administrator failed to immediately suspend CNA B pending investigation per facility policy, when she was accused of slapping Resident #2. An Immediate Jeopardy was identified on 12/14/16. While the IJ was removed on 12/16/16, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and a scope of widespread because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures had the potential to place all 83 residents who resided at the facility at risk for further abuse. Findings included: The facility's current Operational Policy and Procedure Manual for Long-Term Care Resident Behavior and Facility Practices Manual, dated 2001 and provided on 12/14/16 by the DON, reflected: 3. The person conducting the investigation will, at a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident as medically appropriate; f. Interview the resident's attending physician .; g. Interview staff (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care and services, and; j. review all events leading up to the alleged incident .5. Witness reports will be obtained in writing .8. Employees of the facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. 11. The results of the investigation will be recorded on approved documentation forms. .1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse .be reported to the facility, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The state licensing/certification agency responsible for surveying/licensing the facility . . 1. Review of the Face Sheet dated 12/14/16 for Resident #3 reflected she was a [AGE] year-old female, readmitted on [DATE]. She had [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] for Resident #3 reflected she had minimal difficulty hearing with a hearing aid, and was able to be understood by others. Her vision was impaired to the extent she could see large print in written material with glasses. She was severely cognitively impaired. Resident #3 exhibited fluctuating inattention, disorganized thinking, and altered level of consciousness. Resident #3 required extensive one-person assistance for transfers, dressing, and toilet use. An interview with Resident #3 on 12/14/16 at 1:46 PM revealed she had a problem with CNA B and complained one time before, and went to the ADON on the morning of the interview to tell her she didn't get along with CNA B. She said CNA B was real cross and slammed the curtains aside and always acted like she was mad. Resident #3 said CNA B sometimes wanted her to go to bed at 6:30 PM, and she could not go to sleep that early, but she went along with it, because she didn't want to argue. She said the CNA also objected to her keeping her light on at night to read. She thought the CNA worked in the evenings, and she was still working, because she saw her recently. She said CNA B was never rough with her, but she's just got attitude. She said she did think she heard the CNA slap her roommate (Resident #2) once, and her roommate cried out, so she told LVN C about it. Resident #3 was forgetful in her interview, repeated some details, was not able to recall specific dates, and estimated time frames with questionable accuracy. She was able to recall some first names of staff, including that of CNA B, and staff she had spoken with about her concerns. Review of Resident #3's nursing notes for the months of November and December of 2016 revealed no documentation of the allegation. 2. Review of the Face Sheet dated 12/14/16 for Resident #2 reflected she was a [AGE] year-old female, admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] for Resident #2 reflected she was able to understand others without a hearing aid, and was able to be understood by others. Her vision was highly impaired with glasses. She had moderate cognitive impairment. Review of Resident #2's nursing notes for the months of November and December of 2016 revealed no documentation of a concern or potential abuse allegation. Observation and attempt to interview Resident #2 on 12/14/16 at 1:46 PM revealed she was in her bed, in a nightgown. Her affect was flat, and when addressed, she looked away and did not speak. The resident was unable to be interviewed. 3. An interview on 12/14/16 at 3:10 PM with CNA B revealed there were two residents she got the most complaints from: Resident #1 and Resident #3. She said Resident #1 used to complain a lot, but she stopped. CNA B said she just quit trying to do things, because of her (Resident #1's) rights, and if the resident fell because she did not have an alarm on, that's the way it is. CNA B said she told the resident she did not care what the first shift let the resident do, she had to use her call light. However, the resident did not want to. She said the facility did not let her do her job with the resident, and the resident did not use her alarms, and did what she pleased. CNA B said Resident #3 told someone she (CNA B) hit her roommate, and the ADON told her about the allegation about a week or week and a half ago, she thought. At that time she was told to stay out of the resident's room, but they did not suspend her. She said because there were only two to three people to work the hall, it was too hard, and she had to go into the room to do her job. She always took someone else in with her. She said she felt like she couldn't catch a break and people complained about her not smiling. She said it was not realistic to expect her to smile all the time. She said the CNAs were stressed and could not do a good enough job, and she had worked three weeks straight and was tired. She denied having any physical altercations with any residents. An interview on 12/14/16 at 4:43 PM with the ADON revealed when asked about the allegation Resident #3 had made, she said the resident just told her about the allegation of slapping on the morning of 12/14/16. When informed that CNA B stated she was told of the allegation a week to a week and a half ago, the ADON confirmed it was earlier that she was informed of the allegation by LVN C. She did not know it needed to be reported to the state. She said she talked to the Administrator about it, and he told her to go talk to the resident. She checked on the resident, and did not specifically ask her about the allegation, but rather asked her if she could tell me about any bad things going on. The resident said she was fine, just tired, and did not mention the alleged slap. She said all abuse or neglect allegations went straight to the Administrator. She said the Administrator did not believe CNA B would do something like that, and the resident was probably just thinking about something else or dreaming. She confirmed CNA B was not removed from duties which required resident contact. She thought she told LVN C to document the allegation, but if the surveyor did not see any, there was none, and it didn't get done. She said documentation was a problem in the facility. She had no documentation of the allegation or steps taken afterwards. An interview on 12/14/16 at 5:47 PM with LVN C revealed Resident #3 had told her she didn't like a particular CNA very well. Resident #3 could not remember the CNA's name, but it was the CNA who put her to bed. Resident #3 later said she thought the CNA had slapped her roommate, and her roommate yelled out. The resident was not able to say when it happened. LVN C said she immediately informed the former Administrator and the ADON, and someone went to talk to Resident #3 right away. She said she knew it was being investigated. She said the resident never made an allegation like that before, and had not talked about it since. LVN C did not tell the current, interim Administrator after the former Administrator left the facility (12/08/16 was his last day worked), and thought it had been taken care of. An interview on 12/14/16 at 5:50 PM with the current, interim Administrator revealed he was not aware of the allegation made by Resident #3. He said his expectation of his staff was to call him if they called in anything to the state, or if there was any gray area. When the allegation was described to him, he said it sounded like something that should have been reported. He said the Administrator was ultimately responsible for investigations of abuse or neglect allegations. An IJ was identified on 12/14/16 at 6:24 PM, and the DON, MDS F, and the ADON were informed. A Plan of Removal was requested at that time. The Plan of Removal was accepted on 12/15/16 at 11:00 AM, and reflected the following steps taken to remove immediacy: · In-service training with return demonstration for all staff on the process of reporting and investigating allegations of abuse or neglect. · Continued quarterly Abuse and Neglect in-services for all staff. · Facility Abuse and Neglect protocol was initiated for the previously unreported allegation (including terminating the alleged perpetrator, which was not written into the Plan of Removal.) · All residents were given satisfaction surveys. Review of an employee counseling form dated 12/14/16 for CNA B reflected Employee has several allegations of abuse verbal, Employee suspended pending investigation, and in the employee statement area, I quit! It was noted on the form that the CNA refused to sign the form. Review of an employment separation form dated 12/14/16 for CNA B reflected, Employee quit after being informed that she was suspended pending investigation due to allegations of abuse. An interview on 12/15/16 at 8:05 AM with the current, interim Administrator and the DON revealed CNA B was terminated on the previous night. The DON said she only heard about the slapping allegation after the fact, when LVN C told her about the incident that occurred before she started working at the facility. The DON said when she asked the ADON about it, she was assured it had been taken care of, but she did not pursue the matter to see if it had been properly investigated and reported. An interview on 12/15/16 at 9:39 AM with the former DON, revealed she did not have any knowledge of the allegation made by Resident #3, and said her last day was 11/18/16. She said it must have happened after she left the facility. An interview on 12/15/16 at 10:03 AM with the former Administrator revealed he remembered the allegation, and asked the ADON to do an assessment of Resident #2. She completed an assessment and talked with Resident #3. He said he talked with Resident #3 as well, and asked general questions about her care. He asked her if there was something he needed to know, anything bad, and the resident did not say anything about the allegation. He said he did not think it met the qualifications for abuse because he went to validate it that morning, and it was not validated. He said he gave Resident #3 several opportunities to tell him, and she did not. He did not suspend CNA B after the allegation was made. He made no documentation of the allegation or steps taken afterward. An interview on 12/15/16 at 12:46 PM with the Medical Director revealed he did not know how the IJ occurred, because the former Administrator and DON G were usually good at reporting everything to him. He was not made aware of the allegation by Resident #3. An interview on 12/15/16 at 3:05 PM with the ADON revealed she felt the problem was caused by a communication breakdown between administration and nursing. She felt she should not have assumed the former Administrator would take care of it. She did not know what she could have done differently in the investigation, and when she interviewed Resident #3, the resident was given the opportunity to say she heard a slap. An interview on 12/15/16 at 5:20 PM with the current, interim Administrator revealed he reiterated his previously stated expectations of his staff, and explained he would expect the new Administrator, who had been hired, but not yet started, to call him about everything, until he felt comfortable with their judgment. He said he would be further stressing transparency in the facility, and was making sure any staff knew they could call his number if they felt other staff was trying to hide anything or not doing what they were supposed to be doing. He stated they would be spot-checking Abuse and Neglect knowledge, for the future, to make sure staff knew it. An interview on 12/15/16 at 5:40 PM with the DON revealed she felt the former DON and former Administrator did not pay as much attention to detail as they should have, and they did not communicate or follow up as they should have. She acknowledged the interviews could have been stronger, and it was possible they did not want to have to report the allegation; but she was not at the facility at that time, so she did not know. Review of an incident report by the ADON dated 12/14/16, and provided on 12/15/16 by the DON reflected: approximately three weeks ago, it was reported that resident had heard her roommate being hit. It was reported to ADON, and she reported it the administrator. Administrator informed ADON to go in, and talk to resident. After lunch, ADON and CNA went in, and started speaking to resident. When ADON asked how she was doing resident stated she was OK. The resident was asked if anything bad had happened during the night, resident stated that she was tired and couldn't sleep last night, but she was OK and nothing had happened. On 12/16/16, the DON provided sign-in sheets for in-services she provided staff from the evening of 12/14/16 through the morning of 12/16/16 on Abuse and Neglect identification, reporting and investigation. The in-service consisted of written and spoken material. The staff was informed to report to the Administrator, and if the Administrator was not available, to report to the next person in the chain-of-command (which was clarified.) The staff was instructed to call the current, interim Administrator even after the new Administrator arrived, if they ever felt anything was not being dealt with. It was stressed that all suspicions, whether the employee was sure it was abuse or not, were to be reported immediately. They were informed the responsibility for investigating was on the Administrator or his/her designee, and if it was an employee who was alleged to have committed abuse, they were to be suspended immediately for the duration of the investigation. Review of a list, and a letter, provided by the DON via email on 12/16/16 reflected all staff were in-serviced except for five who were on vacation or medical leave. One PRN staff member would require a language interpreter and would be in-serviced on 12/20/16 before they worked a shift; and seven PRN staff, who had not yet returned her call, were left messages they would not be able to work until after they were in-serviced. On 12/16/16 at 8:55 AM, the current, interim Administrator stated if the PRN employees were not able to be contacted for in-servicing, they would be removed from the PRN list because some of them had not been in the facility for a long time. On 12/15/16 and 12/16/16, 19 staff were interviewed by the surveyor. They were asked standard Abuse and Neglect policy and protocol questions, about types and signs of abuse, signs of employee burnout, monitoring staff-employee interactions, handling combative residents, what types of observations they would report as possible abuse concerns, to whom they would report, what they would do if they reported to the Abuse Prevention Coordinator of their designee, and the report was not acted on. In addition, they were asked questions about how they would know if something they reported to the Abuse Prevention Coordinator or their designee and the allegation was handled properly, and they were asked to describe the Abuse and Neglect training they just received. All staff were able to correctly answer questions. The following staff members were interviewed from the 6:00 AM to 2:00 PM shift: · On 12/15/16 at 10:37 AM, LVN H · On 12/15/16at 10:46 AM, RA I · On 12/15/16 at 11:14 AM, COTA J · On 12/15/16 at 11:21 AM, CNA K · On 12/15/16 at 11:32 AM, CNA L · On 12/15/16 at 11:41 AM, RN M · On 12/15/16 at 2:12 PM LVN C The following staff members were interviewed from the 2:00 PM to 10:00 PM shift: · On 12/15/16 at 2:01 PM, CNA N · On 12/15/16at 2:30 PM, CNA O · On 12/15/16 at 2:40 PM, LVN P · On 12/15/16 at 2:53 PM, CNA Q · On 12/15/16 at 3:22 PM, CNA R · On 12/15/16 at 3:47 PM,LVN S The following staff members were interviewed from the 10:00 PM to 6:00 AM shift: · On 12/15/16 at 4:00 PM, LVN T · On 12/16/16at 5:55 AM, MA U · On 12/16/16 at 6:05 AM, CNA V · On 12/16/16 at 6:15 AM, LVN W · On 12/16/16 at 6:22 AM, LVN X On 12/16/16 at 6:39 AM, Hskp. Y, who worked various shifts, was interviewed. Review of resident satisfaction surveys dated 12/14/16 and 12/15/16 reflected 80 residents were surveyed. Included in the surveys were comments by Resident #1 (The CNA with the white headband (CNA B) puts me to bed when I do not want to.) and Resident #3 (I complained about (CNA B), we just clash, acts like she is mad all the time. Fusses because I keep my light on to read. I never have any trouble with anyone else.) Review of DADS Provider Self-Reporting of Incidents documentation reflected the allegation made by Resident #1 on 12/14/16, and the previously unreported allegation made by Resident #3 were both reported to DADS on 12/15/16. An interview on 12/14/16 at 2:32 PM with LVN A revealed the CNAs shifted to work on the other halls periodically, so they could work in any part of the building. On 12/16/16 at 9:19 AM the current, interim Administrator and the DON were informed the IJ was lifted. Review of the CMS form 672 provided on 12/16/16 by MDS F reflected a census of 83 residents.